OFFICIAL USE ONLY SENSITIVE Page 1 of 3 DEPARTMENT OF HOMELAND SECURITY 1. CASE NUMBER 201200186 Immigration and Customs Enforcement Office of Professional Responsibility PREPARED BY (b)(6), (b)(7)(c) REPORT OF INVESTIGATION 2. REPORT NUMBER 001 HB 4200-01 (37), Special Agent Handbook 3. TITLE RIVERA-Romero, Mauro/Unknown/Unknown/EL PASO, EL PASO, TX 4. FINAL RESOLUTION 5. STATUS Initial Report 6. TYPE OF REPORT Allegation 7. RELATED CASES 8. TOPIC Death of detainee RIVERA-Romero at Del Sol Medical Center in El Paso TX. 9. SYNOPSIS On October 06, 2011, the Joint Intake Center (JIC), Washington, D.C., received information from U.S. Immigration and Customs Enforcement (ICE) Assistant Field Office Director (AFOD) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c), El Paso TX. AFOD (b)(6), (b)(7)(c) reported that on October 05, 2011 approximately 18:53 hours Dr. (b)(6), (b)(7)(c) of the Del Sol Medical Center, Emergency Room Physician declared the death of Mauro Antonio RIVERA-Romero Alien Number: (b)(6), (b)(7)(c) an Immigration Customs Enforcement (ICE) detainee house at the El Paso Processing Center (EPC), El Paso TX. 10. CASE OFFICER (Print Name & Title) (b)(6), (b)(7)(c) - Joint Intake Specialist 12. APPROVED BY(Print Name & Title) (b)(6), (b)(7)(c) 11. COMPLETION DATE 14. ORIGIN OFFICE 06-OCT-2011 XXCM CMG View Case 13. APPROVED DATE 15. TELEPHONE NUMBER 06-OCT-2011 No Phone Number - ICE-OPR Special Agent Supervisor THIS DOCUMENT IS LOANED TO YOU FOR OFFICIAL USE ONLY AND REMAINS THE PROPERTY OF THE DEPARTMENT OF HOMELAND SECURITY. ANY FURTHER REQUEST FOR DISCLOSURE OF THIS DOCUMENT OR INFORMATION CONTAINED HEREIN SHOULD BE REFERRED TO HEADQUARTERS, DEPARTMENT OF HOMELAND SECURITY, TOGETHER WITH A COPY OF THE DOCUMENT. THIS DOCUMENT CONTAINS INFORMATION REGARDING CURRENT AND ON-GOING ACTIVITIES OF A SENSITIVE NATURE. IT IS FOR THE EXCLUSIVE USE OF OFFICIAL U.S. GOVERNMENT AGENCIES AND REMAINS THE PROPERTY OF THE DEPARTMENT OF HOMELAND SECURITY IT CONTAINS NEITHER RECOMMENDATIONS NOR CONCLUSIONS OF THE DEPARTMENT OF HOMELAND SECURITY. DISTRIBUTION OF THIS DOCUMENT HAS BEEN LIMITED AND FURTHER DISSEMINATION OR EXTRACTS FROM THE DOCUMENT MAY NOT BE MADE WITHOUT PRIOR WRITTEN AUTHORIZATION OF THE ORIGINATOR. OFFICIAL USE ONLY SENSITIVE OFFICIAL USE ONLY SENSITIVE DEPARTMENT OF HOMELAND SECURITY Page 2 of 3 1. CASE NUMBER 201200186 PREPARED BY (b)(6), (b)(7)(c) REPORT OF INVESTIGATION CONTINUATION HB 4200-01 (37), Special Agent Handbook 2. REPORT NUMBER 001 10. NARRATIVE On October 06, 2011, the Joint Intake Center (JIC), Washington, D.C., received information from U.S. Immigration and Customs Enforcement (ICE) Assistant Field Office Director (AFOD) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) El Paso TX. AFOD (b)(6), (b)(7)(c) reported that on October 05, 2011 approximately 18:53 hours Dr. (b)(6), (b)(7)(c) of the Del Sol Medical Center, Emergency Room Physician declared the death of Mauro Antonio RIVERA-Romero Alien Number: (b)(6), (b)(7)(c) an Immigration Customs Enforcement (ICE) detainee house at the El Paso Processing Center (EPC), El Paso TX. AFOD (b)(6), (b)(7)(c) advised that prior to detainee RIVERA-Romero being transported to the hospital form the EPC detainee RIVERA-Romero in formed the staff he is HIV Positive. OFFICIAL USE ONLY SENSITIVE OFFICIAL USE ONLY SENSITIVE DEPARTMENT OF HOMELAND SECURITY Page 3 of 3 1. CASE NUMBER 201200186 PREPARED BY (b)(6), (b)(7)(c) REPORT OF INVESTIGATION Exhibit List HB 4200-01 (37), Special Agent Handbook None OFFICIAL USE ONLY SENSITIVE 2. REPORT NUMBER 001 OFFICIAL USE ONLY SENSITIVE Page 1 of 11 DEPARTMENT OF HOMELAND SECURITY 1. CASE NUMBER 201200186 PREPARED BY (b)(6), (b)(7)(c) REPORT OF INVESTIGATION 2. REPORT NUMBER 002 HB 4200-01 (37), Special Agent Handbook 3. TITLE RIVERA-Romero, Mauro/Unknown/0108 Death-Detainee/Alien (Unknown Cause)/EL PASO, EL PASO, TX 4. FINAL RESOLUTION Referred to Management 5. STATUS Closing Report 6. TYPE OF REPORT Detainee Death Review 7. RELATED CASES 201200555 8. TOPIC Closing ROI (b)(7)e Mauro RIVERA-Romero (b)(6), (b)(7)(c) 9. SYNOPSIS On October 6, 2011, the Joint Intake Center, Washington, D.C, received notification regarding the death of U.S. Immigration and Customs Enforcement Detainee Mauro Antonio RIVERA-Romero. RIVERA, a citizen of El Salvador, died on October 5, 2011, at the Del Sol Medical Center in El Paso, TX. The County of El Paso Office of the Medical Examiner and Forensic Laboratory reported the cause of death as disseminated cryptococcosis, an infection associated with immune-suppressed individuals. On November 22, 2011, the U.S. Immigration and Customs Enforcement, Office of Professional Responsibility, Office of Detention Oversight initiated a Detainee Death Review of Mauro Antonio RIVERA-Romero's death. This report documents the findings of the review. 10. CASE OFFICER (Print Name & Title) (b)(6), (b)(7)(c) - ICE-OPR Special Agent 12. APPROVED BY(Print Name & Title) (b)(6), (b)(7)(c) 11. COMPLETION DATE 14. ORIGIN OFFICE ICE OPR Office of Detention Oversight (ODO)-Phoenix 15-AUG-2012 13. APPROVED DATE 15. TELEPHONE NUMBER 16-AUG-2012 No Phone Number ICE-OPR Special Agent Supervisor THIS DOCUMENT IS LOANED TO YOU FOR OFFICIAL USE ONLY AND REMAINS THE PROPERTY OF THE DEPARTMENT OF HOMELAND SECURITY. ANY FURTHER REQUEST FOR DISCLOSURE OF THIS DOCUMENT OR INFORMATION CONTAINED HEREIN SHOULD BE REFERRED TO HEADQUARTERS, DEPARTMENT OF HOMELAND SECURITY, TOGETHER WITH A COPY OF THE DOCUMENT. THIS DOCUMENT CONTAINS INFORMATION REGARDING CURRENT AND ON-GOING ACTIVITIES OF A SENSITIVE NATURE. IT IS FOR THE EXCLUSIVE USE OF OFFICIAL U.S. GOVERNMENT AGENCIES AND REMAINS THE PROPERTY OF THE DEPARTMENT OF HOMELAND SECURITY IT CONTAINS NEITHER RECOMMENDATIONS NOR CONCLUSIONS OF THE DEPARTMENT OF HOMELAND SECURITY. DISTRIBUTION OF THIS DOCUMENT HAS BEEN LIMITED AND FURTHER DISSEMINATION OR EXTRACTS FROM THE DOCUMENT MAY NOT BE MADE WITHOUT PRIOR WRITTEN AUTHORIZATION OF THE ORIGINATOR. OFFICIAL USE ONLY SENSITIVE OFFICIAL USE ONLY SENSITIVE DEPARTMENT OF HOMELAND SECURITY Page 2 of 11 1. CASE NUMBER 201200186 PREPARED BY (b)(6), (b)(7)(c) REPORT OF INVESTIGATION CONTINUATION HB 4200-01 (37), Special Agent Handbook 2. REPORT NUMBER 002 10. NARRATIVE DETAILS OF INVESTIGATION On October 6, 2011, the Joint Intake Center (JIC), Washington, D.C., received notification of the death of Detainee Mauro Antonio RIVERA-Romero (Alien Registration Number (b)(6), (b)(7)(c) . RIVERA, a citizen of El Salvador born on January 10, 1968, died on October 5, 2011, at the Del Sol Medical Center (DSMC) in El Paso, TX. RIVERA was 43 years old when he died. At the time of his death, RIVERA was in U.S. Immigration and Customs Enforcement (ICE) custody at the El Paso Service Processing Center (EPC) in El Paso, TX. The EPC is owned and operated by ICE. EPC accommodates adult male and female ICE detainees of all security classification levels for periods in excess of 72 hours. ICE Health Service Corps (IHSC) provides medical services to detainees at EPC. EPC is accredited by the American Correctional Association, the National Commission on Correctional Health Care (NCCHC), and the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). The Field Office Director (FOD), Office of Enforcement and Removal Operations (ERO), El Paso, TX, is responsible for ensuring EPC compliance with the ICE Performance Based National Detention Standards (PBNDS). An Assistant Field Office Director (AFOD) is physically located at EDC and oversees ICE detention operations at the facility. (b)(6), (b)(7)(c) On December 6, 2011, Special Agent (SA) and SA (b)(6), (b)(7)(c) , of the ICE Office of Professional Responsibility (OPR), Office of Detention Oversight (ODO), Phoenix, Arizona, conducted an on-site Detainee Death Review (DDR) regarding RIVERA. ODO was assisted by El (b)(6), (b)(7)(c) Paso OPR, Resident Agent in Charge, SA , and subject matter expert, Chief (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) Medical Officer Dr. is employed by Creative Corrections, LLC (CC), a national management and consulting firm, contracted by ICE to provide subject matter expertise in detention management with a special emphasis on health care. As part of the review, ODO interviewed Doyon-Akal Technical Services, Inc. (DATS), ERO, and IHSC personnel at EPC. ODO also reviewed EPC policies, and immigration, medical, and detention records pertaining to RIVERA. The following is a chronology of events regarding RIVERA while he was in ICE custody. On October 1, 2011, at approximately 4:38 p.m., RIVERA was encountered by U.S. Border Patrol Agents onboard a Greyhound bus at the U.S. Border Patrol checkpoint, West of Sierra Blanca, TX. This was documented on a Form I-213, Record of Deportable/Inadmissible Alien (Exhibit 01). On the same date, Border Patrol Agents issued RIVERA a Form I-862, Notice to Appear, charging OFFICIAL USE ONLY SENSITIVE OFFICIAL USE ONLY SENSITIVE DEPARTMENT OF HOMELAND SECURITY Page 3 of 11 1. CASE NUMBER 201200186 PREPARED BY (b)(6), (b)(7)(c) REPORT OF INVESTIGATION CONTINUATION HB 4200-01 (37), Special Agent Handbook 2. REPORT NUMBER 002 10. NARRATIVE removability pursuant to section 212(a)(6)(A)(i) of the Immigration and Nationality Act, as an alien present in the U.S. without being admitted or paroled (Exhibit 02). According to the I-213, RIVERA stated he had been released from the Los Angeles County Medical Center on September 29, 2011, where he had been diagnosed with a stomach infection (Exhibit 03). At the time of apprehension, RIVERA was experiencing stomach pains and nausea. RIVERA refused medical attention and signed a Border Patrol Declination of Medical Treatment Form (Exhibit 04). RIVERA was processed by the U.S. Border Patrol and an accommodation for housing at EPC was approved. RIVERA was transported to EPC by Wackenhut contract services to await removal proceedings. No information was available regarding the Wackenhut transport personnel, or the time of RIVERA's physical transfer to EPC. The information regarding RIVERA's stomach pains and nausea was contained in RIVERA's Alien Registration File; however, there is no documentation that the information was provided to EPC. On October 2, 2011, at approximately 4:30 a.m., RIVERA arrived at EPC and was booked into the facility. RIVERA was booked into EPC by DATS Security Officer (SO) (b)(6), (b)(7)(c) and DATS SO (b)(6), (b)(7)(c) . (b)(6), (b)(7)(c) and (b)(6), (b)(7)(c) are no longer employed by DATS and were not available for interview. (b)(6), (b)(7)(c) At 10:14 p.m., EPC Registered Nurse (RN) performed an initial screening assessment regarding RIVERA, which was documented on an In-Processing Health Screening (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) Form and its associated Event Listing (Exhibit 05). SA and SA (b)(6), (b)(7)(c) interviewed RN at EPC on December 7, 2011. RN (b)(6), (b)(7)(c) is a contract employee of STG International Corporation. RN (b)(6), (b)(7)(c) stated she screened RIVERA at approximately 5:30 a.m. after he arrived from intake processing. (Agent's note: this information differs from the Event Listing, which reflects that RIVERA was screened at 10:14 p.m.) RN (b)(6), (b)(7)(c) stated she completed a chest X-ray of RIVERA that showed negative results for pulmonary tuberculosis. RN (b)(6), (b)(7)(c) recorded RIVERA's pulse rate at 106 per minute and his blood pressure at 100/71, which were within normal limits. The In-Processing Health Screening Form reflects that RIVERA answered yes when asked if the whites of his eyes or nails turn yellow. A handwritten "Hep C" was recorded next to the question on the form. During medical screening, RIVERA stated to RN (b)(6), (b)(7)(c) that he had Hepatitis C, but no other communicable diseases. RIVERA also stated he was not taking medication, but he was hospitalized for gastritis in 2011 at a hospital in California. RIVERA stated he could not remember the medication provided to him for his condition. RN (b)(6), (b)(7)(c) instructed RIVERA on how to address medical concerns while in ICE custody, and RIVERA stated he understood (refer OFFICIAL USE ONLY SENSITIVE OFFICIAL USE ONLY SENSITIVE DEPARTMENT OF HOMELAND SECURITY Page 4 of 11 1. CASE NUMBER 201200186 PREPARED BY (b)(6), (b)(7)(c) REPORT OF INVESTIGATION CONTINUATION HB 4200-01 (37), Special Agent Handbook 2. REPORT NUMBER 002 10. NARRATIVE to Exhibit 05). The Event Listing documents that RIVERA's medical and mental health screenings were normal, and he was cleared for general population. After completing the screening process, RIVERA was assigned and housed in Barrack #3. (b)(6), (b)(7)(c) On October 3, 2011, at approximately 7:00 a.m., DATS SO began his shift in EPC (b)(6), (b)(7)(c) Barrack #3. DATS SO stated he observed RIVERA decline his breakfast meal. RIVERA was sent to "Know Your Rights" orientation at 9:15 a.m. and walked there without assistance. RIVERA entered the medical building while en route to the EPC detainee orientation (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) program. Later that same day, DATS SO advised DATS SO that (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) RIVERA had remained in bed and did not go to lunch. SA and SA (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) interviewed DATS SO (b)(6), (b)(7)(c) on December 8, 2011. SA and SA (b)(6), (b)(7)(c) interviewed DATS SO on December 7, 2011. DATS SO (b)(6), (b)(7)(c) corroborated the information provided by DATS SO (b)(6), (b)(7)(c) . On October 3, 2011, at 11:36 a.m., RIVERA was seen at the medical clinic as a walk-in, which was documented on an IHSC Sequence of Events Form (Exhibit 06). The form documents that RIVERA walked to the EPC clinic to complain of nausea, headache, and not feeling well. RN (b)(6), (b)(7)(c) examined RIVERA and assessed him as normal except for an elevated pulse of 129. SA (b)(6), (b)(7)(c) and SA interviewed RN (b)(6), (b)(7)(c) on December 8, 2011. RN (b)(6), (b)(7)(c) stated that on October 3, 2011, RIVERA was provided Tylenol and bismuth for his complaints. RN (b)(6), (b)(7)(c) stated that RIVERA remained in the clinic for approximately two hours for evaluation, and returned to general population (refer to Exhibit 06). (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) On October 3, 2011, DATS SO was assigned to the EPC medical clinic. (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) SA and SA interviewed DATS SO(b)(6), (b)(7)(c)at EPC on December 7, 2011. DATS SO(b)(6), (b)(7)(c)stated that on that date she listened to a brief conversation between RIVERA and physician assistant (PA) (b)(6), (b)(7)(c) , during which RIVERA stated he had an ulcer, but the ulcer had not bled. RIVERA also stated he was unaware of any other illnesses. DATS SO (b)(6), (b)(7)(c)stated RN (b)(6), (b)(7)(c) completed the examination of RIVERA and instructed RIVERA to return to the clinic that same day. DATS SO(b)(6), (b)(7)(c)stated she saw RIVERA in the medical clinic later that day; however, there is no documentation that RIVERA visited the medical clinic for a follow-up on October 3, 2011 (refer to Exhibit 06). On October 4, 2011, at approximately 7:25 a.m., RIVERA told DATS SO (b)(6), (b)(7)(c) he was not feeling well and was too weak to walk. SA and SA OFFICIAL USE ONLY SENSITIVE (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) that OFFICIAL USE ONLY SENSITIVE DEPARTMENT OF HOMELAND SECURITY Page 5 of 11 1. CASE NUMBER 201200186 PREPARED BY (b)(6), (b)(7)(c) REPORT OF INVESTIGATION CONTINUATION HB 4200-01 (37), Special Agent Handbook 2. REPORT NUMBER 002 10. NARRATIVE interviewed DATS SO (b)(6), (b)(7)(c) on December 7, 2011. DATS SO (b)(6), (b)(7)(c) stated he observed RIVERA in bed while conducting his appointed rounds and RIVERA complained of a stomachache. At approximately 8:10 a.m., Lieutenant Commander (LCDR) (b)(6), (b)(7)(c) was in Barrack #3 on unrelated issues. DATS SO (b)(6), (b)(7)(c) informed LCDR(b)(6), (b)(7)(c)that RIVERA was ill, and requested their assistance (refer to Exhibit 06). SA (b)(6), (b)(7)(c) and SA interviewed LCDR(b)(6), (b)(7)(c)on December 7, 2012. LCDR (b)(6), (b)(7)(c) stated RIVERA complained of continued weakness and abdominal discomfort. RIVERA stated he was able to walk from his bed to the vending machine, but his legs felt weak when returning to his bed. RIVERA stated to LCDR(b)(6), (b)(7)(c)that the medication provided the previous day was ineffective. LCDR(b)(6), (b)(7)(c)stated RIVERA did not appear to be in acute distress during this encounter. LCDR(b)(6), (b)(7)(c)returned to the EPC clinic and informed the charge nurse, RN (b)(6), (b)(7)(c) of RIVERA's symptoms. LCDR(b)(6), (b)(7)(c)instructed RN (b)(6), (b)(7)(c) to have RIVERA brought into the clinic. The IHSC Sequence of Events documents that RIVERA was advised by medical staff to complete a medical slip (refer to Exhibit 06). (b)(6), (b)(7)(c) On October 4, 2011, at approximately 12:00 p.m., RIVERA did not go to his scheduled lunch period. DATS SO (b)(6), (b)(7)(c) advised DATS SO (b)(6), (b)(7)(c) that RIVERA had not gone to lunch and remained in his bunk. DATS SO (b)(6), (b)(7)(c) stated that DATS SO (b)(6), (b)(7)(c) called DATS SO (b)(6), (b)(7)(c) to advise that RIVERA go to the medical clinic. The IHSC Sequence of Events reflects that at 1:45 p.m., RIVERA was transported to the medical clinic via a cart and that RIVERA complained of fatigue and not being able to walk (refer to Exhibit 06). SA (b)(6), (b)(7)(c) and SA interviewed RN (b)(6), (b)(7)(c) on December 7, 2011. RN stated he transported RIVERA to the medical clinic via a medical cart where RIVERA was evaluated and vital signs were obtained. RN(b)(6), (b)(7)(c) stated RIVERA's blood pressure was 87/60 (mild hypotension) and his pulse was 57 (mild bradycardia). Per open source information, hypotension is low blood pressure, and bradycardia is a slow heart rate usually defined as less than 60 beats per minute (www.medicinenet.com). RIVERA rested in the Medical Unit for 30 minutes and consumed 800 milliliters of water. RN (b)(6), (b)(7)(c) instructed RIVERA to increase his fluid intake to 64 ounces of water daily and to eat all meals. RIVERA stated he understood the instructions, and RN(b)(6), (b)(7)(c) reassessed his vital signs (Exhibit 07). (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) The second assessment determined RIVERA's vital signs as blood pressure 92/42, pulse 111 (mild tachycardia), and oxygen saturation 91% (mild hypoxia). Per open source information, tachycardia is a fast heart beat and hypoxia is a lower-than-normal concentration of oxygen in arterial blood (www.medicinenet.com). RN(b)(6), (b)(7)(c) notified physician assistant (PA) (b)(6), (b)(7)(c) OFFICIAL USE ONLY SENSITIVE OFFICIAL USE ONLY SENSITIVE DEPARTMENT OF HOMELAND SECURITY Page 6 of 11 1. CASE NUMBER 201200186 PREPARED BY (b)(6), (b)(7)(c) REPORT OF INVESTIGATION CONTINUATION HB 4200-01 (37), Special Agent Handbook 2. REPORT NUMBER 002 10. NARRATIVE (b)(6), (b)(7)(c) of RIVERA's condition (refer to Exhibit 07). (b)(6), (b)(7)(c) At approximately 2:55 p.m., RN (b)(6), (b)(7)(c)referred RIVERA to PA (b)(6), (b)(7)(c) . SA (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) and SA interviewed PA on December 8, 2011. PA stated he examined RIVERA and ordered an electrocardiogram (EKG). PA (b)(6), (b)(7)(c) obtained a more detailed medical history of RIVERA and learned that he was diagnosed as Human Immunodeficiency Virus (HIV) positive in 1996. PA (b)(6), (b)(7)(c) documented that RIVERA had abdominal discomfort and that RIVERA noticed some blood tinged emesis (vomit) earlier that day. PA (b)(6), (b)(7)(c) determined RIVERA was not stable and was in need of emergency care. PA (b)(6), (b)(7)(c) instructed RN(b)(6), (b)(7)(c) to contact Emergency Medical Services (EMS) for RIVERA. RIVERA was provided saline intravenously and 4 liters of oxygen via nasal cannula. PA (b)(6), (b)(7)(c) notified Dr.(b)(6), (b)(7)(c)of the situation (Exhibit 08). At approximately 3:31 p.m., El Paso County Emergency Medical Technicians (EMT) arrived at the facility and assumed care for RIVERA. At approximately 3:38 p.m., EMS transported RIVERA via ambulance from the EPC to the Del Sol Medical Center (DSMC) Emergency Department in El Paso, TX. DATS SO accompanied RIVERA in the ambulance (refer to Exhibit 06). (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) SA and SA interviewed DATS SO (b)(6), (b)(7)(c) on December 7, 2011. (b)(6), (b)(7)(c) DATS SO stated he observed the El Paso EMS ambulance parked at the EPC sally port when he arrived at work on October 4, 2011. DATS SO(b)(6), (b)(7)(c) was instructed by his supervisor, Lt.(b)(6), (b)(7)(c) to accompany the ambulance to the emergency room (ER). DATS SO (b)(6), (b)(7)(c) stated the EMTs monitored RIVERA's vital signs and maintained radio contact with DSMC medical staff while en route to DSMC. At approximately 4:09 p.m., the ambulance arrived at DSMC (refer to Exhibit 06). DATS SO (b)(6), (b)(7)(c) stated that DATS SO arrived at the DSMC a short time later to assist. (b)(6), (b)(7)(c) DATS SO stated medical staff attempted to place a tube into RIVERA's nose on two separate occasions to determine if there was bleeding, but the efforts were unsuccessful. For the next six hours, medical staff monitored RIVERA's vital signs. DATS SO (b)(6), (b)(7)(c) stated RIVERA spoke with DATS SO (b)(6), (b)(7)(c) in Spanish while at the DSMC. (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) SA and SA (b)(6), (b)(7)(c) interviewed DATS SO (b)(6), (b)(7)(c) on December 7, 2011. DATS SO (b)(6), (b)(7)(c) stated that on October 4, 2011, he went directly to the ER after he arrived at the hospital and conversed with RIVERA. DATS SO (b)(6), (b)(7)(c) stated RIVERA was complaining of severe stomach pains. RIVERA stated he had contracted an illness from a girlfriend in 1996, and OFFICIAL USE ONLY SENSITIVE OFFICIAL USE ONLY SENSITIVE DEPARTMENT OF HOMELAND SECURITY Page 7 of 11 1. CASE NUMBER 201200186 PREPARED BY (b)(6), (b)(7)(c) REPORT OF INVESTIGATION CONTINUATION HB 4200-01 (37), Special Agent Handbook 2. REPORT NUMBER 002 10. NARRATIVE RIVERA stopped taking the medication prescribed by his doctor in Los Angeles two weeks prior to arriving in El Paso. RIVERA stated that his doctor told him he would die without the prescribed medication. At approximately 10:00 p.m., RIVERA was released from the DSMC ER and admitted to DSMC (refer to Exhibit 06). DATS SO (b)(6), (b)(7)(c) and DATS SO (b)(6), (b)(7)(c) remained with RIVERA until they (b)(6), (b)(7)(c) were relieved from duty at approximately 11:00 p.m. by DATS SO . SA (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) and SA (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) interviewed DATS SO on December 7, 2011. DATS SO(b)(6), (b)(7)(c)stated that sometime during the night, at an hour that DATS SO (b)(6), (b)(7)(c)could not recall, RIVERA was moved from the ER to the intensive care unit (ICU). DATS SO(b)(6), (b)(7)(c) accompanied RIVERA to the ICU, but did not communicate with RIVERA. (Agent's note: on October 5, 2011, at approximately 4:35 a.m., RIVERA was transferred to the DSMC ICU.) RIVERA's condition was reported as stable (Refer to Exhibit 06). (b)(6), (b)(7)(c) On October 5, 2011, at approximately 2:00 p.m., DATS SO arrived at DSMC to (b)(6), (b)(7)(c) perform as the hospital duty officer. SA and SA interviewed DATS (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) SO(b)(6), (b)(7)(c)on December 7, 2011. DATS SO stated that between the hours of 2:00 p.m. and 6:00 p.m. on October 5, 2011, RIVERA occasionally woke up, complained of breathing problems, attempted to remove his oxygen mask, and asked medical staff for help. DATS SO(b)(6), (b)(7)(c)stated each time medical staff assisted RIVERA with his oxygen mask, RIVERA would resume sleeping. At approximately 6:15 p.m., RIVERA awoke and complained of trouble breathing. RN(b)(6), (b)(7)(c) attended to RIVERA while RN (b)(6), (b)(7)(c) notified Dr. (b)(6), (b)(7)(c) of RIVERA's situation. At approximately 6:30 p.m., RIVERA was sedated, and Dr. (b)(6), (b)(7)(c) performed an orotracheal intubation. At approximately 6:34 p.m., RIVERA developed bradycardia (slow heart beat) and arrested. During his interview, DATS SO(b)(6), (b)(7)(c)stated that hospital staff performed chest compressions until Dr. (b)(6), (b)(7)(c) declared RIVERA deceased at 6:51 p.m. (refer to Exhibit 06). The body of RIVERA was transported to the County of El Paso Office of the Medical Examiner and Forensic Laboratory for an autopsy. (b)(6), (b)(7)(c) On October 5, 2011, AFOD (b)(6), (b)(7)(c) reported the death through the chain of command via (b)(6), (b)(7)(c) telephone, Significant Incident Report (SIR), and Executive Summary (ES). SA and (b)(6), (b)(7)(c) SA interviewed AFOD (b)(6), (b)(7)(c) at EPC on December 6, 2011. AFOD (b)(6), (b)(7)(c) stated that on October 5, 2011, he made the required notifications through his chain of command and via the JIC. Additionally, on October 5, 2011, AFOD (b)(6), (b)(7)(c) contacted El Salvador Consulate General (b)(6), (b)(7)(c) and informed her of the death of Detainee RIVERA. AFOD (b)(6), (b)(7)(c) stated he notified (b)(6), (b)(7)(c) , the brother of RIVERA, the following day (October 6, 2011). OFFICIAL USE ONLY SENSITIVE OFFICIAL USE ONLY SENSITIVE DEPARTMENT OF HOMELAND SECURITY Page 8 of 11 1. CASE NUMBER 201200186 PREPARED BY (b)(6), (b)(7)(c) REPORT OF INVESTIGATION CONTINUATION HB 4200-01 (37), Special Agent Handbook 2. REPORT NUMBER 002 10. NARRATIVE On October 6, 2011, an autopsy was conducted by the County of El Paso Office of the Medical (b)(6), (b)(7)(c) Examiner and Forensic Laboratory Interim Chief Medical Examiner M.D. In the autopsy report, Dr.(b)(6), (b)(7)(c) states that RIVERA died from disseminated cryptococcosis. Per open source information, cryptococcosis is an infection caused by inhaling the fungus Cryptococcus Neoformans. It is a disease that often affects AIDS patients. Cryptococcosis may be limited to the lungs, but frequently spreads throughout the body (www.medical-dictionary.com). Dr. (b)(6), (b)(7)(c) determined RIVERA's manner of death as natural (Exhibit 09). On November 3, 2011, the State of Texas Department of State Health Services, Vital Statics Unit issued a death certificate, File Number 142-11-136553, pertaining to RIVERA (Exhibit 10). The cause of death listed on RIVERA's death certificate is identified as disseminated cryptococcosis. MEDICAL COMPLIANCE REVIEW Creative Corrections LLC (CC), a national management and consulting firm contracted by ICE to provide subject matter expertise in detention management with an emphasis on health care, reviewed the medical treatment of Detainee RIVERA at EPC (Exhibit 11). CC found EPC was not compliant with the ICE PBNDS for Medical Care. Specifically, CC concluded EPC medical staff failed to review relevant information in RIVERA's medical record, failed to refer RIVERA to a higher level provider, and failed to properly document RIVERA's medical encounters. MORTALITY REVIEW (b)(6), (b)(7)(c) Dr. , CC Chief Medical Officer, conducted a mortality review as part of the investigation of RIVERA's death. Dr.(b)(6), (b)(7)(c)prepared a report detailing his findings and conclusion. Dr. (b)(6), (b)(7)(c) report concurs with the cause of death (disseminated cryptococcosis) cited by the Medical Examiner. Dr.(b)(6), (b)(7)(c)concluded RIVERA's death may have been preventable if RIVERA had accepted medical care from the U.S. Border Patrol and had been forthright with EPC medical staff about his HIV positive status. Dr.(b)(6), (b)(7)(c)stated that medical staff should have completed a more thorough intake assessment to obtain additional information from RIVERA. Policies and guidelines should have been followed for providing a higher level of care, and a physician should have examined RIVERA in a timely manner. Dr. (b)(6), (b)(7)(c) mortality review is attached to this report (Exhibit 12). IMMIGRATION AND DETENTION HISTORY RIVERA was a citizen of El Salvador and entered the U.S. in January 1991 without being admitted OFFICIAL USE ONLY SENSITIVE OFFICIAL USE ONLY SENSITIVE DEPARTMENT OF HOMELAND SECURITY Page 9 of 11 1. CASE NUMBER 201200186 PREPARED BY (b)(6), (b)(7)(c) REPORT OF INVESTIGATION CONTINUATION HB 4200-01 (37), Special Agent Handbook 2. REPORT NUMBER 002 10. NARRATIVE or paroled. On June 17, 1991, Officers from the former Immigration and Naturalization Service in Las Vegas, NV, arrested RIVERA and charged him with Illegal Entry. The charge was dismissed, and RIVERA was granted Temporary Protected Status. On March 2, 2001, RIVERA renewed his Temporary Protected Status (TPS). On February 6, 2005, RIVERA's TPS was denied after he missed a scheduled appointment with an Asylum Officer from U.S. Citizenship and Immigration Services (USCIS). USCIS determined RIVERA had abandoned his application and declared RIVERA to be out of status. On October 1, 2011, RIVERA was encountered by U.S. Border Patrol Agents while onboard a Greyhound bus at the Border Patrol checkpoint West of Sierra Blanca, TX. RIVERA was issued a Notice to Appear charging removability pursuant to section 212(a)(6)(A)(i) of the INA, as an alien present in the U.S. without being admitted or paroled. On October 2, 2011, RIVERA was detained at EPC, El Paso, TX, pending removal proceedings. CRIMINAL HISTORY No criminal history. INVESTIGATIVE FINDINGS ICE took custody of RIVERA on October 2, 2011, and RIVERA was housed at EPC pending removal proceedings. This review determined that RIVERA complained of ailments while in ICE custody, but did not receive healthcare in a timely and efficient manner. This review also determined that RIVERA did not disclose important medical history information while in ICE custody. Dr.(b)(6), (b)(7)(c)states that RIVERA's death may have been preventable if RIVERA had accepted medical care from the U.S. Border Patrol or had been forthright with EPC medical staff about his HIV positive status. ICE PBNDS, Medical Care, section (II)(2), requires health care needs will be met in a timely and efficient manner. ODO verified IHSC officials at EPC failed to comply with the PBNDS Medical Care standard. OFFICIAL USE ONLY SENSITIVE OFFICIAL USE ONLY SENSITIVE DEPARTMENT OF HOMELAND SECURITY Page 10 of 11 1. CASE NUMBER 201200186 PREPARED BY (b)(6), (b)(7)(c) REPORT OF INVESTIGATION CONTINUATION HB 4200-01 (37), Special Agent Handbook 2. REPORT NUMBER 002 10. NARRATIVE On October 3, 2011, there is no documentation that RN (b)(6), (b)(7)(c) reviewed the electronic medical record and noted that RIVERA reported during intake screening that he was hospitalized in September 2011 for reported gastritis. RN (b)(6), (b)(7)(c) also failed to refer RIVERA to a higher level provider, such as a physician assistant, a medical doctor, or a nurse practitioner, after documenting that RIVERA had an elevated heart rate of 129. On October 3, 2011, and October 4, 2011, RIVERA complained on three separate occasions regarding his ailments. A period of approximately 24 hours passed between RIVERA's first complaint on October 3, 2011, until RIVERA was seen for treatment on October 4, 2011. AREAS OF CONCERN On October 1, 2011, RIVERA advised Border Patrol Agents that he had been released from the Los Angeles County Medical Center on September 29, 2011, after being diagnosed with a stomach infection. At the time of his apprehension, RIVERA was experiencing stomach pain and nausea. RIVERA refused medical attention and signed a Declination of Medical Treatment Form. The information regarding RIVERA's stomach pain and nausea was located in RIVERA's Alien Registration File; however, there is no documentation that the information was provided to EPC. On October 2, 2011, for unknown reasons, RIVERA did not provide an accurate medical history to EPC medical staff during his medical intake screening. RIVERA stated he was hospitalized in September 2011 for gastritis, but could not remember the medication he was prescribed. At the time of the intake screening, RN (b)(6), (b)(7)(c) failed to ask follow-up questions about RIVERA's hospitalization in September 2011. OFFICIAL USE ONLY SENSITIVE OFFICIAL USE ONLY SENSITIVE DEPARTMENT OF HOMELAND SECURITY Page 11 of 11 1. CASE NUMBER 201200186 PREPARED BY (b)(6), (b)(7)(c) REPORT OF INVESTIGATION Exhibit List HB 4200-01 (37), Special Agent Handbook 2. REPORT NUMBER 002 EXHIBITS 01- DHS Form I-213, Record of Deportable/Inadmissible Alien 02- DHS Form I-862, Notice to Appear 03- Los Angeles County USC Medical Center Patient Discharge Instructions 04- Border Patrol Declination of Medical Treatment Form 05- Division of Immigration Health Services, In-Processing Health Screening Form 06- IHSC Sequence of Events Form 07- Event Listing ( (b)(6), (b)(7)(c) RN) (b)(6), (b)(7)(c) 08- Event Listing PA) 09- County of El Paso Autopsy Report 10- State of Texas Death Certificate 11- Creative Corrections Medical Compliance Review 12- Creative Corrections Mortality Review by Dr.(b)(6), (b)(7)(c) OFFICIAL USE ONLY SENSITIVE (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(7)(E) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(7)(E) (b)(6), (b)(7)(c) (b)(7)e (b)(7)e (b)(6), (b)(7)(c) (b)(7)e (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(7)(E) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(7)e (b)(6), (b)(7)(c) (b)(7)e (b)(7)e (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) 4% Continuation Page for Form 1313 0.8. Depart:th of Homeless Security Date 10/01/2011 The subject's personal property was tagged with 1-77 #418333! (Personal Property reg). The subject claimed and reteined'pessessicn of his currency totaling $161.00 m. The subject and his personal property were turned over to 048 for transportation to 81 Peso Processing Center. Wm was issued by Acting rue 7? on 10/01/2011. saints was served by an Agent? on 10/01/2011. the subject res served with forms 1-826, 1-200. 1-286. (Bl Rights), Attachment and 12-613 (List of Legal Services). mum (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(7)e (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) . . ohm?a? .- . 3' Nahum! Wat-alas mm pm Myanmar-nun Alhofqndilhdw Wdl?ah??ny madam; ham Wafwm. Rheum Yunth Pauli-Buddhas: ?admin? 'o?umus?cmwaem - Bun -- Wain uncommtumvdu mu. . .I- - Dale: (Imam 08m 01- "11 mdlmofduha. hm Dunstan-mull WhammwM' f'i?Ltfi'x - - COUNTY OF L05 ANGIE LEE (7 LOS ANGELES COUNTY 1- USC MEDICAL CENTER {x 433:} DEPARTMENT OF HEALTH SERVICES FDR EL DOCTOR AL DAR DE ALTA CON TERMINOS QUE EL PACIENTE ENTIENDA. clinicas. - .Lo slgufente 35 SH plan de tratamfanto al ser dado de alta. Partavor Have esta forma cuando vaya a todas sus cttas de las lDlagn?stico: (?mm-u I 6 Ir mar Dis oslci?n: IE?Gasa stabl?cimlenla de culdado m?dlco cnnlinuu CI Hospital (aim) El Basa can visitas da eniermera. El Contra ordenanza m?dica Citas: Alargias: Mnguna ESLeantelas: Fecha dela hoSpitalIzacic'Jn A 173?; Hombre Para ser vista en dlas, semanas, meses Duclur de su Atanci?n Pdman?a JJ w- lk1.kL?' f?rrLu Tampla de paclente extrema Cuidado de Salud'en Basa I, Medicameutul.? Polencia I a? Via Inslrucciones Danudad Valuer a sum,- nspeclales ?Egan WU {?rrm Ilriil \Pifl grit. l-nl'i Ir w?rl: I LIN MMPOFOMMN commencement.) 1 ?Gnutlnuida? da pmebasz Inslrucciunas especiales: TLabnraton?n: Hayes X: 01m: de cuidadu en [3353 (provisiones. aparato, f?rrnula, equipu, etc.) .irq- Ba?o: Hest?cclunes Guidado a la hedda: Gimqu de gas-as: El Mantenga limpla sang How l'u T-1151S ORIGINAL - CHART COPY - PATTENT I MHUN fgvzan;nauno on 3969 5. - 550 B'Eg?amu? Innis: u/Pc -g%?ugft} INSTRUCCIONES AL DAR DE ALTA AL PACIENTE PATIENT DISCHARGE INSTRUCTIONS new we 11515 (5-10: couuwor LOS ANGELES - . HEALTH SEchss LOS ANGELES COUNTY :9 USC MEDICAL CENTER. gr)? I If . Dieta: - :Aclividad: Reposo en cama El gradualmente El pawl-anti} El Heshiccion?s: Levantar (namero d3 Ilhras) Doblarsa: El Regreso al trabajolesduda EI Hegreso al trabajo/escuela con las slgulentes restriccinnes No manale hasta que el cluster 53 lo permits en?su aha sigulente.-. .- No se Qf?sumng?plcp' . (.M ("Jr-1L1le (GYM- Ll Vaya a la'sala d3 emefgencia'pa'r?g; '4??.L.LL QLfqu . I I Si tlena otros problemas-o preguntas Mame: (W5). M?dlcu Internu Imprima brefI-"Irrna M?dico Residents ID I :fBGh?fHD'ra NombrelFirma Fur 5 ND M?dico Principal al dar de alta Facha/qua Salli: de la sala via: 'amlnando ?e ruedas .. Camilla: Transimrte dB Condadn 01m Fecha dado/a d3 altat? Hora dado/a de alta: 27 Perltenencligts- .. - A?lculus da?Valnrd?vualtasz- - . SE No gl/Nm :sItI?Nh . estas: grammes - .z t?a?iant?IMlEmhm de la Fammanutor legal N?mero d6 Tel?lfo-niu I Fecha?-iora M6 - II: :5 udadestado Zena Postal For media 513 lapresente antiendo recanozouhal reclbpedeur .-- - . . -.. . L.z . - I ?aw: *??u?lumang; A UFIIGINAL- CHART W1 FEB on I953 --HH . I 3 3 ?(pt INSTRUCCIONES AL ALTA AL PATIENT DISCHARGE INSTRUCTIONS PAGE 2 OF 2 1151513401 a A (P astruoclones 13 El Pacient'. sus slnlomas recurran persisten. llama a eu m?dlco regress a la sale de emergencies; 31 so vlda esta en - Adlclonalea: 7 . - Para ?ash Hala en sal. grass/coleslaw. .y la=lngaallgnide liquldosgpmo la haya {ecomendado suit Aumente su gradualrnente. oomo lo haya?re'comandadmsu m?cllco. descanse cuando sea necesa?o. . 3. No fella _a sus cites de-segulrnl?ntoP?sese dlan'amente todas las ma?an'esuaan'dd loa-apuntes do su peso alas cites de segulmlanto. Si aurnenta 2 0 mos llbraa en un dla games do 5 llbras en una semana. regress al hospital. 5. Si siente dalo?r en el nacho, aur'nenfo del '81 sue piernas dilicultad pala'resplrarf-li' Para Pacienees-Diagnoalioados oon-un Ataqua al Canaan 1. Una dicta bale en 33!. grasa/colesterol, 7y la' ingestl?nfde Ilquldos como la haya reoomandado su mam. .. Aumenla su ao?vldad gradualmente, oomo lo haya reoomendedo su medlco. descanse cuando sea levante obletos do mas de 20 libras hasta su clta de segulmlento. Si slenta dolor en el'peoho qua no dasaparaoe. lla'me al 911. -- Para Pacientas Diagnoslioados con Neumonla . 1. La dletay que la haya recomendado-su - - - 2. Si desarrolla flebra de aumento de la toe con llamas verdes. cafe oscuro roles 0 3 tlene di?cultad llama-d 9i] in?dlco regres'??alrhospltal. Sl au Win 3516 en pellgro. llama al 911. daAlla Despu?a do una?Operaolon fl. Pudlera sentir nausaa'o dp?u?ade una oparaoldn. 2. Si ?ene respirar. aangradoexce?slvo. -?ebre. ouos problemas mqulelani?s desb'u?s de?aallr del= hooplte?l?ir'e?'r'ese a la sala de efne'r?gencla's. on vlda en?pellgro. . A c: wwa? .2 _v . -. . .-3. [as pr6xlmas 24 horas. 4. Deepu?'e do ear dado de alta coneulte a su 'm?dlco ?de oabeo'er'a' sobre los medicarnentos qua tomo antes de la clrugla. -, Para oedema: qua Raquleren Aaletenoia Palquiatrloa - . . - 1. Linea do emergencia las 24 horas para al oantm 'de prevenolon'ide auloldloe: 1-877-727-4747 2. Linea da anergancla para acceso a los can'tros clel Mental: 3. Servicioa do emergencia: 911 .l 7? (A a DECLINATION OF MEDICAL TREATMENT I, - was born in I on (date). [have not been injured while in the custody of the US. Border Patrol and received my injuries prior to being arrested. 1 have been advised that medical treatment is available to me; however, I do not desire medical attention. Subject's Signature Date Witness Signature NEGATIVA DE ATENCION MEDICA Yo. Autumn que naci el Galo?l?ibe' (feeha) en Mb?il (Inger), a?rmo que no he recibido helida ninguna durante el periodo en que estuve en eustodia de la Patrulla Fronteriza que mis heridas ocurrieron antes de que me arrestaran. Yo he sido avisado que atencion m?dica me estd disponible. sin embargo. no . deseo ninguna. . Fi?'na?d'el a?rmante ?It/u Division ol?lmmigration Services sing Health Screening Form 1124239047 DETAINEE ID PLATE. COMPUTER LABEL 0R COMPLETE 1- Nam: MAURO mromo 1 1D0l3: 3.91 4. Nationality: EL summon 5. Sex: DJHS LOCANON: EL ?50 PC Today :i Date: October 2- 1511 SECTION I: ASK. THE DETAINEE: (Choc-k magma-rip:wa llm?) nuuk any cuts,orothcr marks Haw: you Soon :1 doctor in the last or distinguishing physical diorama-Times in Ila.- diapms for ?hot? below. and notify the DIHS medical oiliouril'you l'ccl tint An: you lming any pain tho detainee nut-(La any kind ot'mcdiool Lw-aluation. IFYES, whom? Ham: you bum hos tin: {135.1 f: nu was. fo?l?l3 Haw: you ever been mount for mailman wiL?I ding:- or lf?i'ES. when, whom. and for wlm'.? Do you now lam: or how: you $1.5?in any ??lm Your skin larval?; out in or t: nuhlc lirmtliing :i?ur Inking Medication! primlo?, urodrip from your primics'.? )7 Th1: whites ofyour eye: tum yellow? Fits or scinu'cs'.? - ?'liliq "Th, Putsieilmt cough than 3 weeks duration}? (coughing up blood} . . I - 3 Na! boon able to ml with a signlimnt wright loss'.? - YIN 't ?sislmt Firm?? .- "Hi? L.- raj?Ll HEN Ionian; ninth? '1 - An: you afraid you might loose yourmind or go may! i; 0' i. Hm An: you ali'aid you might hurt or kill 1m: mil" or all rors?.? It'll-mile. no: you SECTION ll: YOUR OBSERVATIONS OF THE DETAINEE Dots the detainee appear to be: Dons tho duttlinco appear to be: No] doin 7 what it)? [cl] him to Lln'.? Y3 Shaking 3' IO 2 -. 51W Noodle tmcloiif?? ?r '1 1 . cons mom} or ix Slur] limitcn out in humps. I ?bril. A chating a 10:? or Imziscs'.? YIN TU l. population 2. population with t?oi'ral mocha! can: H'imtrhumc ofir: minim! mil-gluon: 3. Reform] for immediate can: 4. laolmion until medically :iuluoiotl l'ilel [1 951 TI HS Ii! WILL Elli 51 'Nl' TH TI 3.1M mil. Al"! IT [5 I?'lil) Event Listing A Related Case 2011 10020624INT00000 Event Type Encounter Create Date 10351011 Signed l' on lD?l?Z?ll Patient Mauro Antonio at EL PASO SPC Mime Address Mauro Antonio Sex Male Nationality EL SALVADOR Classi?cation Blue ICE Status Status Dcriptlon Complete Intake Ass?sment vent Codes and Related Parties Invisible Weight 143 Temperature 36.? Scheduled Date Respiration 20 Pulse Pain Level 0 Height 63 Ecounter Type Intake Assessment Encounter Date 1 Completed When 10:02:20: 1 Blood Pressure 100 7! Invisible Assigned To DIHS System Perfumed By DIHS Event Test S:Patient was identi?ed by PicttueVerbally If detainee was transferred ?om another facilityI did a medical transfer summary accompany the detainee? WA NIA picked up by the Border patrol Time of arrival in camp: 0430 Time of screening: 22: 14 What language do you speak? Spanish How do you feel today (explain in hisz'her own words)? Bicn Are you currently having any pain? If yes, complete pain assessment below No Do you have any signi?cant medical problems? No Do you take any medication on a regular basis, including over the counter and herbal? No Do you have any allergies to medication or food? No Are you now or have you ever been treated by a doctor for a medical condition to include hospitalizations? No Sept. 2011 RN 04:01:05 PM 4?19: 1 - Report Revision VLH A. Event Listing California ?rr Gastritis Have you ever had a persistent cough for more than three weeks, coughed up blood. had a persistent fever. night sweats or unexplained weight loss? No Are you pregnant? NIA male Have you had any recent acute changes with your vision? No Are you having any signi?cant dental problems? No Have you ever tried to kill yourself? No Suicide Method Are you currently thinking about killing or harming yourself? No Do you have a history of assaulting or attacking others or have you ever been locked up for ?ghting while in jaillprison? No Do you know of someone in this facility whom you wish to attack? No Do you now or have you ever heard voices that other people don?t hear; seen things or people that other?s don't see; or felt others were trying to harm you for no logical or apparent reason? No Have you ever: received counseling, medication, hospitalization or any other form of treatment for mental health di?culties? No Have you been a victim or physical or sexual abuse? No Do you feel that you are currently in danger of being physically or sexually assaulted? No Have you ever sexually assaulted anyone? No Is there anything important for us to know about your religious or cultural beliefs that are of concern to you while in detention? No Have you ever had dif?culties learning or understanding written information? No can read and write in Spanish Have you ever been treated for drug or alcohol problems or suffered withdrawal ?'om drug use? No Do you now or have you ever used tobacco products, drank alcohol or used drugs? No 0:Patient appears to have normal physical/emotional characteristics and no barriers to communication. Yes Patient appears to have the following abnormalities none Patient appears oriented to person, place and time Yes Patient appm not oriented to Select any of the following you observe None observed HCG Results NA (male) A: Initial Health Screening? Normal P: Detainee Disposition? General Population Tuberculosis and CXR explained to detainee and process completed with appropriate shielding Access to medicalldentallmental health care, grievance process explained to patient Patient given the Medical Orientation and Health Information and Dealing with Stress Brochure in patients language Patient Verbalized understanding ofany teaching and instruction Patient was asked if he or she had any additional questions, and any questions were addressed Physical scheduled for patient Additional Comments: denies any medical condition except for Gastritis; was hospitalized in Sept 20] but not taking medications as to time of screening 2- Repclt mm.? Date Time Sequence of Events 09l29l2011 unknown Discharged from hospital in Los Angeles. Unable to decipher diagnosis. Medication ordered included ?clotrimazole cream, azithromycin, and ievaquin." Orders to ?follow up with primary care doctor." 10/01/2011 unknown Apprehended by Border patrol. Reported having been ?released? from hospital on 9129/2011 and having ?stomach pains and feeling nauseated" but refused medical attention. Above ihforrnatrbn was not available to medical personnel until 10/6/2011 10i02i2011 0610 Arrived at El Paso Processing Center 10i02/2011 2214 Intake screening completed. Reported history of hepatitis and having been hospitalized in September 2011 for "gastritis." Denied taking medication and stated he felt "bien" Cleared to General Population 10/03/2011 1136 Received call from barracks with report that detainee had medical complaints. Nurse cannot recall the speci?c complaints. He walked to the clinic and was seen as a walk-in. Complaints included ?nausea, headache and just not feeling well.? He reported being treated for "unknown abdominal infection months ago." Assessment was normal with the exception of elevated pulse of 129. He was treated with Tylenol and bismuth and, ?Kept in clinic for evaluation", and released back to GP. Reevaluation to include vitais signs was not documented. However, per registered nurse he was kept in the clinic for approximately two hours and reevaluation revealed a pulse of 98 and blood pressure remained in the 905/ 605. 10i03/11 1315 Entry in barracks security officer log, ?detainee complaining of weakness, high blood pressure." No docomentation of actions taken in the clinic of?cer log or detainee medical record. 10i04l2011 0725 Entry in barracks officer log, complained of feeling ?to weak to walk" in barracks. Entry states clinic security of?cer returned his call and per medical staff to have detainee ?ll out a "medical slip.? 10f04/2011 approx While in barracks for another reason, medical staff was informed that detainee was 0810 not feeling well. Detainee did not appear to be in acute distress. Upon returning to the clinic charge nurse was asked to have detainee br?ght to clinic and evaluated. approx Transported from barracks to the clinic via cart with complaint of, "fatigue and not 1345 being able to walk." He did not require assistance to walk. Evaluation by PA. Vitals obtained, 87/60, pulse 57, respirations 20, temp 97.3. Continued to be evaluated and was hydrated. 10l04i2011 1455 EKG obtained. 8P 92f42, pulse 111. 02 sat 91% 10104i2011 approx 02 started, IV access obtained, started on IV ?uids, EMS activated. For the time 1520 admils to history of HIV 4? 10l04[2011 1531 EMS entered facility 10i04f2011 1538 EMS departed facility 1609 Seen in ER approx Admitted to hospital. 2200 IOIQSJZOH 0435 Transferred to ICU. Reported as being stable. 10,!05f2011 1230 Hospital report. Admission diagnosis absolute hyponatremia and hypotension. 1010532011 1249 Hospital report. In ICU, stable on following medications neosynephrin I?v' drip, bactrirn 05 P0, solumedrol IV, rocephin IV, avelox and protonix. 1834 Hospital report Mr. Rivera's initially converted to V?b, at which time a code was called. Per hospital records, ?the patient required orotracheal intubation and, at the time of his intubation, the patient developed bradycardia and arrested.? 10l05{2011 1851 Pronounced dead. Expiration diagnosis, ?Acute respiratory failure, possible Pneumocystis carinii pneumonia (PCP) with metabolic acidosis and probable sepsis (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) a" Event Listing P: l. EMS was called and the pt was taken to the Del Sol ED via ambulanee for further work up and Ix. Pt was explained in Spanish what was going on and that he needed to be taken for further care and evaluation. Pt verbalized understanding. 2. men the CD was made aware of the situation. . 2. wnaumm Eff?1?17 COUNTY OF EL PASO OFFICE OF THE MEDICAL EXAMINER AND FORENSIC LABORATORY Post Mortem Report Case 11?0433 October 6, 2011 On the body of MAURO ANTONIO Cause of Death: Dissen?nated Manner of Death: Natural .- rig. 1L 3. LLAE- .. a MEDICAL AUTOPSY ll 1 1-0483 Time: 3:00 pan. October 6, 201 MAURO ANTONIO RIVERA-ROMERO (43) EXTERNAL TION The body is that of a well deveIOped, well nourished, Latin male. measuring 69 inches in height and weighing 158 pounds. He is wearing a hospital gown. The hair is brown, measuring up to inches in length. The irides are brown. The pupils are mid-dilated and equal. The conjunctiva: are injected but reveal no hemorrhages. The comeas are transparent. The nose and ears reveal nothing remarkable. The teeth are in good repair. The neck presents no masses or marks. The chest is symmetrical. The abdomen is prominent. The extremities reveal no gross deformities or edema. The external genitalia, perineum. anus and back reveal nothing remarkable. Rigor mortis is present throughout. Lividity is present on the posterior aspect of the body. AND Three round well healed burn scars lateral aspect of the left leg with the largest measuring about V4 of an inch in length. EF JURY: None. Endotracheal tube in place in the mouth. IV line in place dorsal aspect of right wrist. IV line in place le? antecubital fossa. IV line in place ?exor surface of left forearm. Three lumen catheter medial aspect of right arm. ME 1 1-0483 (43) PAGE 2 The body is opened in by the usual shaped incision. Each pleural cavity contains about 100cc of clear ?uid. Small amount of ?uid is also present in the peritoneal cavities. No ?uid is identi?ed in the pericardial sac. All the serosal surfaces are smooth and glistening. There is no evidence of injury to the neck. thorax or abdomen. The hyoid bone is intact. The HEART weighs 360 grams. The epicarditun is smooth and glistening. The heart is opened in the direction of the blood ?ow. The measurements of the valves rings circumferences are as follows: pulmonary is 6.5 centimeters; tricuspid is 12.0 centimeters; mitral is l0.0 centimeters and aortic is 7.0 centimeters. The pulmonary mitral and aortic valves reveal nothing remarkable. The tricuspid lea?ets are thickened. redundant and corrugated. All of the chambers have the usual con?guration. The atrial and ventricular septa are intact. The le? ventricular wall measures 1.4 centimeters in thickness at the level of the out?ow tract. The right ventricular wall measures 0.3 centimeters below the pulmonary conus. The ventricular septum measures 1.0 centimeters below the aortic valve. The papillary muscles and trabeculae carneae reveal nothing remarkable. The chordae tendineae are thin and delicate. The myocardium has a reddish-brown color. ME [-0483 RIVERA-ROMERO (43) PAGE 3 No necrosis or ?brosis noted The coronary ostia are widely patent. The coronary arteries reveal minimal atherosclerosis and are free of thrombi and ernboli. The venous system is of normal appearance. The aorta and large vessels arising from it reveal minimal atherosclerosis. Nothing remarkable is seen in the large abdominal, thoracic or neck veins. SYSTEM: The right LUNG weighs l.040 grams and the le? 1.090 grams. The pleural surfaces are red-purple and are smooth and glistening. The cut surfaces exude a large amount of pinkish, frothy ?uid and have a cameous appearance. No contusions, nodularities or noted. The TRACT-TEA, and LARYNX contain a small amount of clear ?uid. The tracheobronehial mucosa is pink. The larynx reveals no injury. The pulmonary arteries and veins contain no emboli or thrombi. The TONGUE, PHARYNX and ESOPHAGUS reveal nothing remarkable. The is empty. The gastric mucosa reveals a small scattered hemo 'c area. No ulcerations or erosions noted. The SMALL BOWEL contains a few small pockets of partially digested blood. The LARGE BOWEL contains a moderate of soft feces. HEPATO-B LLIARY SYSTEM- The LIVER weighs 2,490 grams. The capsular surface is translucent revealing a reddish-1 brown There is no evidence of cirrhosis or fatty metamorphosis. ME 11-0483 RIVERA-ROMERO (43) PAGE 4 The contains a yellowish-green granular calculus, measuring about 1.5 1.2 it l.2 centimeters. The extral'tepatic biliary ducts reveal nothing remarkable. PAN The PANCREAS has a pinkish. lobulated appearance with no evidence of necrosis, contusion, hemorrhage or GE YSTE The right KIDNEY weighs 140 grams and the left ISO grams. The capsules strip with ease revealing smooth surfaces. The cut surfaces reveal the cortices and medullae to be of normal appearance. The CALYCES. PELVES. URETERS and URINARY BLADDER reveal nothing remarkable. The latter contains about 100cc of urine. The prostate is of normal size. The testicl are in the scrotum and appear normal. EN CRINE SYST M: The THYROID is of normal size and con?guration. The ADRENALS reveal nothing remarkable. POI STE The SPLEEN weighs 680 grams. The is very soft. The cut surfaces reveal scattered ill de?ned grayish nodules, the largest measuring 1 centimeter in diameter. The bone marrow is of normal appearance. LMTIC SYSTEM: All the nodes are of normal size and con?guration. ME 11-0483 RIVERA-ROMERO (43) PAGE 5 All the muscles are well developed. There are no skeletal injuries or diseases identi?ed. EERVOUS SYSTEM: The scalp is reflected and the skull is opened in the usual manner. There is no evidence of injury to the scalp. The BRAIN weighs 1,320 grams. The dura, sinuses and leptomeninges reveal nothing remarkable. There is no evidence of increased intracranial pressure. The vessels of the Circle of Willis reveal no discernable atherosclerosis. They contain no ernboli or thrombi. The cranial nerves are intact. Multiple coronal sections of the cerebral hemispheres, mid-brain, cerebellum and medulla oblongata reveal no evidence ofcontusion, hemorrhage or infarction. The ventricular system is of normal size. The spinal ?uid is clear. The choroid plexus has a normal con?guration. The pituitary gland appears normal. No fractures or dislocations of the cranial bones or the cervical spine can be identi?ed. MLCROSQOPIC EXAMINATION Lungs and spleen: sections reveal innumerable neoforrnans organisms. Many of them with gelatinous capsules. Minimal in?ammatory reaction noted. Brain, heart, pancreas. stomach, thyroid, prostate. adrenals, kidneys and bone marrow reveal nothing remarkable. ME 11-0483 RIVERA-ROMERO (43) PAGE 6 EEDINGS I. Disseminated 2. Tric'uspid valve ptolapse 3. Cholelidiiasis ON It is the opinion ofdiis examiner am this man died from disseminated crypiocoecosisl This condition is more commonly seen in imam-suppressed individuals. The manner of dead: is natural. . (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) A Detainee Death Review Mauro Antonio El Paso Service Processing Center, El Paso, TX Section 1: Medical Compliance Review As requested by the ICE Of?ce of Professional Responsibility, Of?ce of Detention Oversight, Creative Corrections (CC) participated in a review of the death of detainee Mauro Antonio at the - Services Processing Center (EPSPC). CC accompanied Special Agen on a site visit during the week of November 28, 2011, and participated in interviews of correctional and medical sta?'. Additionally, CC reviewed the medical record of detainee RIVERA and relevant policies and procedures. The following chronicles detainee period of detention based on documented and reported information. observations and ?ndings with respect to compliance with the ICE Performance Based National Detention Standards governing medical services appear in commentary. Medical terminology is de?ned in parentheses and brackets. Background According to information provided to CC by ODO, detainee RIVERA was taken into custody on October 1, 201 1 by Customs and Border Protection (CBP) o?cers. He reported having been released ?oor a hOSpital on September 29, 2011 and ?having stomach pains and feeling nauseated.? He refused medical attention. October 2, 2011 6:10 am Per ICE, detainee arrived at EPSPC. 6:24 am Per Chronological Record of Medical Care note and entry to the electronic medical record intake medical screening was completed by Registered Nurse (RN) 0n the Immigration Health Services Corp (IHSC) ln-Processing Health Screening Form she documented temperature as 36.7, pulse 106 (normal heart rate is between 60-100 beats per minute), respirations 20, blood pressure 100/71 (normal blood pressure is 120/80), weight 148, and pain at zero on a one to ten pain scale, with ten being highest. In addition, she circled ?Yes? to the question: ?The whites of your eyes or your nails turn ellow?? noting Hepatitis C. ?See was stamped on all other r: was eeling ?Bien? and noting ?denies any medical condition except for Gastritis; was hospitalized in Sept 2011 but not taking medications as to time of screening.? Negative responses were documented to all screening questions. Detainee was approved for general population housing. gag DETAINEE DEATH REVIEW: Mauro Antonio Page 1 Section 1 - Medical Compliance Rewew Creative Corrections. LLC es A COMMENT: Though not documented in the medical record, ICE personnel informed CC intake and subsequent medical encounters were completed in Spanish. COMMENT: The recorded temperature of 36.7 is presumably an error. COMMENT: Detainee RAMIREZ reported he was hospitalized in September 2011, the month ending the day before his admission to EPSPC. There is no documentation RN asked any follow up questions, including more speci?c information on the dates, hospital name, and medications. As learned after his death, he had been discharged from the Los Angeles County Hospital just two days earlier with medications frequently prescribed for patients who could be HIV positive or who might have respiratory involvement secondary to being immune-suppressed. The purpose of the intake screening is to identify any medical conditions requiring immediate medical evaluation and/or urgent treatments. If detainees are not forthcoming with complete information, it is incumbent upon the screener to ask follow up questions as may be necessary or appropriate. Medical Consent Form signed.? Radiology report documents chest x-ray negative for tuberculosis. 7:00 am Per Chronological Record of Medical Care, viewed intake screening, concurring with ?ndings and noting ?routine appointment? for 14-day physical. October 3, 201 11:36 am According to information provided by ICE and reviewed during interviews, the barracks o?cer called it it tau- 1 the detainee had medical concerns. EMR Urgent Care entry by ocuments, ?Detainee seen as walk in with complaints of nausea, headache, and just not feeling States was treated for unknown abdominal infection months ago.? RN \bxs), ~>evaiuated the patient and doctunented the assessment as normal except for an elevated heart rate of 129 (normal heart rate is between 60-100 beats per minute). Assessment: Alteration in comfort; Plan, ?Detainee pulse elevated at 129. Kept in clinic for evaluation and hydrated detainee in clinic.? Detainee given with Bismuth (for upset stomach/nausea/t'ndt'gestion) and Tylenol. Per information provided by ICE and reviewed during interviews, detainee RIVERA was observed for approximately two hours and re-evaluated. His heart rate was found to be 98 (normal) with a blood pressure in the 905/605 (low). DEATH REVIEW: Mauro Antonio Page 2 Section 1 - Medical Compliance Review Creative Corrections. LLC COMMENT: Re-evaluation of the detainee was not documented in the medical record, including vital signs and decision to return him to general population. CONIMENT: There is no documentation RN the EMR and noted detainee RIVERA reported at intake he was hospitalized in September 2011, reportedly for gastritis. Given the detainee?s complaint of nausea, this information was particularly relevant and may have led to an alternative course of action, including pen-suit of hospital records. Regardless, according to the El Paso Processing Center health services clinic guidelines, the RN should have referred the detainee to a higher level provider, (nurse practitioner, physician assistant, and/or medical doctor) due to the marked elevation of his heart rate. The need to refer detainee RIVERA to a provider was heightened by the fact the blood pressure reading in the 903/603 was lower than that taken at intake: 100/71. CC cites de?ciency in ICE Medical Care, section (10(2) requiring that health care needs be met in a timely manner. 1:15 pm An entry in the barracks security o?icer log documented, ?detainee complaining of weakness, high blood pressure.? COMMENT: There is no documentation medical was informed of the detainee?s complaint, and during interview, medical staff indicated they do not recall being noti?ed. October 4, 2011 7:25 am An entry in the barracks security o?cer log documented, the detainee complained of being too weak to walk. The entry re?ected this complaint was conveyed to the security o?cer in the medical clinic, who returned his call stating medical staffs instructions were to have the detainee ?ll out a medical slip. COMMENT: This contact is not documented in the medical record. Given the nature of the complaint, medical personnel should have reviewed his record and had him brought to the clinic. 8:10 am According to information provided by ICE and reviewed during interviews, while in the detainee?s housing unit for another reason, medical staff was informed detainee RIVERA was not feeling well. The staff person indicated the detainee did not appear to be in any acute distress. Upon the return to the clinic, the clinic charge nurse requested detainee be transported to the clinic for medical evaluation. DEATH REVIEW: Mauro Antonio Page 3 Section 1 Medical Compliance Review Creative Corrections. LLC (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) (b)(6), (b)(7)(c) examination revealed decreased bowel sounds, though the abdominal wall was not rigid and skin was cool to touch. Oxygen and IV ?uids started. Assessment: Rule out bleeding gastric ulcer versus possible early AIDS. Plan: was called and the [patient] was taken to the Del Sol [Emergency Department] via ambulance for further work up and [treaunent].? comm: The encounter with PA was the ?rst in which detainee RIVERA provided his medical history, including diagnosis of HIV in l996 and more detailed information on his hospitalization the week prior to his detention. 3:32 pm According to information provided by ICE, EMS entered the facility and departed at 3:38 pm. 4:09 pm Detainee RAMIREZ was seen in the Emergency Department. 10:00 pm (approximate) October 5, 201 1 4:35 am Detainee RAMIREZ transferred to the Intensive Care Unit. 12:23 pm . Per hospital report, admission diagnosis absolute hyponatremia 12:49 pm Per hospital report, detainee RAMIREZ in ICU and stable on medications. 6:34 pm Per hospital report, code called. ?The patient required orotracheal intubation and, at the time of his intubation, the patient developed bradycardia and arrested.? 6:51 Detainee RAMIREZ was pronounced dead. Expiration diagnosis, ?Acute respiratory failure, possible Pneumocystis carinii pneumonia (PCP) with metabolic acidosis and probable sepsis in a patient with noncompliance with treatment of acquired immunode?ciency October 6, 2011 Medical obtained detainee discharge instructions from Los Angeles County and USC Medical Center for his hospitalintion September 23 - 29, 201 l. The DEPAINEE DEATH REVIEW: Mauro Antonio Page 5 Section 1 Medical Compliance Review Creative Corrections. LLC (A a instructions re?ected the detainee was to follow up with his primary provider and was prescribed Clotrimazole cream, Axithromycin, Bactrim, and Levaquin (medications frequently prescribed for patients who could be HIV positive or who might have respiratory involvement secondary to being immuno-suppressed). MEDICAL COMPLIANCE REVIEW CONCLUSIONS The ICE Medical Care, requires that detainees have access to emergent, urgent, or non-emergent medical, dental, and mental health care that are within the scope of services provided by II-ISC so that their health care needs are met in a timely and ef?cient manner. As discussed in the above timeline, CC cites the de?ciency in the following component: 0 Section requiring that detainees? healthcare needs be met in a timely and e?cient manner. 0 The documentation suggests the RN who evaluated detainee RIVERA for his ?rst complaint of nausea failed to review relevant information in his medical record, failed to refer him to a higher level provider, and failed to properly document the encounter disposition. Detainee RIVERA was not provided with medical care over a 24-hour period in which he complained he was feeling increasingly worse and weak. It is noted when ?nally brought to the clinic, he could not ambulate on his own and within two hours, was sent to the emergency room. In addition, though not a technical de?ciency, CC cites as an area of concern failure to perform adequate intake screening. The screener did not ask pertinent follow up questions when the detainee reported he had been hospitalized the previous month, missing an opportunity to obtain more accurate medical history critical to his care. DETAINEE DEATH REVIEW: Mauro Antonio Page 6 Section 1 Medical Compliance Review Creative Corrections, LLC Detainee Death Review Mauro Antonio El Paso Service Processing Center, El Paso, TX Section 2: Mortality Review This mortality review is based on a review of medical records from the El Paso Service Process Center (EPSPC), Del Sol Medical Center, and Los Angeles County and USC Medical Center. Autopsy Findings The autopsy report performed on October 6, 2011 revealed RIVERA was a forty-three year old Hispanic male who died ?'om disseminated This condition is most commonly seen in immuno-suppressed individuals. Detainee had a history of Auto Immune De?ciency disease, (AIDS). The pathology report revealed tricuspid valve prolapse as well as cholelithiasis. Narrative Summary September 29, 2011: According to Los Angeles County Hospital and the University of Southern California Medical Center, Rivera-Romero was discharged on Clonimazole cream, azithromycin, Bacu'im, and Levaquin, medications frequently prescribed for patients who could be HIV positive or who might have respiratory involvement secondary to being immuno- suppressed. Orders on the discharge instructions indicated to the Rivera-Romero to ?follow up with primary care doctor.? As indicated below, (EPSPC) came into possession of this documentation and was unaware of detainee hospitalization until October 6, 2011, after his death. October 1, 2011: According to ICE, detainee RIVERA was apprehended by the Border Patrol. Their records indicate detainee reported ?stomach pains and feeling nauseated? but refused medical attention. October 2, 2011, 6:10 am: Detainee arrived at EPSPC. Intake medical screening was completed by the RN during which detainee indicated that he had a history of ?Hepatitis and was hospitalized in September of 2011 for ?gastritis?. There is no documentation the screener attempted to gain additional information concerning the details of his hospitalization, including dates, location, and medications. Detainee informed the screener he was feeling ?Bien? Detainee was released to the general population following completion of the medical screening. October 3, 2011, 11:36 am: Detainee RIVERA complained to the barrack o?cer he had medical concerns. He ambulated to the health clinic informing the nurse of nausea, headache, and ?just not feeling well.? He reported to the nurse he was treated for ?unknown abdominal infections months ago.? "The nurse evaluated the patient and documented the assessment as normal except for an elevated heart rate of 129. Detainee was treated with Bismuth and Tylenol DEATH REVIEW: Mauro Antonio Page 1 Section 2 - Mortality Review Creative Corrections LLC A. for upset stomach and pain. was observed for two hours in the clinic released to the general population after he presented with normal vital signs except for low blood pressure, though this disposition is not documented in the medical record. The detainee was not referred to a higher level provider as required by facility protocols. October 3, 2011, 1:15 pm: Detainee RIVERA returned to his barrack and complained to the barrack of?cer of having ?weakness and high blood pressure.? There is no documentation indicating medical was informed of and evaluated these complaints. October 4, 2011, 7:25 am: Detainee RIVERA stated to the barrack of?cer ?he was too weak to walk? in the barrack. This complaint was conveyed to the security of?cer located in the medical clinic with instructions given by medical personnel to have Rivera-Romero ??ll out a medical slip.? October 4, 2011, 8:10 am: Detainee RIVERA informed a medical provider present on the housing unit he ?was not feeling well,? and the medical provider noted detainee ?did not appear to be in any acute distress.? Upon the provider?s return to the clinic, the clinic charge nurse requested detainee be transported to the clinic for medical evaluation. October 4, 2011, 1:45 pm: Detainee RIVERA was transported to the clinic via a cart with complaint of ?fatigue and not being able to walk.? He was evaluated by and RN and referred to the Physician Assistant (PA). The evaluation performed by the PA revealed the detainee had the a unstable vital sigis and an abnormal EKG. Subsequently, EMS was activated and the patient was transported to the local community hospital via ground ambulance for further evaluation and u-eannent. October 5, 2011, 4:35 am: According to local community hospital records, patient was transferred to ICU and his condition was reported as stable. October 5, 2011, 6:34 pm: According to local community hospital records, detainee heart became irregular and fast, and a code (cardiac arrest) was called. Detainee RIVERA expired at 6:51 pm. Findings and Conclusion: 1. Initial Assessment of Patient Intake screening did not serve the critical purpose of determining detainee medical history and needs. For unknown reasons, detainee RIVERA did not provide a full and complete medical history when asked about his past medical history. However, by reporting he was hospitalized the month before, he opened the door for pin-suit of additional information. The screener failed to ask follow up questions that could have led to the uncovering of detainee?s true medical history and initiation of proper treatment protocols. The screener should emphasize to detainees prior to performing the intake oammss DEATH REVIEW: Mauro Antonio Page 2 Section 2 Mortality Review Creative Corrections LLC A: screening the importance of answering questions as thoroughly and honestly as possible because it may have a signi?cant impact on their medical treatment and care. 2. Failure to Follow Policy Guidelines The RN who evaluated detainee RIVERA upon his ?rst complaint of feeling poorly failed to follow facility protocol and refer him to a higher level provider; i.e. nurse practitioner, physician assistant (PA), or medical doctor due to the marked elevation of his heart rate. This abnormal heart rate can re?ect various medical conditions which could require immediate medical intervention. An individual with an elevated heart rate should have a thorough, physical exam and various other tests performed such as EKG and labs, to identify the medical conditions which could lead to having an abnormal heart rate. All medical providers should work within clinical practice guidelines as established by the Clinical Medical Authority. It is imperative to consult with the MD andlor CD in a timely manner if a detainee appears to be medically unstable. 3. Timeliness of Medical Care Detainee RIVERA did not receive medical attention over a 24-hour period despite voicing complaints of feeling progressively worse to the barrack omcer. It is imperative the barrack o?icer notify a medical provider in a timely manner of detainees? medical complaints, and that medical sta?? take necessary and appropriate action to determine if meat is necessary. Conclusion I conctu' with the medical examiner?s cause of death. This death may have possibly been preventable if Mauro Antonio Rivera-Romero had accepted medical care from the border patrol and had been forthright with El Paso Service Processing Center medical sta?? about being HIV positive. assessments and treatments for this condition could then have been considered. Also, medical staff should have completed a more thorough intake assessment to obtain additional information ?'om the detainee. Policies andlor guidelines should have been followed for providing a higher level of care. A physician should have examined the patient in a timely manner. Had these actions been taken, laboratory tests and physical examinations would likely have prompted the provider to seek outside consultation andlor transferred the detainee to the local community hospital for further evaluation and treatment. Review was performed on site at the El Paso Service Processing Center, December 6, 2011 to December'l, 2011 by Dr. DETAINEE DEATH REVIEW: Mauro Annonlo Page 3 Section 2 - Mortality Review . Creative Corrections LLC