DETAINEE DEATH REVIEW – Sergio Alonso LOPEZ JICMS #201706199 SYNOPSIS On April 13, 2017, Sergio Alonso LOPEZ, a fifty-five year old citizen of Mexico died while in the custody of U.S. Immigration and Customs Enforcement (ICE) at the Victor Valley Global Medical Center (VVGMC), in Victorville, California (CA). The State of California Certificate of Death for LOPEZ, issued June 1, 2017, documented his cause of death as an upper gastrointestinal bleed from esophageal varices, 1 cirrhosis 2 of the liver, and heroin and alcohol abuse. LOPEZ was detained at Adelanto Detention Facility (ADF), in Adelanto, CA, from February 9, 2017, until his death. ADF is privately owned and operated by the GEO Group, Inc. (GEO) under an Intergovernmental Service Agreement (IGSA), which requires the facility to comply with the ICE Performance Based National Detention Standards (PBNDS) 2011. Medical care at ADF is provided by Correct Care Solutions (CCS). At the time of LOPEZ’s death, ADF housed approximately 1,691 detainees of all classification levels for periods in excess of 72 hours. DETAILS OF REVIEW From May 16 to 18, 2017, ICE Office of Professional Responsibility, External Reviews and Analysis Unit (ERAU) staff visited ADF to review the circumstances surrounding LOPEZ’s death. ERAU was assisted in its review by contract subject matter experts (SME) in correctional healthcare and security. 3 ERAU’s contract SMEs are employed by Creative Corrections, a national management and consulting firm. As part of its review, ERAU examined immigration, medical, and detention records pertaining to LOPEZ, in addition to conducting in-person interviews of individuals employed by GEO, CCS, and the local field office of ICE’s Enforcement and Removal Operations (ERO). During the review, the ERAU review team took note of any deficiencies observed in the detention standards as they relate to the care and custody of the deceased detainee and documented those deficiencies herein for informational purposes only. Their inclusion in this report should not be construed in any way as indicating the deficiencies identified contributed to the detainee’s death. ERAU determined the following timeline of events, from the time of LOPEZ’s apprehension by ICE, through his detention at ADF, and eventual death at VVGMC. IMMIGRATION AND CRIMINAL HISTORY 4 In 1963, LOPEZ was admitted as a child to the United States (U.S.) through San Ysidro, CA, as a Lawful Permanent Resident (LPR). Varices are abnormal blood vessels, in this case, in the esophagus. Cirrhosis is chronic liver damage from a variety of causes, to include alcohol and drug abuse, leading to scarring and liver failure. The most efficient means of transmission include intravenous drug use and blood transfusions. 3 See Exhibit 1: Creative Corrections Medical and Security Compliance Analysis. 4 See Detainee Death Notice. 1 2 1 DETAINEE DEATH REVIEW Sergio Alonso LOPEZ IC MS #201706199 Between December 8, 1981 and March 4, 1994, LOPEZ was charged and sentenced by the Superior Court of California for the County of Los Angeles for the 14 criminal offenses outlined in the table below. Offense Conviction Date Sentence Possession of a weapon to December 8, 1981 44 days in jail assault Assault with a deadly December 10, 1982 44 days in jail weapon Receiving stolen property October 3, 1983 150 days in jail Second degree burglary December 12, 1983 365 days in jail Using a controlled August 27, 1984 215 days in jail substance Petty theft April 8, 1985 One day in jail Vehicle theft ere 25, 1985 16 months in state prison Theft of personal property March 24, 1987 Three days in jail Bru?glaiy March 24, 1987 180 days in jail Possession of a controlled August 29, 1988 Two years in state prison substance Use of a controlled August 29, 1990 365 days in jail substance Possession of a hypodermic October 11, 1990 150 days in jail needle Spousal abuse April 8, 1993 180 days jail Tampering with a vehicle March 4, 1994 180 days jail On August 15, 1994, the legacy Irmnigration and Natiu?alization Service (INS) served LOPEZ an Order to Show Cause and Notice of Hearing, Form I-221, pursuant to Section of the Immigration and Nationality Act (INA), for a controlled substance conviction. On October 5, 1994, an inmrigration judge (U) in Los Angeles, CA, ordered LOPEZ deported to Mexico. LOPEZ waived his appeal, and on October 6, 1994, the INS deported LOPEZ to Mexico at San Ysidro, CA. LOPEZ reentered the US. on an unknown date at an unknown location without admission, inspection or parole by an immigration of?cer. On October 22, 1997, the Superior Court of Los Angeles for the County of Los Angles convicted LOPEZ for bru?glary and sentenced him to two years in state prison. On December 10, 1997, INS personnel encormtered and served LOPEZ with a Notice of Intent/Decision to Reinstate Prior Order, Form I-871, and on February 17, 1998, the INS removed LOPEZ to Mexico. LOPEZ again reentered the US. on an unknown date and at an unknown location without admission, inspection or parole by an immigration of?cer. On March 3, 1999, the United States District orut for Eastern District of California convicted LOPEZ of Illegal Reentry in violation of Title 8, United States Code, Section 1326(a) and sentenced him to 2 years in prison. DETAINEE DEATH REVIEW – Sergio Alonso LOPEZ JICMS #201706199 On December 5, 2000, INS encountered LOPEZ at the Elkton Federal Correctional Institution, Lisbon, Ohio, and served him with an Immigration Detainer – Notice of Action, Form I-247. On January 3, 2001, INS reinstated LOPEZ’s prior deportation order, and on January 10, 2001, INS removed LOPEZ to Mexico. On January 12, 2001, LOPEZ reentered the U.S. near Laredo, TX, without admission, inspection or parole by an immigration officer. On December 11, 2015, the Superior Court of California for the County of Los Angeles convicted LOPEZ for the offense of driving under the influence of alcohol and possession of a controlled substance and sentenced him to 3 days in jail. On February 7, 2017, an ERO Los Angeles fugitive operations team arrested LOPEZ at his residence in Whittier, CA and served him with a Notice to Appear (NTA), Form I-862, pursuant to Section 212(a)(6)(A)(i) of the Immigration and Nationality Act (INA), as an alien present without admission or parole. ERO temporarily placed LOPEZ at the Los Angeles Staging Facility (LASF) pending his transfer to ADF on February 9, 2017. While at the LASF, ERO transported LOPEZ to the White Memorial Hospital that same day, to rule out active pulmonary tuberculosis (TB). 5 The hospital cleared him of active TB on February 9, 2017 but diagnosed him with heroin abuse, psoriasis, 6 hypertension, 7 and cirrhosis of the liver. A hospital physician prescribed LOPEZ Amlodipine 10 mg and Atenolol 100 mg daily for blood pressure control, methadone 70 ml daily heroin withdrawal, 8 and topical triamcinolone, a medication used to treat a variety of skin conditions, twice daily for psoriasis. 9 NARRATIVE On February 9, 2017, at 11:25 p.m., LOPEZ arrived at ADF. Security staff appropriately classified him as a level three detainee based on his criminal history and gang membership, and assigned him to a general population housing unit accordingly. 10 On February 10, 2017, at 12:20 a.m., LOPEZ received a medical intake screening by (b) (6), (b) (7)(C) noted that LOPEZ arrived with medical Registered Nurse (RN) (b) (6), (b) (7)(C) . 11 RN documentation from the ICE Los Angeles Staging Facility (LASF) and from the White Memorial Hospital. She noted LOPEZ arrived with several of the prescribed medications, 12 including methadone, which she placed in a secure narcotics cabinet and logged on a Drug Enforcement Administration (DEA) Controlled Substances Patient Specific Flow Sheet. Creative Corrections (b) (6), (b) (7)(C) notes RN logged the number of bottles rather than the total measurement of methadone, Health Services Administrator (HSA) (b) (6), (b) (7)(C) stated that LOPEZ tested positive for TB after his apprehension by ICE which resulted in the LASF transferring him to White Memorial Hospital where hospital staff ultimately determined he did not have active TB. 6 Psoriasis is a skin condition in which skin cells build up and form scales and itchy, dry patches. 7 Hypertension refers to high blood pressure. 8 Methadone is a narcotic which treats opiate addiction and/or treatment of moderate to severe pain. 9 See White Memorial Discharge Plan by Dr. (b) (6), (b) (7)(C) , dated February 9, 2017. 10 See ICE Custody Classification Worksheet, dated February 9, 2017. (b) (6), (b) (7)(C) 11 See Exhibit 2: CCS Receiving Screening by RN dated February 9, 2017. 12 Amlodipine 10 mg, Atenolol 100 mg, and six bottles of liquid Methadone. 5 3 DETAINEE DEATH REVIEW – Sergio Alonso LOPEZ JICMS #201706199 and that proper accountability for narcotics requires entry of the amount of methadone in the bottles, by milliliter. 13 During the intake screening, LOPEZ stated that his primary language was English and reported he had a history of hepatitis C.14 His vital signs were within normal range 15 with the exception of a significantly elevated blood pressure of 194/87. LOPEZ reported taking methadone for (b) (6), (b) (7)(C) more than 17 years for heroin withdrawal but denied symptoms of drug withdrawal. RN noted she observed LOPEZ had hand tremors and fidgeted during the intake screening, and she determined he was likely in withdrawal. 16 Although the intake screening form guided RN (b) (6), (b) (7)(C) to immediately notify a provider and initiate an alcohol withdrawal assessment based on (b) (6), (b) (7)(C) the withdrawal symptoms, she did not initiate the assessment. 17 RN stated LOPEZ was the first detainee on methadone she encountered and that ADF did not provide nurses training specific to opioid withdrawal. As a result of the chronic conditions identified during his intake screening, RN referred LOPEZ for an expedited physical examination by a provider and directed security staff to assign him to the medical housing unit pending provider assessment. 18 LOPEZ signed an authorization and consent for medical examination and treatment and co-signed his intake screening form. 19 (b) (6), (b) (7)(C) At approximately 10:00a.m., 20 LOPEZ received an initial physical examination by Clinical (b) (6), (b) (7)(C) Director Dr. (b) (6), (b) (7)(C) , MD. Dr. stated that the transfer summary and records from White Memorial Hospital were not provided to him to review in advance of the physical (b) (6), (b) (7)(C) documented the following: 22 examination. 21 Dr. • LOPEZ reported a history of hypertension, long term use of methadone for heroin (b) (6), (b) (7)(C) addiction, and a pain level of nine on a scale of zero to ten. 23 Dr. did not See Exhibit 3: DEA Patient Specific Controlled Substance Flow Sheet, February 10 and 11, 2017. ERAU notes the methadone was incorrectly logged on both dates. 14 Hepatitis C is a disease characterized by liver inflammation, often caused by a virus or substance abuse. 15 Normal temperature is 98.6; normal range for pule is 60 to 100 beats per minute; normal range for respirations is 12 to 20 breaths per minute; and, normal blood pressure is 120/80, with 90/60 to 139/89 considered within normal range. (b) (6), (b) (7)(C) 16 ERAU Interview with RN dated May 18, 2017. (b) (6), (b) (7)(C) 17 See CCS Receiving Screening by RN dated February 9, 2017. (b) (6), (b) (7)(C) 18 ERAU Interview with Dr. dated May 16, 2017. 19 See CCS Patient Authorization and Consent to Medical Examination and/or Treatment, dated February 9, 2017. By signing the screening form, LOPEZ was affirming it contained correct information and that he understood how to access medical, dental, and mental health services. (b) (6), (b) (7)(C) 20 Although the electronic form indicates the physical examination was completed at 4:22 p m., both HSA (b) (6), (b) (7)(C) and Dr. confirmed it took place before 10:00 a m. but was signed, and thus time stamped, later in the day. (b) (6), (b) (7)(C) 21 ERAU Interview with Dr. (b) (6), (b) (7)(C) dated May 16, 2017. During the interview, HSA stated that RN (b) (6), (b) (7)(C) provided the transfer documents to medical records staff to be scanned into LOPEZ’s electronic medical (b) (6), (b) (7)(C) record, but they were not scanned in prior to Dr. (b) (6), (b) (7)(C) examination. As a result, Dr. did not see the (b) (6), (b) (7)(C) transfer summary prior to LOPEZ’s death. HSA stated that following LOPEZ’s death, he implemented procedures requiring that copies of transfer summaries, and any additional medical records arriving with detainees, remain in their admission packets which the provider receives, to ensure continuity of care. 22 See Exhibit 4: CCS Medical Progress Note by Dr. (b) (6), (b) (7)(C) Physical Examination, dated February 10, 2017. 23 A zero to ten pain scale measures a patient’s reported pain intensity, with zero indicating no pain, and ten being the worst pain ever experienced. 13 4 DETAINEE DEATH REVIEW – Sergio Alonso LOPEZ JICMS #201706199 • • • • • document any specific information regarding LOPEZ’s reported pain and stated during interview that the detainee did not want to discuss it. LOPEZ indicated that he was taking 120 mg of methadone daily provided at a methadone clinic, but the dose was lowered to 70 mg daily during his recent stay at White Memorial Hospital. LOPEZ stated that while at the hospital, a physician informed him he potentially had cirrhosis. LOPEZ denied a history of hepatitis 24 but acknowledged a history of primary hypertension. 25 LOPEZ indicated that he possibly had a seizure in January of 2017. LOPEZ’s vital signs were normal with the exception of an elevated blood pressure of 156/80. Dr. diagnosed LOPEZ with hypertension, psoriasis, and opioid dependence with withdrawal and ordered the following medications: (b) (6), (b) (7)(C) • • • A topical corticosteroid 26 twice daily for psoriasis; Blood pressure medication, metoprolol 25 mg, twice daily for hypertension; 27 and, A 12-day tapering prescription of liquid methadone, starting at 70 mg and decreasing by five to ten mg daily until discontinued on February 21, 2017. 28 Throughout LOPEZ’s detention period, medical staff gave him all medications as prescribed, with two exceptions: • A nurse gave LOPEZ his first dose of methadone on February 10, 2017, and per the order, he received his last dose on February 21, 2017. However, his medical record contains no documentation that he received the scheduled dose of 60 mg (30 ml) on February 11, 2017. 29 After this date, nurses made entries to both his MAR and Patient Specific Flow Sheet documenting that methadone was given. • Although Dr. ordered administration of metoprolol twice daily starting February 10, 2107, LOPEZ did not receive his first dose of metoprolol until the evening of February 11, 2017. (b) (6), (b) (7)(C) Dr. also ordered laboratory studies for February 15, 2017, ordered a follow-up appointment in two weeks, cleared LOPEZ for general population, and provided him with a (b) (6), (b) (7)(C) ERAU notes this contradicts information he reported to RN during his intake screening. Primary hypertension occurs when an elevated blood pressure does not have a known cause, such as the result of another identified medical condition (e.g. diabetes, chronic pain, cardiovascular disease, etc.). 26 Corticosteroid ointments are used to relieve skin inflammation, itching, dryness, and redness. 27 ERAU notes this medication is not the same hypertension medication prescribed by White Memorial Hospital. (b) (6), (b) (7)(C) During his interview, Dr. stated he would have continued the medication prescribed at the hospital if he had seen LOPEZ’s transfer summary. 28 See CCS Medical Progress Note by Dr. (b) (6), (b) (7)(C) dated February 10, 2017. 29 See CCS Medication Administration Record (MAR), dated February 11, 2017. 24 (b) (6), (b) (7)(C) 25 5 DETAINEE DEATH REVIEW – Sergio Alonso LOPEZ JICMS #201706199 special needs form for assignment to a lower bunk on a lower tier. 30 Laboratory tests 31 ordered (b) (6), (b) (7)(C) by Dr. included a Complete Blood Count (CBC) with differential 32 and platelet count, 33 complete metabolic panel, 34 hepatitis panels, 35 ammonia level, 36 and plasma levels. 37 According to HSA ADF and CCS follows the Federal Bureau of Prisons Clinical Practice Guidelines (CPG), Detoxification of Chemically Dependent Inmates, which is consistent with Immigration Health Services Corps (IHSC) Directive 03-13, Detainees with Substance Dependence and Abuse. As noted by Creative Corrections, the CPG recommends an HIV 38 test, a mental health evaluation, urinalysis, and electrocardiogram (EKG), 39 none of which were (b) (6), (b) (7)(C) ordered by Dr. In addition, the CPG recommends a specific methadone and 40 clonidine dosing regimen not in place at ADF and emphasizes that medical staff closely monitor vital signs and withdrawal symptoms. When he cleared LOPEZ for general population, (b) (6), (b) (7)(C) Dr. did not order nurses to monitor LOPEZ using a standard assessment tool at (b) (6), (b) (7)(C) appropriate intervals during the withdrawal period. 41 Dr. stated that ADF had no specific opioid withdrawal protocols in place at the time of LOPEZ’s detention. 42 Regarding the (b) (6), (b) (7)(C) decision to clear LOPEZ for general population, Dr. stated he offered LOPEZ continued housing in medical, but the detainee strongly declined. (b) (6), (b) (7)(C) While housed at ADF, LOPEZ submitted five sick call requests between February 10 and February 15, 2017, described below. • On February 10, 2017, LOPEZ submitted a health services request in which he stated he (b) (6), (b) (7)(C) needed his blood pressure and other medications. RN responded to the request on February 11, 2017, informing LOPEZ that the pharmacy ordered his medications, See CCS Medical Progress Note by Dr. (b) (6), (b) (7)(C) dated February 10, 2017. LOPEZ’s blood was drawn for laboratory testing on February 15, 2017, as ordered, and the results are discussed in the entry for February 25, 2017. 32 CBC with differential is a blood test that measures the levels of red blood cells, white blood cells, platelet (clotting cells) levels, hemoglobin (oxygen transport cells) and hematocrit (ratio of red blood cells to the total blood volume). 33 A platelet count is a measure of the cells which assist in blood clotting. 34 A complete metabolic panel is a blood test that measures glucose level, electrolyte and fluid balance, kidney function, and liver function. 35 Hepatitis panels are blood tests to identify the presence of viral hepatitis A, B, and C or their antibodies to determine past infection with present immunity. 36 An ammonia test is a blood test that measures the amount of ammonia (by-product formed when protein is broken down by bacteria in the intestines). The liver normally converts ammonia into urea, which is eliminated in the urine, and ammonia levels rise in the blood when the liver is not able to perform this conversion. This may be caused by cirrhosis or hepatitis. 37 A plasma test measures the amount of protein in the colorless fluid part of the blood after the red cells, white cells, and platelets have been removed. 38 HIV is a deadly viral infection which destroys the body’s immune system, making a person susceptible to opportunistic infections. 39 An EKG is a test that records the electrical activity of the heart to determine the presence of heart disease. 40 Clonidine is used to treat high blood pressure and body pain related to conditions of cancer or withdrawal. 41 The commonly used assessment tool for this purpose is the Clinical Opiate Withdrawal Scale (COWS), an 11item scale which rates signs and symptoms of opiate withdrawal. (b) (6), (b) (7)(C) 42 HSA stated that although nurses are trained in opioid withdrawal, ADF had not received an opioiddependent detainee since he started working at the facility in 2015. Nurses interviewed all stated they did not recall any training in opioid withdrawal and were unaware of any policies and protocols related to opioid withdrawal. 30 31 6 DETAINEE DEATH REVIEW – Sergio Alonso LOPEZ JICMS #201706199 though she did not specify when he would receive them. 43 LOPEZ received his first dose of blood pressure medication during the evening of February 11, 2017, and his first dose of methadone on February 10, 2017, presumably after he submitted his request. • On February 12, 2017, LOPEZ wrote in a health services request that medical staff did not provide his medications and that he needed to see a doctor. RN responded to the request on February 13, 2017 and noted she referred LOPEZ to the provider. 44 ERAU notes LOPEZ’s MARs show he received his medications as ordered with the exception of a missed dose of methadone on February 11, 2017. ERAU also notes (b) (6), (b) (7)(C) LOPEZ did not see a provider until his scheduled appointment with Dr. on February 16, 2107. (b) (6), (b) (7)(C) • On February 13, 2017, LOPEZ submitted a health services request complaining that security staff had not yet moved him to a lower bunk on a lower tier. 45 RN responded to the request on February 15, 2017 and noted LOPEZ was scheduled to see a provider within the week. RN did not take any action regarding the bunk and tier (b) (6), (b) (7)(C) 46 complaint. According to HSA at the time of LOPEZ’s detention, detainees were responsible for providing special needs forms to their housing unit officer for assignment to an appropriate bunk and tier. ERAU was unable to determine whether LOPEZ provided his form to security staff. Following LOPEZ’s death, ADF changed the process to require issuance of a copy of the special needs form to both a security supervisor and the detainee to ensure proper bunk and tier assignment. 47 (b) (6), (b) (7)(C) (b) (6), (b) (7)(C) • On February 14, 2017, LOPEZ wrote in a health services request that he needed to see a doctor “ASAP,” that he could not sleep, and that he was in pain. RN responded to the request on February 15, 2017 and noted LOPEZ was scheduled to see a provider the week of February 20, 2017. 48 (b) (6), (b) (7)(C) • On February 15, 2017, LOPEZ wrote in a health services request that he needed to see a doctor, that he could not sleep, and that he was in a lot of pain. RN responded to the request on February 16, 2017 and noted LOPEZ was referred to RN sick call. The nursing sick call appointment was completed on February 17, 2017. 49 (b) (6), (b) (7)(C) Regarding sick call requests, HSA stated nurses are expected to comply with NCCHC Standard J-E-07, which states, “When a request describes a clinical symptom, a face-to-face encounter between the patient and qualified health care professional occurs within 48 hours (72 hours on weekends).” While nurses triaged LOPEZ’s requests in an overall expedient manner, (b) (6), (b) (7)(C) See CCS Patient Health Services Request Form, dated February 10, 2017. See CCS Patient Health Services Request Form, dated February 12, 2017. (b) (6), (b) (7)(C) 45 Although Dr. ordered assignment to a low bunk on a lower tier during initial assessment on February 10, 2017, LOPEZ was assigned to a cell on an upper tier of the housing unit for the majority of his time in detention and was not moved to a lower bunk until March 13, 2017. 46 See CCS Patient Health Services Request Form, dated February 13, 2017. (b) (6), (b) (7)(C) 47 ERAU Interview with HSA dated May 16, 2017. 48 See CCS Patient Health Services Request Form, dated February 14, 2017. ERAU was unable to determine why (b) (6), (b) (7)(C) (b) (6), (b) (7)(C) RN noted this, since LOPEZ already had an appointment scheduled with Dr. for February 16, 2017. 49 See CCS Patient Health Services Request Form, dated February 15, 2017. 43 44 7 DETAINEE DEATH REVIEW – Sergio Alonso LOPEZ JICMS #201706199 they did not ensure he was seen within the required timeframe. HSA stated expectations concerning proper handling of sick call requests were clarified with nursing staff following LOPEZ’s death. 50 (b) (6), (b) (7)(C) On February 16, 2017, Dr. saw LOPEZ for his scheduled methadone follow-up appointment. LOPEZ complained of general body pain at level ten and exhibited mild trembling. LOPEZ’s vital signs were within normal limits with the exception of an elevated (b) (6), (b) (7)(C) blood pressure of 146/86. Dr. ordered new medications for LOPEZ’s withdrawal treatment, as follows: (b) (6), (b) (7)(C) 1. 2. 3. 4. 5. 6. Clonidine 51 0.1 mg twice daily for ten days; Loperamide 2 mg twice daily for ten days to treat diarrhea; Ibuprofen 600 mg twice daily for ten days for pain; Cyclobenzaprine 10 mg twice daily for ten days to treat body pain; Ondansetron 4 mg twice daily for ten days to treat nausea; and, Hydrocortisone cream to psoriatic areas twice daily for 60 days. Dr. also noted he would reevaluate LOPEZ in two weeks, on March 2, 2017. However, LOPEZ’s medical record shows his next provider appointment was scheduled for March 9, 2017. (b) (6), (b) (7)(C) HSA stated providers schedule their own appointments in eClinicalWorks (eCW), the (b) (6), (b) (7)(C) facility’s electronic medical record-keeping system. Dr. did not recall why he scheduled the appointment for March 9, 2017. (b) (6), (b) (7)(C) On February 17, 2017, RN (b) (6), (b) (7)(C) saw LOPEZ for a rescheduled nursing sick call encounter to address his complaint of pain from February 15, 2017. During the encounter, (b) (6), (b) (7)(C) LOPEZ reported that the ibuprofen Dr. ordered for him the day before was effective in relieving his pain, but he complained of itching and irritation, and stated he did not receive the (b) (6), (b) (7)(C) (b) (6), (b) (7)(C) hydrocortisone cream ordered by Dr. RN provided the hydrocortisone cream. (b) (6), (b) (7)(C) RN did not take LOPEZ’s vital signs during the encounter. 52 On February 21, 2017, LOPEZ refused his morning dose of metoprolol and all other medications except for methadone. 53 Although nurses noted the refusals on the MAR, they did not complete refusal forms or document the refusals in a progress note, as required by CCS policy. On February 22, 2017, RN responded to a sick call request in which LOPEZ complained that he felt sick, was vomiting, and requested different medications. 54 RN reviewed the request and referred LOPEZ to a provider. ERAU notes a provider did not see LOPEZ until March 30, 2017. RN stated that she only knew LOPEZ could not keep his food down, and that she was unaware he was withdrawing from methadone because it was not (b) (7)(C), (b) (6) (b) (6), (b) (7)(C) (b) (6), (b) (7)(C) ERAU Interview with HSA dated May 16, 2017. 51 Clonidine is a medication used to treat high blood pressure and also acts as a sedative to help with sleep disturbances and reduce anxiety and agitation related to withdrawal. (b) (6), (b) (7)(C) 52 See Exhibit 5: CCS Medical Progress Note by RN dated February 17, 2017. 53 See CCS Medication Administration Record, dated February 21, 2017. 54 See CCS Patient Health Services Request Form, undated. 50 (b) (6), (b) (7)(C) 8 DETAINEE DEATH REVIEW – Sergio Alonso LOPEZ JICMS #201706199 identified on the problem list 55 in his medical record. 56 HSA verified LOPEZ’s problem list did not note methadone withdrawal and stated that providers are responsible for making entries to the problem list, as appropriate. 57 (b) (6), (b) (7)(C) On February 25, 2017, Dr. reviewed and signed the results of the laboratory tests ordered during LOPEZ’s initial physical examination, which ADF received on February 21, (b) (6), (b) (7)(C) 2017. 58 Dr. noted that the results included past resolved infections for hepatitis A and B. The results also included a positive hepatitis C antibody, which indicated a past infection. However, because the antibody was determined “strong reactive,” the lab recommended followup viral load testing 59 to determine whether the infection was resolved. 60 (b) (6), (b) (7)(C) Creative Corrections notes Dr. did not address the abnormal findings 61 in the laboratory (b) (6), (b) (7)(C) report, or the recommendation for follow-up hepatitis C viral load testing. 62 Dr. stated that it was Dr. (b) (6), (b) (7)(C) responsibility to address these findings during LOPEZ’s first chronic care appointment following his physical examination. 63 However, LOPEZ’s chronic care appointment was scheduled for March 30, 2017, more than four weeks later. As noted by Creative Corrections, this led to a delay in medical care between the receipt of the laboratory results and clinical action by a provider. (b) (6), (b) (7)(C) Later that day, LOPEZ refused all his medications, and Licensed Vocational Nurse (LVN) stated he did not and LVN (b) (6), (b) (7)(C) signed his refusal form. 64 LVN recall this specific encounter but stated he consistently provides patient education when detainees refuse medications and signs the refusal forms as a witness. 65 ERAU notes that if a detainee (b) (6), (b) (7)(C) refuses to sign a refusal forms, two witnesses must sign the form. LVN stated that although she signed this particular refusal form, she was not present in the unit when LOPEZ (b) (6), (b) (7)(C) refused his medications. 66 HSA indicated that following LOPEZ’s death, LVNs were instructed to request unit officers to sign the forms as the second witness instead of a nurse who was not present at the time of refusal. 67 (b) (6), (b) (7)(C) (b) (6), (b) (7)(C) A “problem list” is a document that states the most important health problems facing a patient and anything else that has affected or is currently ongoing with the patient. (b) (6), (b) (7)(C) 56 ERAU Interview with RN dated May 18, 2017. (b) (6), (b) (7)(C) 57 ERAU Interview with HSA dated May 16, 2017. 58 See Laboratory Corporation of America Final Report, dated February 21, 2017. The laboratory report indicated that ADF did not provide a blood sample for LOPEZ’s Complete Blood Count (CBC) testing to the lab, and as a (b) (6), (b) (7)(C) result, several tests were not completed (differential levels, platelet count, and plasma). According to HSA the tests were not completed due to a broken test tube. ADF did not draw an additional blood sample until March 1, 2017. 59 Viral load testing measures the amount of virus in the blood. 60 See Laboratory Corporation of America Final Report, dated February 21, 2017. 61 See Exhibit 1. Creative Corrections provides detail on LOPEZ’s abnormal laboratory results, and identifies potential implications including possible diabetes, and possible cirrhosis or other liver disease. 62 See CCS Medical Progress Note by Dr. (b) (6), (b) (7)(C) dated February 25, 2017. 63 ERAU Interview with Dr. (b) (6), (b) (7)(C) dated May 16, 2017. (b) (6), (b) (7)(C) 64 See CCS Refusal of Medical Services and Release Form by LVN dated February 25, 2017. (b) (6), (b) (7)(C) 65 ERAU Interview with LVN dated May 18, 2017. (b) (6), (b) (7)(C) 66 ERAU Interview with LVN dated May 16, 2017. (b) (6), (b) (7)(C) 67 ERAU Interview with HSA dated May 16, 2017. 55 9 DETAINEE DEATH REVIEW – Sergio Alonso LOPEZ JICMS #201706199 On February 27, 2017, LOPEZ refused his morning dose of metoprolol. 68 Although the nurse (name unknown) who attempted to give LOPEZ his medication notated the refusal on the MAR, s/he did not complete an associated refusal form or create a progress note documenting the refusal. On February 28, 2017, RN responded to a February 27, 2018 health services request in which LOPEZ asked to see a doctor because his medications were stopped. 69 At the time of this request, methadone was LOPEZ’s only expired medication, and his MARs reflect he received his other medications as ordered, excluding the refusals noted above. RN referred LOPEZ to the provider, but he was not seen until his chronic care appointment on March 30, 2017. 70 (b) (6), (b) (7)(C) (b) (6), (b) (7)(C) On March 2, 2017, Dr. reviewed and signed LOPEZ’s CBC laboratory results. The CBC was within normal limits, with the exception of a significantly low platelet count of 75, 71 (b) (6), (b) (7)(C) which Dr. did not address in his progress note. As noted by Creative Corrections, platelets are cells that stop bleeding by clotting the blood. Abnormally low platelets can result in easy bruising, superficial bleeding into the skin, prolonged bleeding from cuts, blood in the urine or stool, or bleeding from the gums or nose. Two weeks following these laboratory results, LOPEZ submitted a sick call request complaining of nose bleeds. (b) (6), (b) (7)(C) On March 16, 2017, LOPEZ submitted two sick call requests. In the first, reviewed by RN (b) (6), (b) (7)(C) LOPEZ complained of nosebleeds, and RN scheduled him for nursing sick (b) (6), (b) (7)(C) call. In the second, reviewed by RN , LOPEZ requested to see a doctor for cold and (b) (6), (b) (7)(C) allergy symptoms. RN responded to LOPEZ to let him know he was already scheduled for RN sick call. 72 LOPEZ was not seen during nursing sick call until the afternoon of March (b) (6), (b) (7)(C) 21, 2017, six days later. RN who evaluated LOPEZ on March 21, 2017, noted his vital signs were within normal limits, with the exception of an elevated blood pressure of 161/96. She gave LOPEZ calcium carbonate for heartburn 73 relief, and medication to treat cold and allergy (b) (6), (b) (7)(C) symptoms, and advised him to return to the clinic, if needed. RN failed to document subjective and objective findings for the assessment and did not order blood pressure monitoring for three days for readings equal to or greater than 140/90, as required by the nursing protocol for hypertension. 74 (b) (6), (b) (7)(C) On March 23, 2017, RN responded to a sick call request in which LOPEZ asked for (b) (6), (b) (7)(C) additional allergy medications. RN scheduled LOPEZ for RN sick call. LOPEZ was not seen for RN sick call until March 28, 2017, five days later. 75 (b) (6), (b) (7)(C) See CCS Medication Administration Record, dated February 27, 2017. ERAU identified that only expired medication order was for methadone. 70 See CCS Patient Health Services Request Form, dated February 27, 2017. 71 Normal range for platelet count is 150 to 379. 72 See CCS Patient Health Services Request Form, dated March 26, 2017. 73 Heartburn is a form of indigestion felt as a burning sensation in the chest, caused by acid regurgitation into the esophagus. Calcium carbonate is used as an antacid to relieve heartburn; common brands include Maalox and Mylanta. (b) (6), (b) (7)(C) 74 See Exhibit 6: CCS Medical Progress Note by RN dated March 21, 2017. 75 See CCS Patient Health Services Request Form, dated March 23, 2017. 68 69 10 DETAINEE DEATH REVIEW – Sergio Alonso LOPEZ JICMS #201706199 On March 28, 2017, RN (b) (6), (b) (7)(C) saw LOPEZ during RN sick call. LOPEZ complained of nasal allergies, diarrhea, and acid reflux. His vital signs were all within normal limits, with the exception of an elevated blood pressure of 167/95, and he indicated his pain was (b) (6), (b) (7)(C) at level nine. 76 RN gave LOPEZ antacid tablets and allergy medications but did not document the location, quality, aggravating factors, and alleviating factors of his pain, which is standard nursing practice according to Creative Corrections. In addition, she did not follow the hypertension nursing protocol which requires ordering blood pressure checks daily for three days, and checking for cardiac involvement. Regarding the delay in seeing LOPEZ for nursing sick call, RN stated appointments were often rescheduled in February and March of 2017, due to limited staffing. She said nursing supervisors instructed nurses to prioritize completion of physical examinations, but gave no direction on how to manage the volume of sick call appointments. She described the sick call (b) (6), (b) (7)(C) process during that time as sporadic and disorganized. 77 RN also stated she was unaware LOPEZ recently underwent methadone tapering at time of her assessment, as the treatment was not documented on the detainee’s problem list. (b) (6), (b) (7)(C) On March 30, 2017, Dr. saw LOPEZ for a chronic care appointment for hypertension (b) (6), (b) (7)(C) and psoriasis. During the appointment, Dr. documented the following: (b) (6), (b) (7)(C) • • • • • LOPEZ reported a history of hepatitis B, for which he was treated. LOPEZ complained of heartburn and bloating, level ten abdominal pain, and stated he had a lump in his stomach. LOPEZ stated the bloating was accompanied by nausea and loose stools, and that he used another detainee’s Pepto-Bismol to help manage the symptoms. LOPEZ initially denied light-headedness, confusion, dizziness, or change in mental status, but later during the encounter, he reported a level three headache with a lightheaded feeling. LOPEZ’s vital signs were all within normal limits, with the exception of an elevated blood pressure of 168/92. (b) (6), (b) (7)(C) Dr. noted she found red patches of peeling skin on LOPEZ’s face and arms, and that the detainee’s abdomen was mildly distended with an increased venous pattern 78 on the upper half. Based on her assessment, Dr. • • • • (b) (6), (b) (7)(C) determined LOPEZ’s conditions included: Essential (primary) hypertension; Opioid dependence with withdrawal; Psoriasis; Raised antibody titer; 79 See CCS Medical Progress Note by RN dated March 28, 2017. (b) (6), (b) (7)(C) ERAU Interview with RN dated May 18, 2017. 78 Venous pattern refers to the presence of veins on the swollen abdomen as a result of liver disease. 79 Raised antibody titer is the concentration of an antibody. 76 (b) (6), (b) (7)(C) 77 11 DETAINEE DEATH REVIEW – Sergio Alonso LOPEZ JICMS #201706199 • • • Gastro-esophageal reflux disease (GERD) 80 with esophagitis; 81 Allergic rhinitis; 82 and, Unspecified cirrhosis of liver. 83 Dr. wrote that LOPEZ had a history of hepatitis B and that his increased abdominal girth, increased plasma ammonia level, 84 and increased abdominal discomfort might indicate early cirrhosis of the liver. She noted LOPEZ was successfully weaned off chronic use of methadone but later experienced onset of heartburn and reflux. Based on her assessment of (b) (6), (b) (7)(C) LOPEZ, Dr. documented the following orders. (b) (6), (b) (7)(C) • • • Medications: o Metoprolol, increased from 25 mg to 50 mg, once daily; o Claritin for seasonal allergies; o Omeprazole (antacid) and ondansetron (anti-nausea) for GERD and related abdominal discomfort. A CAT scan 85 of LOPEZ’s abdomen, with a referral for a radiology appointment for possible cirrhosis of the liver. Laboratory studies: o Ammonia plasma 86 on March 30, 2017; and, o HIV, hepatitis B viral load, 87 and hemoglobin A1c, 88 on April 6, 2017. During (b) (6), (b) (7)(C) interview, Dr. commented that a provider should have ordered an HIV test following LOPEZ’s initial physical examination, due to his high-risk behaviors prior to admission. 89 On April 1, 2017, at approximately 8:18 a.m., LOPEZ approached his housing unit officer, Officer (b) (6), (b) (7)(C) , 90 and complained that he was unable to control his bowels which (b) (6), (b) (7)(C) prevented him from sleeping the night before and was spitting up blood. Officer (b) (6), (b) (7)(C) (b) (6), (b) (7)(C) contacted medical and spoke with RN who directed Officer to send LOPEZ to Gastro-esophageal reflux disease is a digestive disease in which stomach acid or bile irritates the lining of the esophagus. 81 Esophagitis is an inflammation of the esophagus. 82 Allergic rhinitis is an allergic response causing itchy, watery eyes, sneezing, and other similar symptoms. (b) (6), (b) (7)(C) 83 See CCS Medical Progress Note by Dr. dated March 30, 2017. 84 LOPEZ’s increased plasma ammonia level was evidenced in the February 21, 2017 laboratory report. 85 Also known as a CT scan, a CAT scan it is a diagnostic procedure using computerized radiology to produce multiple images inside the body. 86 Ammonia is one of the by-products of protein metabolism. Elevated blood ammonia levels have been associated with severe liver dysfunction. 87 Creative Corrections notes the February 21, 2017 laboratory report documented that the surface antigen (the viral toxin that induces immune response which, when positive, may indicate the patient is actively infectious) for (b) (6), (b) (7)(C) hepatitis B was negative, and that a viral load test for hepatitis C was recommended. Neither Dr. nor Dr. (b) (6), (b) (7)(C) ordered a hepatitis C viral load test. 88 Hemoglobin A1c is a blood test which provides an average of blood glucose levels over the past two to three months. (b) (6), (b) (7)(C) 89 ERAU Interview with Dr. dated May 16, 2017. (b) (6), (b) (7)(C) 90 Officer wrote a detailed incident report on April 16, 2017. ERAU notes many of the details in his report conflict with events documented on the CCTV and the related post logbooks, and could not be corroborated. 80 12 DETAINEE DEATH REVIEW – Sergio Alonso LOPEZ JICMS #201706199 the clinic. 91 RN stated Officer informed her LOPEZ was spitting up blood, but she did not recall learning that LOPEZ also experienced diarrhea and sleeplessness. As evidenced by video surveillance footage, LOPEZ remained in the housing unit until 9:27 a.m. At 8:41 a.m., a nurse (identity unknown) arrived in the unit with a medication cart to distribute medications. LOPEZ approached and spoke to the nurse before she departed the unit at approximately 8:51 a.m. ERAU was unable to determine what LOPEZ told the nurse because his medical record contains no documentation of the conversation, and ADF could not affirmatively identify the nurse. (b) (6), (b) (7)(C) (b) (6), (b) (7)(C) At approximately 9:27 a.m., security staff escorted LOPEZ to the medical clinic with five other (b) (6), (b) (7)(C) detainees. 92 Upon his arrival, RN assessed LOPEZ for his complaint of spitting up. As reported by Officer (b) (6), (b) (7)(C) , LOPEZ vomited blood on the floor of the clinic during the (b) (6), (b) (7)(C) then contacted Dr. who directed her to call 911 and send assessment. 93 RN LOPEZ to the Emergency Room (ER). 94 Dr. notified the West Central Control Officer to contact 911, which he did at 9:58 a.m., and American Medical Response (AMR) arrived on (b) (6), (b) (7)(C) did not notate the events of the morning in medical site at 10:06 a.m. 95 ERAU notes RN record. Her only documentation was an Emergency Room/Inpatient Referral request and a Transport/Escort Authorization form. The referral request shows LOPEZ’s vital signs were abnormal with a temperature of 99.4, heart rate of 105, and blood pressure of 155/88. (b) (6), (b) (7)(C) (b) (6), (b) (7)(C) At 10:19 a.m., AMR placed LOPEZ into the ambulance and departed for VVGMC. 96 GEO Officers (b) (6), (b) (7)(C) and (b) (6), (b) (7)(C) escorted LOPEZ to the hospital. LOPEZ arrived at VVGMC at 10:39 a.m. According to Officer LOPEZ waited in a hallway of the hospital for approximately one hour. The AMR report shows ER staff assumed care of LOPEZ at 11:26 a.m. 97 (b) (6), (b) (7)(C) Victor Valley Global Medical Center LOPEZ remained at VVGMC from April 1, 2017 until April 13, 2017 (date of death). ADF posted hospital vigil officers to LOPEZ’s room during the entirety of his time there. Upon admission to the hospital, LOPEZ underwent a CT scan of the abdomen which showed ascites 98 around his liver and spleen. A hospital physician determined LOPEZ’s initial diagnoses were upper gastrointestinal bleed, anasarca, 99 sepsis, 100 and leukocytosis. 101 Following his admission, ERAU Interview with Officer dated May 17, 2017, and RN dated May 16, 2017. ERAU notes (b) (6), (b) (7)(C) ADF did not have security or medical documentation of the communication, and Officer and RN (b) (6), (b) (7)(C) accounts differed slightly. The sequence of events was determined primarily though viewing of video surveillance footage of LOPEZ in his housing unit. 92 CCTV footage, dated March 30, 2017. 93 ERAU Interview with GEO Officer (b) (6), (b) (7)(C) , dated May 18, 2017. 94 See CCS Emergency Room/Inpatient Referral Request, dated April 1, 2017. 95 See GEO West Central Control Log, dated April 1, 2017. 96 VVGMC is approximately 11 miles from ADF. 97 See GEO West Medical Bag Logbook, dated April 1, 2017. 98 Ascites is the accumulation of fluid in the abdomen, most commonly due to cirrhosis. 99 Anasarca is general body edema, or widespread swelling of skin due to effusion of fluid through the extracellular space. 100 Sepsis is a life-threatening complication of an infection that infects the blood stream. 101 Leukocytosis is a high level of white blood cells in the blood due to underlying disease. 91 (b) (6), (b) (7)(C) (b) (6), (b) (7)(C) 13 DETAINEE DEATH REVIEW – Sergio Alonso LOPEZ JICMS #201706199 ADF medical staff contacted VVGMC daily to obtain updates on LOPEZ’s condition including the following: 102 • • • • • Testing and evaluation revealed LOPEZ had anemia 103 and cirrhosis of the liver. On April 4, 2017, LOPEZ underwent esophageal banding of the varices 104 to control his gastrointestinal bleeding; From April 5 to April 8, 2017, LOPEZ remained relatively stable with no signs of bleeding; On April 9, 2017, LOPEZ was diagnosed with edema (swelling) in his lower extremity which was spreading to his thighs and scrotal area; and, From April 10 to April 12, 2017, LOPEZ remained relatively stable with no signs of bleeding or complaints of distress. On April 13, 2017, (Date of the Death) GEO Officers (b) (6), (b) (7)(C) and (b) (6), (b) (7)(C) assumed their posts as hospital vigil officers at 7:09 a.m. 105 Both Officer and Officer (b) (6), (b) (7)(C) stated that LOPEZ initially seemed stable, and was sitting up, talking, and watching television for most of the shift. However, starting at approximately 2:00 p.m., LOPEZ started using the restroom more frequently. 106 (b) (6), (b) (7)(C) At approximately 3:58 p.m., LOPEZ asked to use the restroom. 107 Because LOPEZ was (b) (6), (b) (7)(C) restrained to the guardrail of his bed with a leg cuff around one ankle, Officer removed the cuff from the guardrail and attached it to the other ankle so LOPEZ could walk to the (b) (6), (b) (7)(C) restroom. According to Officer as LOPEZ shifted his weight to get out of the bed, he (b) (6), (b) (7)(C) 108 fell back and began to cough up blood. Officer turned LOPEZ’s head to the side so ran out of the room and yelled “Code he would not choke on the blood, 109 while Officer Blue” to hospital staff to let them know LOPEZ was in distress. Hospital staff responded immediately and wheeled LOPEZ to the Intensive Care Unit (ICU). 110 (b) (6), (b) (7)(C) While hospital staff moved LOPEZ to the ICU, Officers (b) (6), (b) (7)(C) and (b) (6), (b) (7)(C) (b) (6), (b) (7)(C) arrived at the hospital to relieve Officers and for the 4:00 p.m. shift. 111 Officer stated he observed a large amount of blood coming from the LOPEZ’s mouth but that LOPEZ appeared to be conscious. 112 (b) (6), (b) (7)(C) (b) (6), (b) (7)(C) See VVGMC Medical Updates, dated April 3-13, 2017. Anemia is a low level of iron in the body. 104 Varices are abnormal blood vessels. In esophageal banding, bleeding varices are banded through endoscopic application of rubber bands onto the bleeding sites to stop the bleeding. 105 See GEO West Medical Bag Logbook, dated April 13, 2017. (b) (6), (b) (7)(C) 106 ERAU Interview with Officer dated May 16, 2017. 107 See GEO West Medical Bag Logbook, dated April 13, 2017. (b) (6), (b) (7)(C) 108 See GEO General Incident Report by Officer dated April 17, 2017. (b) (6), (b) (7)(C) 109 ERAU Interview with Officer dated May 16, 2017. (b) (6), (b) (7)(C) 110 ERAU Interview with Officer dated May 16, 2017. 111 See GEO West Medical Bag Logbook, dated April 13, 2017. (b) (6), (b) (7)(C) 112 ERAU Interview with Officer dated May 16, 2017. 102 103 14 DETAINEE DEATH REVIEW – Sergio Alonso LOPEZ JICMS #201706199 For the next two hours, VVGMC staff sedated LOPEZ and worked to stabilize him, though he continued to bleed from the mouth. 113 At approximately 6:24 p.m. a nurse called a Code Blue, hospital staff responded and administered emergency care, and LOPEZ regained a pulse at 6:40 p.m. At 7:35 p.m., hospital staff called a second Code Blue and administered emergency care, but LOPEZ did not recover. At 7:44 p.m., a hospital physician pronounced LOPEZ dead. Post-Death Events On April 13, at approximately 9:58 p.m., Victor Valley Mortuary personnel arrived at the hospital and took possession of LOPEZ’s body. 114 An autopsy was not conducted at the request of LOPEZ’s family. However, VVGMC physician Dr. (b) (6), (b) (7)(C) documented LOPEZ’s final diagnoses as the following: 115 • • • • • • Massive upper gastrointestinal bleeding from esophageal varices; Severe portal hypertension; 116 End stage liver disease with cirrhosis of liver; History of previous alcoholism; Hemorrhagic anemia; 117 and, Hemorrhagic shock. 118 On June 1, 2017, the County of San Bernardino, CA, issued a State of California Certificate of Death for LOPEZ which documented his causes of death as an upper gastrointestinal bleed, esophageal varices, cirrhosis of the liver, and heroin and alcohol abuse. 119 MEDICAL CARE AND SECURITY REVIEW ERAU reviewed the medical care LOPEZ was provided at ADF, as well as the facility’s efforts to ensure that he was safe and secure while detained at the facility. ERAU found deficiencies in ADF’s compliance with certain requirements of the ICE PBNDS 2011. CONCLUSIONS ERAU found ADF deficient in the following areas of the ICE PBNDS 2011: 1. ICE PBNDS 2011, Medical Care, sections (V)(A)(2) and (6), which states, “Every facility shall directly or contractually provide its detainee population with the following: … 2) See GEO West Medical Bag Logbook, dated April 13, 2017. See GEO West Medical Bag Logbook, dated April 13, 2017. 115 See VVGMC Death Summary by Dr. (b) (6), (b) (7)(C) , MD. 116 Portal hypertension is hypertension (high blood pressure) in the hepatic portal system – made up of the portal vein and its branches that drain from most of the intestine to the liver. Cirrhosis (a form of chronic liver failure) is the most common cause of portal hypertension. 117 Hemorrhagic anemia is a precipitous drop in red blood cells due to internal bleeding. 118 Hemorrhagic shock results from a loss of more than 20 percent of the body’s blood or fluid supply, making it impossible for the heart to pump a sufficient amount of blood to the body. 119 See Exhibit 7: State of California Certificate of Death. 113 114 15 DETAINEE DEATH REVIEW – Sergio Alonso LOPEZ JICMS #201706199 Medically necessary and appropriate medical, dental and mental health care and pharmaceutical services; … and, 6) Timely responses to medical complaints.” • ADF’s orders for detoxification were not in accordance with the Bureau of Prisons CPG, Detoxification of Chemically Dependent Inmates. The CPG, adopted by IHSC (b) (6), (b) (7)(C) and according to HSA by CCS, describes appropriate care for patients withdrawing from opioids. Medical staff did not monitor and assess LOPEZ while he underwent withdrawal, did not conduct a mental health evaluation, and did not complete an HIV test, urinalysis, or EKG. • Nurses did not identify LOPEZ’s withdrawal symptoms when responding to his sick call requests. Their ability to do so was hampered by the absence of opioid withdrawal and methadone tapering on his problem list. • LOPEZ was not seen by a provider until March 30, 2017, more than four weeks following Dr. (b) (6), (b) (7)(C) February 25, 2017 review of his laboratory test results which showed abnormal findings. Consequently, provider consideration of further testing and treatment was delayed. • Although nurses promptly triaged LOPEZ’s ten sick call requests and made appropriate referrals to providers and nursing sick call, the detainee never saw a provider or nurse within 48 hours of submitting a sick call request, unless he was already scheduled for a follow-up appointment. • A nurse did not obtain LOPEZ’s vital signs during the nursing sick call on February 17, 2017, and another nurse did not obtain a pain assessment from the detainee during the nursing sick call on March 21, 2017. • A nurse failed to direct three-day blood pressure monitoring for LOPEZ after his elevated blood pressure readings on March 21 and March 28, 2017, in contravention of nursing protocols for hypertension. 2. ICE PBNDS 2011, Medical Care, section (V)(G)(5), which states, “Each detention facility shall have and comply with written policy and procedure for the management of pharmaceuticals, to include secure storage and disposal and perpetual inventory of all controlled substances (DEA Schedule II-V), syringes, and needles.” • Nursing entries to the DEA Patient Specific Controlled Substance Flow Sheet on two consecutive days, February 10 and 11, 2017, recorded the number of bottles of methadone rather than the amount of liquid in the bottles. This also constitutes a deficiency in (V)(G)(9), below. 3. ICE PBNDS 2011, Medical Care, section (V)(G)(9), which states, “Each detention facility shall have and comply with written policy and procedure for the management of pharmaceuticals, to include administration and management in accordance with state and federal law.” 16 DETAINEE DEATH REVIEW – Sergio Alonso LOPEZ JICMS #201706199 • Dr. (b) (6), (b) (7)(C) order for detoxification from methadone over a 12-day period was not in compliance with the Narcotic Addiction Treatment Act, Title 21, Code of Federal Regulations, Part 1306.07(b), Three Day Rule. 4. ICE PBNDS 2011, Medical Care, sections (V)(X)(7) and (9), which states, “If the detainee refuses to consent to treatment, medical staff shall make reasonable efforts to explain to the detainee the necessity for and propriety of the recommended treatment. Medical staff shall explain the medical risks if treatment is declined and shall document their treatment efforts and refusal of treatment in the detainee’s medical record. Detainees will be asked to sign a translated form that indicates that they have refused treatment.” • Nurses did not complete refusal forms for LOPEZ’s medication refusals on February 11, 21, and 27, 2017. AREAS OF CONCERN Although not reflective of any violation of the requirements of the detention standards, ERAU noted the following area of concern related to ADF’s documentation of LOPEZ’s housing. • Security staff failed to document LOPEZ’s placement in the medical housing unit following his admission. As noted by Creative Corrections, complete and accurate records of a detainee’s housing history supports accountability and record integrity. ERAU noted the following area of concern pertaining to medical records and documentation. • LOPEZ’s transfer summary from LASF, including medical record attachments from White Memorial Hospital, was not available to the physician at the time of LOPEZ’s initial physical examination, hindering the physician’s ability to ensure continuity of treatment. • Nurses did not fully document adherence to nursing protocols during sick call encounters. In addition to failing to initiate blood pressure monitoring as noted in the above deficiency, they did not consistently record subjective and objective assessment factors. • The RN who sent LOPEZ to the hospital on April 1, 2017, did not create any medical record entries addressing the events which lead to the transfer. Creative Corrections advises that complete, accurate documentation of healthcare encounters are critical to the integrity of the medical record. In addition, ERAU found ADF did not comply with the following GEO policies. • D-02, Health Care Services and Support, Medication Services, Section (9)(a) which states, “A patient’s first refusal of medication shall be documented in the medical record and MAR.” 17 DETAINEE DEATH REVIEW – Sergio Alonso LOPEZ JICMS #201706199 o A nurse who completed a medication refusal form on February 21, 2017, did not include a nursing note documenting efforts made to explain the necessity of the medication to LOPEZ. • ADF Housing Unit Post Orders, section (IV)(B), which states, “Make written and oral reports as necessary.” o Officer did not document in the housing unit logbook his communications with the pod control officer concerning detainee LOPEZ’s symptoms and request for medical assistance, including the time(s) and information received in response. (b) (6), (b) (7)(C) o Officer the pod control officer, did not log notification of medical concerning the detainee’s symptoms and request for medical assistance, including the time and response received. (b) (6), (b) (7)(C) • ADF Policy 7.1.3.A, General Incident Reports, which states, “Emergency situation and unusual incidents will be documented on a General Incident Report (GIR) Form…”, “Immediately following any incident, staff members will submit an incident report…” and, “All incident reports and any supporting documentation must be completed before the end of the shift the incident occurred on…” o Officer did not file a written report describing the events of April 1, 2017, until April 16, 2017. (b) (6), (b) (7)(C) o Officers and who were in the medical unit and observed the detainee vomit blood prior to his transport to the hospital by ambulance, did not write incident reports. (b) (6), (b) (7)(C) (b) (6), (b) (7)(C) o Officer who was on vigil duty when detainee LOPEZ coded and was taken to ICU on April 13, 2017, did not file an incident report until May 19, (b) (6), (b) (7)(C) 2017. Officer who was also on vigil duty on April 13, 2017, did not file an incident report until April 17, 2017. (b) (6), (b) (7)(C) 18 DETAINEE DEATH REVIEW – Sergio Alonso LOPEZ JICMS #201706199 EXHIBITS 1. 2. 3. 4. 5. 6. 7. Creative Corrections Medical and Security Compliance Analysis (b) (6), (b) (7)(C) Receiving Screening by RN February 9, 2017 DEA Patient Specific Controlled Substance Flow Sheet, February 10 and 11, 2017 (b) (6), (b) (7)(C) Medical Progress Note by Dr. Physical Examination, dated February 10, 2017 (b) (6), (b) (7)(C) Medical Progress Note by RN dated February 17, 2017 (b) (6), (b) (7)(C) Medical Progress Note by RN dated March 21, 2017 State of California Certificate of Death 19