NUMBER: GLADES COUNTY DETENTION CENTER 720.00B PAGES: 8 ACA STANDARD(S): POST ORDER Annual Review: 03-17-17 Revision Dates: 03-12-14 POST: HOUSING OFFICER Effective Date: 06-01-07 [ " )(6), (b)(7)(C) Facilit Administrator PURPOSE To specify the duties of the housing officer in controlling the inmates and their activities in keeping an accurate count of all inmates assigned to the housing unit. Con-ectional officer posts are locate d in or immediately adjacent to inmate living areas to permit officers to hear and respond promptly to emerge ncy situations. AUTHORITY Glades County Sheriffs Office Policy and Procedure Florida Model Jail Standards National Detention Standard s PROCEDURE When assuming a new post, all officers shall sign the attached post order sign-off sheet indicating they have read and understand the post orders for this post. A. Shift Change Officers will log at shift change the following mandatory entries in the housing unit log: 1. Shift change date/time of relief 2. Name of officer being relieved 3. Name of relieving officer 4. Equipm ent and conditi on rece ived shall be recorded within the Smartcop Housing Log during each shift change. 2020-ICLl-00006 4129 GCDC- 720.00B Page 2 of 8 B. a. Key ring LD. tag and number of keys, condition of emerge ncy key box and key present in box b. Body alarm, if applicable c. Fire Extinguisher (expiration date of tag, pin and tag in place , number of extinguisher in place) d. Flash light and battery e. Inmate /Detainee Handbook 5. Result of log book inspection 6. Daily entries a. Maintenance inspect ion of area and results b. Name of other employ ees and guest who ente r area c. Results of physical check of locks of emergency doors d. Unusual occurrences e. Daily events f. Emergency situations g. Results and action taken of officer s' sanitation and hygiene inspection of housing area h. Number and results of inmates and area shakedowns 1. Inmate transfers in and out of housing area J End of shift entry, eq uipment/inform atio n pa ssed on and signature of officer being relieved k. The issuance of inmate sanitary supplies and products Inmate Traffic 1. The officer shall prepare the inmates for scheduled activities fifteen (15) minutes prior to calling that particular activity. 2020-ICLl-00006 4130 GCDC- 720.00B Page 3 of 8 C. 2. The officer shall ensure that all inmates turning out are properly dressed for that activity. 3. Inmates who fail to turnout for required activities shall be reported to the shift supervisor. 4. Frequent pat searches of inmates exiting and entering the housing area shall be conducted. Inmates should be challenged regarding where they are going, what they are doing and pat searches shou ld be a regular occurrence in the facility. 5. During the administrative hours Monday through Friday, all inmates shall exit the housing areas to attend their assigned programs or work assignments. Key Control: 1. Keys shall be on your person at all times, never leave keys in lock or lay keys on desk. 2. At no time shall the keys be given to an inmate. 3. Count and inspect your keys at issue and report a visible damage to your housing Sergeant. No officer will have a fire exit key, but there will be fire exit keys for each dormitory in the officer's station of each dorm. The key will be in a key cabinet with a glass front. In case of emergency the glass can be broken and key utilized. The exit doors will be checked on each shift by the housing officer shaking them and on the evening shift by the internal officer checking them with a key to ensure the locks work smoothly and properly. 4. D. Keys may be passed from one shift to the next; however, the log must reflect the key movement. Security of the Housing Unit: 1. Security of the housing unit is the priority objective of the housing unit officer. 2. The officer shall ensure that all doors are shut and locked except during times of authorized movement. 3. The control room door shall remain closed and locked at all times except for authorized movement. Inmates are not allowed inside the contro l room. 4. The officer shall keep inmate traffic to a minimum by limiting traffic only to and from housing unit or dayrooms or other authorized movement. 5. Inmates shall not be allowed in housing sections not assigned to them. 2020-ICLl-00006 4131 GCDC- 720.00B Page 4 of 8 E. 6. All exit doors shall be check immediately following a power failure or fire alarm. 7. Officers assigned to this post are under the direct supervision of the unit manager/housing sergeant. Counts 1. 2. Dming count time the officer shall: a. Announce count time and require each inmate to go to his assigned bed. b. Ensure no inmate is allowed to stay on the run. c. Count the inmates in each section. During formal count in the open bay dorms two officers will conduct the count of each pod. Both officers will conduct a head count and compare as they exit the pod. If there is any discrepancy between the two counts, the pod will be recounted. In the confinement pod, all cell doors will be locked and two officers will conduct count. One officer will count the top floor and one count the bottom, then the officers will switch. The ~i(7l(El •:ill ho ,mpar ed and if there are any discrepancies the pod will be recounted. I~.---~--~}'ill make individual count entries into the housing log. Officers will ensure t at they see living breathing flesh when counting. 0 3. F. During master roster counts, the counts will be conducted in the same manner as all others with the following exceptions. The officers counting will conduct a name and number count. Inmates will be required to show their wrist band during the count. Housing Unit Inspections 1. It shall be the duty of the assigned officer to make rounds/inspections of his/her assigned area every fifteen minutes. 2. Inspection of inmate areas shall involve inspecting all areas of housing unit, including dayrooms and shower area. Officers inspecting areas shall ensure that no inmates are on the runs, except assigned orderlies who are on duty and that housing unit appearance is clean and orderly. 3. In the course of each shift, the shift supervisor or assistant shift supervisor shall make an inspection of inmate living areas, runs, dayrooms and shower area for safety/fire hazards. 4. All window frames in the housing units shall be visually inspected for tampering once per shift and logged into the housing log. In addition to the visual inspection, an officer from the second shift is responsible for inspecting the window frames and 2020-ICLl-00006 4132 GCDC- 720.00B Page 5 of 8 middle bars for movement and/or damage. All window inspections should be logged in the housing log. G. H. Dayroom Dress for Inmates 1. Inmates using the dayroom will be expected to be fully dressed. 2. Inmates are required to have their shirts and pants on while in the dayroom. 3. Inmates not complying with this directive are subject to disciplinary action. Inmate Turnouts 1. All inmates leaving their sections (except for mass movements) will be checked out to a specific location (i.e. job , lay-in, school, etc.) using Smartcop. 2. If an inmate is found in any area other than the area checked out to, the inmate will be subject to disciplinary action. 3. I. J. Inmates not complying with this directive are subject to disciplinary action. Wrist Bands 1. All inmates will be required to wear their wrist band I.D. their wrist at all times when out of their assigned housing units. 2. The only exception to this rule will be those inmates who are newly arrived. 3. Any inmate who does not meet one of these exceptions and is found without his wrist band will be subject to disciplinary action. Other Duties and Responsibilities 1. The officer shall conduct a random pat search of inmates before allowing entrance into the housing units. 2. The officer shall allow only those inmates assigned to the housing section to enter. 3. The officer shall directly supervise the inrnate(s) assigned to clean the housing area. 4. The officer shall make periodic inspections of the housing unit to ensure cleanliness, security, and safety of inmates. 5. The officer shall supervise all activities occurring in the dayroom area. The officer shall ensure the approved television schedule is being adhered to. 2020-ICLl-00006 4133 GCDC- 720.00B Page 6 of 8 6. The officer will supervise the inmate showers in the housing unit. 7. The officer shall announce sick call and attempt to have those inmates who have signed up for sick call to turnout. 8. The officer shall report any incidents which occur in the housing unit to the housing supervisor. 9. The officer will issue all necessary hygiene and sanitary items using the schedule posted within each pod. While issuing necessary items, the officer will ensure that all empty container s or rolls are provided to them before issuing or re supplying items. 10. The officer shall be responsible for any other duties as might be assigned by a supervisor. 11. Housing unit officers will perform routine unannounced searches/inspections of the inmate living areas for contraband, and log search results in the housing log. 12. The officer shall also distribute inmate mail. 13. Frequent contac t with the inmates in your area of responsibility is essential to ensure proper supervision. Effective listening and addressing inmate concerns as they are presented to you will prevent the escalation of minor proble ms. Report all serious inmate complaints to your housing sergeant. 14. Emergency procedures: in the event of a medical emergency extension #2145 (a direct line to the medical department) shall be utilized. The housing officer is then respon sible to notify central control of the medical emergency. In the event of any emergencies other than medical, telephone extension # 2161 shall be utilized to contact central control with the location and nature of the emergency. 15. In cases of suicide attempts, it should be noted that a suicide cutting tool has been placed in the fire exit key box of each housing unit' s officer station. This tool is for the specific purpose of cutting any material used by an inmate in an attempt to hang hin1self. The officer is to cut the inn1ate down, and cut the material from around the neck in order to render first aid. lnlm ediate medical care to the inmate is top priority. Securing the scene and evidence are all secondary. 16. Dormitory Staff will supervise the process of filling housing unit water kegs. Sanitary water faucets have been installed beside the ice machines in the hou sing areas. The water kegs may be loaded, one at a time, on the small push carts for refilling of ice and fresh water at this specific location. ALL DORMA TORY STAFF WILL ENSURE THAT THIS IS THE ONLY LOCATION IN THE 2020-ICLl-00006 4134 GCDC- 720.00 B Page 7 of 8 HOUSING UNIT THAT WILL BE USED. Staff will ensure the water faucet in the mop close t area will NEVE R be utilized for this function or process. Like wise, staff will ensure that mop bu ckets and other items assoc iated with clean ing and sanitation are ALWAYS filled or service d in the secured mop close t areas and NEVE R serviced at the water keg filling stations by the ice machines. In the event a keg filling station becomes inoperable, the kegs must be taken to the kitchen for re-fillin g, until necessa ry repairs are complete d . 17. L. When entering a housing unit , staff of the opp osite gender shall announce the ir presence by stating, "Male or Female on the floor ", when entering a living area housing opp osite gendered individuials. T his allows inm ates/detainees to showe r, perform bodily functions, and change clothin g without nonmedical staff of the oppos ite gender view ing their breasts, buttocks , or genitalia, except in ex igent circumstances when performin g normal custod ial and security functions or when such viewing is incidental to rou tine cell checks. Meal Times 1. During each meal time, the housing unit officer(s) will supervise the feeding of inmates of his/her assigned housing units, under the supervision of the housing unit supervisor. Officers will ensure each inmate has an opportunity to eat, and that good order is maintained during the feeding process . BODY FLUID AND BLOOD SPILL CLEAN UP PROCEDURES 1. Contact on duty medical staff for immediate response USE OF FORCE Should force become necessa ry, only the minimum amount of reasonable force necess ary will be utilized. INMATE MEDICAL CARE Med ical care shall not be impeded, hindered or refused by any member of the staff at Gl ades Co unty Detention Center. All officers will be aware of confidentiality of med ical information, and any medical information seen or overheard concerning any person, staff or inmate will be maintained as compl etely confide ntial. Sho uld you be confronted by an inmate com plaining of illness or reques ting treatment , you will attempt to evaluate the subjec t's cond ition; however, you may refer face value informa tion acco rdingly. Deference or refusal by the medical department to see the subject shall cause immediate notification to the shift supervisor. 2020-ICLl-00006 4135 GCDC- 720.00B Page 8 of 8 HOSTAGE DISCLOSURE STATEMENT Employees taken hostage have no authority while they are ho stages. In no circ umstances will an inmate be allowed to be released nor will weapons, or other equipment be given to an inmate. There will not be any exchange of hostages. PROCEDURES NOT COVERED BY THIS POST ORDER Employees are not pe1mitted to have reading materials on this post other than that, which pertains to this duty. There will be no sleeping on this post, consumption of alcoholic intoxicants or other drugs, watching television or listening to commercial radios while assigned to this post. It is possible that situations may arise that are not covered by this post order. In such instances, it is expected that good jud gment and common sense be used and applicat ion of Facility Operating Procedures, Department Policy and Procedure Directives, and Florida Statutes will be implemented. If time and situation permit, notify your immediate supervisor. RELIEF The Security staff working this post will not be dismissed until properly relieved by the oncoming shift. This relief will at a minimum include a proper briefing of events that transpired during your tour of duty, inspection of all equipment, furnishing, fixtures, etc. assigned to that post. Once the oncoming shift is satisfied that there are no discrepancies, the exchange of post may be completed. If this post is not being manned by the oncoming shift, you must obtain the oncoming OIC' s authori zation before leaving your assigned post. COUNTERMAND The Facility Administrator retains the authority to countermand the procedures outlined within this post order. Under no circumstances will this authority be retained should these individuals become hostages. REVIEW THIS POST ORDER WILL BE REVIEWED ANNUALLY AND UPDATED AS REQUIRED . 2020-ICLl-00006 4136 NUMBER: GLADES COUNTY DETENTION CENTER 720.0 l A PAGES: 8 ACA STANDARD(S): POSTORDER Annual Review: 03-17-17 POST: HOUSING SUPERVISOR Revision Dates : Effective Date: 06-01-07 r b)(6); (b)(7)(C) Facility Administrator PURPOSE To specify the Duties of the Housing Supervisor in the Supervision of all Correctional Officers assigned to the Housing Unit. AUTHORITY Glade s County Sheriffs Office Policy and Procedure Florida Mode l Jail Standard s National Detention Standard s PROCEDURES Any officer upon assuming a new post shall sign the attached post order sign- off sheet indicating that they have read and und erstan d the orders for that po st. I. Shift Change A. B. The Housing Supervisor will rece ive a complete and detailed briefing from the off -go ing Housing Supervi sor to includ e; 1. Condition s of all locks, keys, safety and security equipmen t, and discrepancies reported durin g their tour of duty, locat ion of, logged, reported to whom , etc. 2. Incidents occu rrin g in the Hou sing area. Ensure all Hou sing Officers have been properly relieved and briefed and have initiated the hou sing log in accordan ce with Post Order: GCDC- 24.006; 1. The Housing Supervi sor shall conduct periodic review s of the housing log to ensure all entries are legible, accurate and entered in a timely manner. 2020-ICLl-00006 4137 GCDC-720.0lA Page 2 of 8 2. IL a. time out and in; b. purp ose of dep arture ; c. desig nated act ing hou sing supervi sor durin g yo ur absence . Inmate Traffic A. III. The hous ing super visor may be requir ed to leave the housing area to perform othe r duti es for short duration s of time . You will sign out on the housing log and sign in upon yo ur return , to includ e: Shall ensure all inmat es are prepar ed for schedul ed ac tivitie s. 1. Inmat es are prepared (15) minute 's prior to schedule ; 2. Inmat es are properl y dre ssed. Sec urity of the Hou sing Un it A. Shall supervise, direc t and ensure the ho using officers comply with and enforce : 1. All Hou sing rule s; 2. Conduct required safety and sanitation checks; 3. All sec urity checks are conducted to ensure all windows , doors, and locks are sec ure and in worki ng orde r. This inspection will be documented on the hou sing unit log . The housing unit superviso r will conduct a lock inspec tion daily. All discrepan cies will be reported to the OIC immediate ly. The OIC will initiate imm ediately corre ctive action . Inmate s will not be ho used in any ce ll that ca nnot be properly locked or unlocked; 4. Superv ision of in-h o use activiti es; 5. a. Day Room Act ivities b. Dining Activities c. Hou se Keepin g D etails Will ensure a ll areas of ho using uni t are clean prior to activat ing the television, telephon es and dayroom activiti es; 2020-ICLl-00006 4138 GCDC-720.0lA Page 3 of 8 IV. 6. Shall maintain close contact and interactio n with the inmate population addressing minor complaints as they occur and reporting major complaints to the Officer in Charge; 7. Ensure that the officers' station and dormitory doors are secured at all times when not in use. Inmates will not be allowed in the officers' station for any reason; 8. Ensure that officers assigned to the housing area are conducting searches of inmate property as required. These searches will be properly disposed of in accordance with 33-602.201 FAC; 9. Ensure that when an inmate transfers from the housing unit his property is collected, inventoried and stored in accordance with Inmate Property; 10. Ensure cell /bunk inspection are conducted each time an inmate is assigned to or reassigned from a cell. These cell /bunk inspections will be appropriat ely documented and the inmate will be held accountab le for any damage found to the cell /bunk; 11. Be thoroughly familiar with procedures relating to fire alarms, fire drills, and evacuation requirements of your assigned area; 12. Ensure inmates comply with linen and clothing exchange and all laundering procedures to ensure sanitation is kept high; 13. Monitor the use of television in the housing unit. Television will be turned on and off according to schedule; 14. Ensure that cleaning materials are obtained and that general housekeeping responsibi lities are completed daily by assigned housemen; 15. Ensure that direct escort is provid ed for inmates depart ing the housing area for any reason after secure compound count; 16. When an inmate is moved from one housing unit to another, the housing unit supervisor will ensure that the proper changes are made within Smartcop as it relates to Dorm, Pod, Cell, and Bed Assignments. Inmate Discipline A. Shall ensure the enforcement of the Rules of Discipline: 1. Will ensure that officers encourage preventive discipline; 2020-ICLl-00006 4139 GCDC-720.0lA Page 4 of 8 B. C. 2. Will assist officer in the effective coun seling of inmat es to encourage positive behavior; 3. Will instruct officers in the prop er use of the inmate discipline module and ensure that all infractio ns are recorded. Shall ensure Housing Officers follow the steps of progressive discip line: 1. Verbal Warning; 2. Corrective Consultation; 3. Formal Disciplinary Reports. Shall review for correctness all Disciplinary Reports initiated in the housing area: 1. Infraction is of a serio us natur e to req uire disciplinary report; 2. Correct Disciplinary char ge; 3. Body of report substantiates charge. D. Shall forward reports to the Shift Commander for review and approva l. E. When directed, shall condu ct invest igat ions of Disciplinary Reports; 1. Ensure that invest igatio n is initi ated within (24) hours from the time the repo rt is written; 2. Obtain statement from reporting officer; 3. Advise inmate of charge and read "Notice of Hearing" to inmate; 4. Obtain inmates version of offense; 5. Offer staff assistance, note acceptance or refusal; 6. Obtain signed witness stateme nts from all inmate witnesses and a signed written witness stateme nt from the charged inmate; 7. Obtain statement from all persons (staff or inmates); 8. Write summary of investigation; 9. Return report to Shift Commander within the spec ified time frame. 2020-ICLl-00006 4140 GCDC-720.0lA Page 5 of 8 V. Counts A. VI. Shall supervi se and direct the housing officers in proper count procedures: 1. Will visually observe the housing officers as they take counts; 2. Will correct officers who utilize improper procedures by demons tratin g the correct procedur es; 3. Will ensure inm ates comply with all co unt procedures appropriate action to correct or document inmat e violations; 4. Upon notification of a re-count shall ensure officers are rotated to re-coun t a different housing pod; 5. Ensure all co unts are reported to the con trol room in timely manner and recorded as req uired ; 6. Ensure officers see "living breat hing fles h" when countin g inm ates. Meal Time s A. Shall ensure mea ls are delivered to each inmate and distribution is superv ised: 1. B. C. VII. and take Monitor inmate conducts and observes feeding. At feeding, all inmat es should be checked to ensure complian ce with all uniform and groomin g regulations: a. ensure inmate has adequ ate time to eat ; b. ensure inm ates do not abuse time limits. Shall interview , at time of compl aint, any complaint from an inmat e concerning: 1. Food temperat ure ; 2. Food quantit y; 3. Food palatability. Will advise the shift comm ander of any compl aints in regard s to inmate meals and document same when directed. Unit Manageme nt 2020-ICLl-00006 4141 GCDC-720.0lA Page 6 of 8 A. VIII. IX. Duties will includ e making decisions regard ing security classification, jobs, services, and programs for all inmates within the unit. The Hous ing Supervisor has the ab ility to complete regular secur ity checks, maintain visual and auditor y contact, maintain personal contact and interaction with inmates, and be aware of the Unit's conditions. Staff Supervision A. The Housing Supervisor is the line superviso r for the housing unit. The Supervisor should monitor the performance of staff, and teach employees the routine and proper security procedure. B. The Supervisor is responsible for the quality of the professional work environment in his/her area. Sexual Harassment, or any form of discrimination or unfair work assignments will not be tolerated. C. The Supervisor will correct employee behavior or substa ndard performance by counseling, and when necessary formal reporting of the infractio n. The Supervisor will work closely with the Shift Supervisor to ensure that staff is trained, and have the necessa ry tools and equipment to do the job. They will con-ect substandard work habits, and make reports where required. D. All uses of force must be in compliance with the Florida Administrative Code Chapter 33-602.210 and Glades County Detention Center Policy. Should force become necessary, only the minimum amount of reasonable force necessary will be utilized. E. All housing supervisors will receive certification to carry and dispense chemical agents (OC). Cleansing of Inmate Housing Areas After Detection of Lice and Scabies A. B. The Housing Supervisor shall ensure that the following directives are completed to ensure that these infestations do not spread to other inmates and staff: 1. All inmates involved in cleaning infested areas will wear gloves and will shower thoroughly after cleaning is completed; 2. Infested inmates will be sent to medical for appropriate treatment; 3. Spray mattress and bed with "Liceall Spray" or other similar solution to kill lice/scabies. Then take mattress to the Intake Sally Port area where the mattress will be allowed to air out for 72 hours. The inmate will receive fresh linens, blanket, and a complete set of clothing. Procedures to follow for the different housing location of infestation : 2020-ICLl-00006 4142 GCDC-720.0lA Page 7 of 8 X. 1. Open bay dorm s; security will ask all inmates that have been in close contact with the infe sted inmate if they are experiencing any symptom s. If so, they will be sent to medical for evaluation and treatment; 2. Cell Block dorm s; the cellmate of any infested inmate will follow the same procedure s as the infested inmate outlined above. SECURITY OFFICERS ARE TO SEND THE CELLMATE AND/OR ALL CLOSE CONTACTS IMMEDIATELY TO MEDICAL FOR EVALUATION AND TREATMENT. Any que stion on the clean up procedure s after an infestation occurs should be directed to the m edical supervisor. Inmate Medication A. Over the counter medication s will be distributed by medical staff. BODY FLUID AND BLOOD SPILL CLEAN UP PROCEDURES 1) Contact on duty medical staff for immediate re spo nse INMATE MEDICAL CARE Medical care shall not be impeded, hindered or refu sed by any member of the staff at Glade s County Detention Center. All officers will be aware of confidentiality of medical information, and any medical information see n or overheard concerning any person, staff or inmate will be maintained co mpletely confidential. HOSTAGE DISCLOSURE STATEMENT Employees taken ho stage have no authority while they are hostages. Under no circumstances will an inmate be allowed to be relea sed, nor will weapons, or other equipment be given to an inmate. There will not be any exchange of hostages. PROCEDURES NOT COVERED BY THIS POST ORDER It is pos sible that situations may arise that is not covered by this Post Order. In such in stance s, it is expected that good judgment and common sense be used and application of Facility Operating Procedure s, Department Policy and Procedure Directive s, and Florida Statutes will be implemented. If time and situation permit , notify your immediate superv isor. COUNTERMAND The Facility Administrator retain s the authority to counte1mand the procedures outlined with this Post Order. Under no circumstance will this authority be retained should these individuals become hostages. 2020-ICLl-00006 4143 GCDC-720.0lA Page 8 of 8 REVIEW THIS POST ORDER SHALL BE REVIEWED ANNUALLY AND UPDATED AS NEEDED. 2020-ICLl-00006 4144 GLADES COUNTY SHERIFF 'S OFFICE PROCEDURAL GENERAL ORDER EFFECTIVE DATE 06-01-2007 RESCINDS /AMENDS 10-17-14 NUMBER 720.03 REFERENCE : ADM ISS IONS, CLASS IFICAT ION AND RELEASE OF ADULTS INDEX AS : ADM ISS IONS, CLASSIF ICAT ION AND RELEASE OF ADULTS DISTRIBUTION: ALL DETENTION PERSONNEL POLICY: It is the responsibility of the Detention Booking Deputy conducting bookings to inquire and reasonably determine that a prisoner brought into the Glades County Detention Center can legally be confined . Furthermore , all established rules , regulations and legal procedures for that prisoner's admission are met and any questions are clear ly resolved prior to completing the admission process . When a foreign citizen is received/adm itted to the Glades County Detent ion Center for any reason , the Booking Deputy shall inform the Department of State in accordance with the US Department of State rules . PROCEDURES : A. The Glades County Detention Center shall not admit an unconscious person or person who appears to be seriously ill or injured. Any such person shall be afforded necessary medical attention and must be medically cleared prior to admission . Any person being booked into the Glades County Detention Center shall not be admitted if that individual's blood alcohol content is .30% or above . This percentage is considered potentially lethal and anyone with such a reading will be treated as an overdose case and shall receive medical treatment before admission to the faci lity. B. A female employee shall be present to admit and process female inmates/detainees . A male employee shall be present to admit male inmates/detainees. A female Detention Deputy must be on duty at all times when the faci lity houses female inmates/detainees . C. During the admission process , a certified officer will search each inmate/detainee for weapons and contraband. D. Inmates/detainees shall not be held longer than eight hours in holding cells, unless the inmate's/detainee's behavior or intoxication prevents him/her from placement into general population. E. An inmate/detainee record shall be started and maintained on each individual when admitted . This record shall include : • Full name and known aliases • Age , date of birth, and sex • Date admitted • Race • Height • Weight Admission , Classification and Release of Adu lts 720 .03 2020-ICLl-00006 4145 • Offense with which the inmate/detainee is charged, or held for other agencies , or for which the inmate has been sentenced • Signature of person delivering and receiving inmate • A written descriptive inventory of all monies, valuables or other personal property . All items allowed to be kept by the inmate/detainee and those taken and stored will be recorded. The inmate/detainee and the Receiving Deputy will verify and sign the inventory. If the inmate/detainee refuses to sign, a notation will be placed on the proper inventory and a second employee will witness and sign the inventory . After the initial receipt is completed , any change authorized in the personal property inventory must also be documented, verified and signed by the inmate/detainee and the employee making the transaction. • Current or last known address • Name and address of next of kin • Marital status • Religion F. All persons booked into the Glades County Detent ion Center on criminal charges shall be photographed and fingerpr inted. Each inmate/detainee admitted shall be given orientation and a copy of the rules and regulations pertaining to inmates/detainees. G. All deta inees/inmate will be screened upon arrival at the facility for potent ial risk of sexual victimization or sexually abusive behavior, and shall be housed to prevent sexual abuse or assault. 1. The requirements outlined in GCSO Policy 720 .13 Sexua l Misconduct and PREA will be utilized during the intake process . H. During the admission process , inmates/detainees shall be perm itted to bathe, and issued two clean inmate uniforms, an admission pack , two new pairs of socks and two new pairs of underwear . Admission pack consists of the following: 1. One comb 2. One tube of toothpaste 3. One toothbrush 4. One conta iner of bath/body wash I. During the admission process, inmates/deta inees shall be permitted reasonable access to a telephone in order to contact their attorney, family members, or others . The inmate/detainee will be allowed use of the telephone only after all paperwork has been completed . Any inmate/detainee that poses a threat to the security of the Glades County Detention Center or safety of anyone present will not be permitted to use the telephone until such time as his/her behavior is in line with rules and regulations . J. As soon as practical following admission to the Glades County Detention Center , each inmate/detainee shall be classified . The classification process shall include all Adm ission , Classification and Release of Adu lts 720 .03 2 2020-ICLl-00006 4146 information available or obtainable from the social, legal and self-reported medical history of the inmate/detainee. K. The primary objective of classification is to place inmates/detainees in the type of quarters that best meet their needs and to provide reasonable protection for all inmates/detainees. The Glades County Detention Center shall have designated classification personnel. L. No inmate/detainee shall be subjected to more restrictive conditions of confinement and out-of-cell time than is justified by the inmate's/detainee's classificat ion. M. All ICE Detainees shall be classified upon their initial admission based upon the classification level listed on the 1-216. N. All ICE Detainees shall be re-classified by an ICE Agent following their initial admission. This Class ification Form shall be completed by an ICE Agent in accordance with the current National Detention Standards . 0 . The ICE Agent completing the re-class ification shall also ensure that the Initial Classification Form (1-213) and the Classification Form are forwarded to Central Records for proper filing. P. Classification criteria as to housing, programs, and privileges shall be written and incorporated into the Glades County Detention Center's rules and regulations . Q . Personal records shall be maintained on each inmate/detainee. Such information shall be confidential and not accessible to other inmates/deta inees. contain at a minimum: These records will • Legal authority for commitment • All information contained in the booking record • Classificat ion information and progress reports • Sustained disciplinary reports including investigation and disposition • All absences from the faci lity • Fingerprint card and photograph when taken • Record of any detainers or other civil or criminal process • Personal property records • The date and terms or conditions of release, the author ity for release , and signature of the releasing employee • Medical information , pursuant to law , is maintained in a separate file R. In determining custody grade, special handling, housing and programs for each inmate/detainee , a uniform classification process shall be applied to all inmates/detainees . The aforement ioned classificat ion process in (h) and (I) above shall follow the inmate/detainee throughout incarceration as a method of assisting in his/her 3 2020-ICLl-00006 4147 Admission , Classification and Release of Adults 720 .03 handling or treatment. The inmate's/detainee's adjustment should result in the gaining or loss of privilege, reduced custody housing, involvement in better job assignments, etc . S. Inmates/detainees will be released only in accordance with the written instructions as contained in the rules and regulations of the Glades County Detention Center , which will include the proper authority and procedure for the release. Release procedures include, at a minimum , the positive identification (photo wrist band and printed picture) of an inmate to be released, the authorization and verification of release, the receiving of facility property issued to the inmate/detainee, the release of inmate or detainee property and the documentation of the release. Inmates shall be released only after it has been positively determined that there is no other pending cases and/or detainers (holds) . At no time will an inmate/detainee be informed of his expected release/transfer by Glades County Detention Center Staff. T. At the time of release , inmate/detainee will sign for the return of their property , which was held in safe keeping by the Glades County Detention Center. An employee will counters ign this form confirming the return of personal property to the inmate. U. Effective July 1, 2007 , pursuant to Senate Bill 1604 and reflected in Florida Statutes: 775.21, 944 .606, and 985.4815, Florida Sexual Predator and Sexual Offender registration statutes were amended to explicitly require the custodian of the local jail to "register the sexual predator and sexual offender (including juvenile sexual offenders as defined in Senate Bill 1604 and 943.0435) within 3 business days after intake of the sexual predator or sexual offender for any reason and upon release, and shall notify the Department of Law Enforcement of the sexual predator or sexual offenders release and provide to the Department the specific information" All County Jails shall in addition to electronically registering sexual offenders and sexual predators upon release from the local County Jail shall also enter directly into the FDLE Sexual Offender database an "Incarceration Field Intelligence" report indicating that the subject is currently in a Florida County Jail and when the sexual predator or sexual offender is released from the local County Ja il. By completing an electronic registration form on a sexual predator or sexual offender prior to the release from jail ensures that FDLE and more specifically, law enforcement and the general public via the FDLE Sexual Offender Site: 1. Will receive the most currently reported permanent, temporary, or transient/home less status/residence of the sexual offender or sexual predator upon their release from ja il instead of the residence maintained prior to incarceration. 2 . Completing an electronic registration prior to release from county incarceration ensures that FDLE and local law enforcement have a signed electronic sexual offender/sexual predator registration form documenting the sexual offenders/sexual predators understanding of their sexual offender/sexual predator registration requirements by law. This is especially important in the case where the sexual offender or sexual predator is released on a law enforcement detainer to another Florida County Jail, to another state, to Federal/ICE custody , or Florida Department of Corrections custody . This form could serve as evidence in a potentia l failure to register case in the future . 3. This will also simplify the process for local County Jail staff from having to complete two electronic registrations. 4 2020-ICLl-00006 4148 Admission , Classification and Release of Adults 720 .03 The Glades County Detention Center in coope ration with the Glades County Sheriff's Office has established a method of operation to ensure compliance with Senate Bill 1604 as well as Florida Statutes: 775.21, 944.606 , and 985.4815. UPON ADMISSION: 1. Upon admission each inmate should be screened to determine whether they are a Sexual Predator or Offender. a . If the person is determined to be a Sexual Predator or Offender booking staff must forward a copy of the inmate 's JMS Face Sheet to the Chief of Security. The booking Deputy shall label the top of the Booking Report in legible ink "Sexual Offender'' or "Sexual Predator". 2. The Chief of Security will then contact the Crim inal Investigations Division Captain of the Glades County Sheriff's Office and inform them that a sexual offender/predator is current ly in custody . 3. The Criminal Invest igations Divis ion Captain of the Glades County Sheriff 's Office or his designee will ensure that the inmate/detainee is properly registered with FDLE using the electronic registration form . UPON RELEASE, BAIL OR TRANSFER: 1. Prior to release , bail or transfer from the Glades County Detention Center the Booking Deputy shall contact the Chief of Secur ity and inform him/her regarding the release of the Sexual Offender/Sexual Predator. 2 . The Chief of security will then contact the Cr iminal Investigations Division of the Glades County Sher iff's Office and inform them that a sexual offender/predator is current ly preparing for release. 3. The Criminal Invest igat ions Division of the G lades County Sheriff 's Office will ensure that the inmate/detainee electron ic registration form. is properly registered with FDLE using the b)(6); (b)(?)(C) (b)(6); (b)(?)(C) Adm ission , Classification and Release of Adults 720 .03 5 2020-ICLl-00006 Sheriff 4149 GLADES COUNTY SHERIFF'S OFFICE PROCEDURAL GENERAL ORDER EFFECTIVE DA TE 06-01-2007 RESCINDS /AMENDS 07-15-09 REFERENCE : HOUSING OF ADULTS INDEX AS : HOUSING OF ADULTS DISTRIBUTION: ALL DETENTION PERSONNEL NUMBER 720 .04 It is the policy of the Glades County Detention Center to house inmates or in accordance with chapter five of the Florida Model Jail Standards. POLICY: PROCEDURES: A. Housing standards will conform to the applicable standards of Chapter 5, Florida Model Jail Standards B. Male and female inmates shall not share the same cell and shall be separated by sight and normal sound in housing areas . For purpose of housing, sound separation is defined as restricting normal verbal communications . C. Separation of inmates 1. County Inmates should be separated in the fo llowing manner whenever possib le: • Adult female felons • Adult fema le misdemeanants • Adult female non-sentenced • Adult female sentenced • Adult male felons • Adult male misdemeanants • Adult male non-sentenced • Adult male sentenced 2. Dangerous felons shall not be housed with misdemeanants. dangerous felons may be housed with misdemeanants . However, non- 3. Immigration and Customs Enforcement Detainees shall be separated in the following manner : • Adult Male Criminals (Level 3) • Adult Male Criminals (Level 2) Housing of Adu lts 720 .04 2020-ICLl-00006 4150 • Adult Male Non-Criminal (Level 1) • Adult Female Criminals (Level 3) • Adult Female Criminals (Level 2) • Adult Female Non-Crimina ls (Level 1) 4. Criminal Detainees (Level 3) shall not be housed with Non-Criminal Detainees (Level 1). However , Low Criminal Detainees (Level 2) may be housed with Non-Criminal Deta inees (Level 1). 5. High Crim inal Detainees (Level 2) shall not be housed with Non-Criminal Detainees (Level 1). However , High Criminal Detainees (Level 2) may be housed with Criminal Deta inees (Level 3) . D. Inmates/detainees , who present a threat to the staff, other inmates or themselves, should be separated and closely supervised . Such inmates /detainees shall be known as special inma tes/detainees and may include the mentally ill, alcoholic, drug addict , sex deviate or suicide risk , or persons w ith contagious or commun icable diseases . Until such time as the health authority determines otherwise , in writing, any inmate/detainee who is identified as a suicide risk shall not be housed in a "single cell " unless the inmate/detainee is observed by direct visual observation 24 hours each day, wh ich shall be supported by documentation with notations at increments not to exceed 15 minutes. Close superv ision for special inmates as defined herein shall include regular , documented physical sight checks by Detention Deputies or medical staff persons at intervals not to exceed 15 minutes. Special housing shall be provided to inmates and detainees for medical reasons upon orders of the health authority. E. Persons brought to the jail for detoxification will be kept in an area designated for that use and will be held only so long as necessary to meet the requirements of Florida State Statute 397 .675. F. Inmates and detainees shall be assigned housing based on a classification process approved by the Detention Administrator w ith particular care to the assignment of those persons who have a recorded or demonstrated history of, or exh ibit aggressiveness toward other inmates or detainees. G. Inmates shall not be discriminated against , based on: • Race • National Origin • Creed • Disab ility - as defined and prescribed in the Americans with Disabilities Act • Economic statu s • Political belief 2 2020-ICLl-00006 4151 Housing of Adults 720.04 • Sex - except that males and females shall be housed separate ly. H. The following housing standards apply to the Glades County Detention Center: 1. Specified unit of floor space • Single cells shall contain a minimum of 63 square feet of floor space • Multiple occupancy cells shall contain a minimum of 40 square feet of floor space per inmate in the sleep ing area • Dormitory housing units shall contain a minimum of 75 square feet of floor space per inmate, including both sleeping and day room areas . However, inmates who are allowed out of their unit for a minimum of 8 hours per day (e.g., work programs, treatment programs, educationa l programs, etc.) May be housed in areas designated with a minimum of 70 square feet of floor space per inmate (sleeping and day room areas included) . • Day rooms shall contain a minimum of 35 square feet per inmate for all cell areas , except disciplinary and administrative confinement. 2. Each single cell will contain at least: • A sink with cold and either hot or tempered running water • Flushable toilets • Bunk • Artificial lighting which is of at least 20 foot-candles at 30 inches above the floor for reading purposes • Ventilation, which circulates, at least 10 cubic feet of fresh air or purified air per minute per person • Acoustics that ensure noise levels that do not interfere with normal human activities • Temperatures shall be maintained within a normal comfort range 3. All other housing areas shall provide a minimum of: • Artificial lighting which is of at 20 foot-candles at 30 inches above the floor • Ventilation, which circulates, at least 10 cubic feet of fresh or purified air per minute per person • Toilets and sinks in the ratio of a minimum of 1 to 8 inmates • Shower facilities in the ratio of a minimum of 1 to 16 inmates • Cold and either hot or tempered running water in the shower and sinks • Ready access during non-sleeping hours to tables and chairs or areas designed for reading or writing 3 2020-ICLl-00006 4152 Housing of Adu lts 720.04 • Temperatures shall be maintained within a normal comfort range 4. Upon admission and thereafter if indigent, inmates and detainees shall be provided reasonable access to toothpaste , toothbrush, shaving equipment, a comb, soap, and a clean towel. Dangerous shaving implements shall be restricted or issued for use only under observation when it is determined that issuance of such equipment would pose a threat to the safety of the inmate/detainee, staff or other inmates/detainees. 5. Female inmates/female detainees shall be provided necessary hygiene items. 6. Hair grooming will be made available. 7. Inmates/detainees shall be required to bathe at least twice weekly. 8. Drinking cups shall be provided unless the living area is provided with drinking bubblers or fountains. 9. Each inmate/detainee in general population will be allowed to shower daily. 10. Sinks, toilets and floor drains will be kept in good repair. 11. Utility closets, pipe chases, and corridors will be kept clean and free of clutter at all times. 12. The sergeant on duty or his designee shall determine what personal items may be kept in the cell or stored with the inmate/deta inee; however, an inmate/detainee shall be allowed to retain a reasonable amount of personal property including but not limited to his or her legal material, personal hygiene items, writing paper and writing instrument, and authorized reading material, in reasonable quanti ties, as approved by the sergeant on duty or designee. Personal items will be kept in an orderly manner. Limiting the amount of personal property in the cells reduces fire potential. 13. The sergeant on duty or designee shall inspect all areas daily or cause them to be inspected. Appropriate disciplinary action should be taken against inmates/detainees who fail to have their area, the common areas, and their persons clean and orderly. 14. A physician or designee shall examine an inmate/detainee confined in an isolation cell used for medical purposes within 48 hours following his/her confinement in such area or cell. A physician or designee shall determine when the inmate/detainee will be returned to the general population. The inmate/detai nee shall remain in isolation if the physician or designee: • Finds that the inmate/detainee presents a serious risk to himself or others, and • Continue to provide the inmate/detainee with follow-up medical care and treatment during the entire time that the inmate/detainee remains confined in such area or cell as deemed necessary . b)(6); (b)(7)(C) (b)(6); (b)(7)(C) ,..__ _____ 4 2020-ICLl-00006 4153 ..,,heriff Housing of Adults 720.04 (b)(6); (b)(7)(C) From: Sent To: Subject I fb )(6); (b)(7)(C) Monday, September 25, 2017 2:25 PM ~b)(6); (b)(7)(C) I Phone Calls The following detainee Almazan-Ruiz, Felipe A# 028866428 did not make any phone calls from September 9th , 2017 to September 11th , 2017 while he was detained here at IAH-MTC Management & Training Corporation Livingston, TX 77351. r )(6); (b)(7)(C) AccountingClerk MTC/IAH SecureAdult Detention Facility 3400 FM 350 South Livingston, Texas 77351 Ofc: 936 9 (b)(6); (b)(7)(C) Em b)(5); (b)(?)(C) mtctrains.com 1 2020-ICLl-00006 4154 U.S. Departmentof HomelandScturity 126 Northpoint Drive Houston,TX. 77060 U.S. Immigration and Customs Enforcement September 25, 2017 MEMORANDUM FOR: tee Director THROUGH: etent10n and De ortation Officer FROM: eportat1on SUBJECT: cer ALMAZAN Ruiz, Felipe A028 866 428 6 hod On September 13, 2017, Deportation Officf"J (b)( ); (b)(?)(C) myself spoke with detainee ALMAZAN Ruiz, Felipe at the Conroe Regional Medical Center (CRMC) in the Intensive Care Unit (ICU). Upon arrival, ALMAZAN was asleep but awakened during ~ur conversation with the Management & Training Corporation (MTC) security officers. Office ~b)\~);_~7 and I briefly discussed with ALMAZAN the status of his immigration case. ALMAZAN stated he had intentions of appealing his case as he has a petition pending. ALMAZAN did not state what petition he had filed. We then discussed whether he has any family in the United States and ALAMZAN stated he has family in Florida and possibly New York. At that point our interview concluded. www.ice.gov 2020-ICLl-00006 4155 9/19/2017 10:49:09 AM PAGE 1/049 Fax server -► PARALLON HOUSTON SSC FAX TO: FAX: " Houston =ROM: 9193691378846 =AX: PHONE. PHONE. PAGE NUM: b)(6); (b)(?)(C) l(b)(6); (b)(?)(C) 49 DATE: 9/19/2017 10:Ll2:"i6 AM COMMENTS: CONFIDENTIAL 2020-ICLl-00006 4156 Fax Server 9/19/2017 10:49:09 u u NOTICE OF DEATH - Must be compleled \__) .. I ~.O. ·-., t I ) '!_EATH PRONOUNCED 91111\l L;._) ' n full ff" ~p Other. c]lk I :I Q JP released remains (Sendr•H Dealh certi~ca'.e to be oomplelec' l>y""'(Attending p~.y~1cljn 0 ,, JUSTICE OF THE PCACE: (Je') NOTIFICAT1b\1: ONA 1u RM with p,~enr ir,(urm~h·rm) requesled autopsy I : "Mote: Consent from nex/ o/ ki .j5 nor req11/red 1/'iln autopsy IS ~rr1~rert OP; by a Jusr;ce or me Paace or ,¼:¥ca, Examiner"~ 4arl ofa death inques/. (b)(6); (b)(7)(C) DISPOSITION REQUESTS I ! ConroeRegional Med•ca!Genier. Its physicians. andrevresentatlvesare avthorizedto do the following: 1 Q, No AUTOPSY ~ Ye~ If au!cp5)c ~ame offul'\eral ho!T\ia: ---------"---------~-- Time:----- Date: ---+-----! AUTHORIZATION FOR RELEASE OF REMAl:NS: Signature-: I · 7eKas Deparime,i/ of Stale H~•Nh 's~rvices "Pos!morum : ' l l l lnciic111e pre~ence of known or suspected communi:i~le diseaseon :ag per policy. Fune•~·u~-A I b)(6); (b)( 7)(C) ,-, 1------ Date: Wilm ,__ ____ Date: q-17 ~:J..oif q_/7-/ I 11111111111111111111!11111111111111 Co"roe Re~ionalMedical Center Page 1 of 2 EPEMF0322./ Rev. Oa\a 3120/2017 ' r )(7)( EJ MRN:BH00861890 2 5~6Sfet,~ 00G 4157 1 Patient:RUIZ, FELIPE I 7 D-1· II limJ: -,! ) Qf~ ,, I Q4'3{) ! Tim~: l} ----------- u DEATHREPORT I Remains lo be tr,mspo sci lo above name<:'.funoral homo. Sign, DEATH 1 O For tr.a1;spo1lalio·1serv~~• only. iAA~~8• 1111111 IIUIIIIIIIIIIIUlllllllllllllllll ll!I ' ~~~~,:~~w. lee: ,-0 f Ansari, ~ ia MD Page 1 of S l1A# BH008C51 B90 DOB: 0~126166 51 M 09/12117 ·i Fax Server 9/19/2017 10:49:09 AM PAGE Fax server 3/049 :, J (b)(6) (b)(7)(C) ' r-- Exp: iiii ;;;;;: -..J .t. :-' { ... ---------"--,--+-"--'--'-'----~--- I Illllllllllll llllllllll 1111111 FACE FACES HEET Patient:RUIZ, FELIPE Conroe Regional Medical Center Paye I al 1 EAOMF0001 I RAV. Pal~ . I, .l 11111111111111111111111111111111111111! l .: c Rur------ Acct II DOB: 6 51 Ans.lri,Nafla t,m Page 2 of 5 # BH00861890 09/J;?/17 Fax Se rv er 8/19 /2 017 10:49:09 AM PAGE 4 /049 Fax Server NOTICE OF DEA TH • MtJst b~ completed in fufl for ALL deaths . I()5 \ 5 DATE OF 'DEATH: I TIME OF DEATH : qi 11 1 1 l Q_EATH PRON OU NCED BY: ~ .D. QRr-. QJUSTICEOFTHEFEACF NEXTOF KIN NOTIFICATION: 0 Name ol ~o~fied neX\ o f llil':._ _ _______ PHYS ICIAN NOTIFICATI0~~ (6) ; (b)(7)(C) phy$iCian notifie ~? -= ~tloMins Prcliminary cause of death: _ _ _______ _ I ed JUSTI CE OF THE PCAC E (JP) NOTIFICATI O N: 0 NA ~JPnolmed ='!:a"" .=- """l'--~~----_J·- I 6 \e _ _ __ _ _ _ _ _ ___ ~P d 'je mack. .jq er _ with p1 t. nl it1lormatio11} requested aulopsy Wo lra: eon~ ~nlfmm """' of kin Is no/ rer,uir~d II an autopsy h ordered by a Ju3ti:e o f lhtJ P.,~ce or Madi~ / E>arnine, s,i p~tl ol a deat h inques t "···---- - -- (b)(6); (b)(7)(C) ; Rea e;on· I $ 00 P ( Q JP re leau d rel'\e ln.s(Selld err .all lo RM Death cer1if1catero oe ~cwnp!e1ed by: ~ -Attending phy, fcian 0 0'.her:,__ _ _ ____ 0 JP :.__ _ I 1 9Tj: 11 l I 1 I T;E5 =? i DISPOS1T!ON REQUESTS Come>eR•gi on. l M-i icaJCe nic,, its phy sicians. and ieorcs entatives are aultlortzed lo do 11' .e folfowi'l g: 1. · 2. AUTOPSY O No -.....~ Yu ~~ l'\ - : STILLBORN 1NFANT SI MEONATAL DEATHS _0 For st illbo rn infan 1stneon~ 1a1dea th5 who are ot greater t!Mn 20 weeks gectall ona l age or g1eale r tha n 350 gm body weight. t ~nderst a nd relea se to fun eral home i$ 1equ1re<1 . Fo1stillborn infainl~n eon:i tal death s who are ofless th an 20 weeks gestational age or less than 350 gm body weight, (inilia l O'l e of the following) O ~__ 3. - ; vtc;,sy is 1-,q,,,ut,d t,y ne-.:t of kiri or physi~fl. comp el• /he Texas o,partm enr or State He,;/th .fW.i... !f) Plan lo discuss withdrawal of life sus taining theraoies with the fa rn~y (this pati ent l'las the potential to tJuoat;; liv er and/ or kid ney:i immed iately aff er c:ardjae death). 1. Contact li feGift a ,, (b)(6) ; (b)(l) (Ci 2. LUeGift Coorelinato~ 3. LifeGift Respo n:ie : ~ The p atlent is NOT a candlc:late for urgan donation cue to: O CO C C e: f' C'- I b O 0 ::>onot appr oach the family . 0 The p atien t is a cand idate fo r orga n donation . PrC11ide next of kin cont act information to LifeGift Coordinator . LlfeGift Coo'rdinator will contact next nf kin. [b)(6); (b )(7)(C) 9 I l JI I 1 _ Date: S\gn11tur TISSUE DONATION REFERRAL FOLL OWING CARDIAC DEAT H DSY 3 ' Tim e: -- - - -- -- -- - --- Referral criteria : --, Call li feGift within one hour of cardiac asystole lo determ ine suitab ilrty 'or tis sue donation . 1. Date of death: 9 j I 1 I \1 2. Cont3ci LifaG11tOrga n 3. """'"' 4. UfeGift Response: D5 Time of cealh; Dc.,(b,)(B), (b)(?)(C) 1 ' 7 d" S j s 1:11 or iPOOl sn 6567 to det em1ine eli gibility for eye /tissu e donation. 2n /cm , DI 1 - 0 9 -I5 0 2 2. UfeGm c.,o,d~ -~ The patient:, _ NOT a ca ndidate for tissu e and eye dOn!!1iOn due _ __ , <:0. ,..C c~r c-...·1 \ 0 to:_i..D ci Do Mt app roach the family . · :] The pati ent Is a ca ndlda le for dona tion of the follow ing : _ _ .E ye __ nssue '"'-- .: .J- -•w •r.f lcin ,.,..,...,.,,.+Information to Life Gift Coo' dinator . LifeGill Coordinator w ·11con lact next of kin . (b)(6); (b)(7)(C) ; _3_Li J j} 1 Sign at L Time : QS Y 3 OUTCOM E FOR POTENTIAL DO NORS O O O Pat ient is a regis lered donor. Next of k.in con sented to donat ion . Next of ~in does NOT con sent 10 donation Signa tu re:_ _ _ _ _ _______ _ ___ _ _ _ _ Date: _ _ _ ___ EDEMro322 REPOR T Patient :RUIZ, FELIPE Date 31201201I • MRN:BHOO861890 2~ ~ !:! . )(7)(E) 06 4160 Tim e:__ __ _ _ flII~Illflllllllllmlllllllllllllllll !ll11 1 Conroe Regional Medical Center 1111111111111111111111111111111 1 P..of2 g~~~ _ lfrFEI!PE • e~] bl/71 El c: B.CCU36-D 00t . Aflsari,NilZla MO Paga 4 of 5 ; l BHO086189O ,6G &1 M ~112117 9/19/2017 Fax Server 10:49:09 AM PAGE • • • Fax 6/048 Server LIFE GIFT DONATION REFERRAL ORGAN DONATION REFERRAL FOR IMMl~ENT DEATH (Ventilator-dependent patienls on y) Referral criteria: 1) Al firs( indication that the patient begins to lose neuro reHexes; GCS of"' 5 OR. 2) Pl,m to di$C\./Sswithdrawal of life sustaining ther.ipies with the iamily (this pc1lier,ihas tha potcnfo:::! !o don~!~ liver '!nd/ or kidneys immediately after cardiac dealh). 1. --1...._;2.=--.;a=-..::1_1...!,.._----=o:___i_-_!_1 S=-.=0__::.::'.l-=---- 2.. LileGift Coordinat...__ _____________ 3. lileGift Response: ~The patient is NOT a candidate for organ donation due lo: \ o co CC er O h D 0 Do not approach the family. 0 The patient is a candidate for organ donation. Provide nel/1 of kin contar..t information to LifeGift Coordinator. LifeGi/t Coordinator will con1.ici next of kin. b)(6); (b)(7)(C) Signature: Date: 9 I \ J IIJ Time: DSY 3 TISSUE DONATION REFERRAL FOLLOWING CARDIAC DEATH Referral criteria; Call Li!eGilt within one hnur □f cardiac a$ystole 9 t I J i IJ todetermine Time of death: suitability for th,sue donation. D5 ) 5 1. Dale. of c1eath: 2. Contact LifeGift Organ Donation Center et (713) 737-8111 or(800) 633-6562 to determine eligibility for eye/tissue donation. 3, Name ofllfeGift 4. LifeGift Response: }{ Cl) w .,, __ 0 0 ,-.. J - 0 9 -!5 D 2 ·=--=---:.-======---:::--:~-~-__.· The patient is NOT a r:andic:'ate for I &S\.J8 and eye d~~a;i~~ du~ Do not approach the family. ~ ~ Case: Z..D \ Co:>rdinator:j5<); (b)(?)(C) 10:49:09 MDon 09/14/2017 l(b)(6); (b)(7)(C) El ectroni AM PAGE cal 1 y si gncd byj 11/049 Fax Server O~:OS:15 PM MDon 09/14/17 at ?lOS l"'"'' ACCOUN PATIE~T NAME: RUIZ,~ELIPE (b)(7)(E) Patient:RUIZ, FELIPE MR.N:BH008618902~r'lt9 006 4166 Page 3 of 3 Fax 9/19/2017 Server 10:49:08 AM Fax 12/049 Server CONROEREGIONALMEDICALCENTER 0917-0047 504 Medical center Blvd. Conroe, Texas 77304 ,~~a ADMITDATE: 09/12/1-7 ROOMNO: B.CCU36 AGE: Sl PATIENT NAME: RUIZ,FELIPE ACCOUNT NO: % \17\/ Fi,,., MED[CAL PAGE RECORD NO: BH 61890 SEX: REPORTTYPE: DISCHARGESUMMARY M PHYSICIAN(b)(G); (b)(7)(C) ATTENDINGPHYSICIAN ADMITTING ADMISSION DATE: 09/12/2017 DISCHARGE DATE.: 09/17/2017 PRIMARYCARE PHYSICIAN: Florida None. The patient is from immigration facility in jail. ADMITTING DIAGNOSIS: Hematemesis. HOSPITAL COURSE: The patient was a 51-year-old Hispanic inca~cerated male who was taken to I ivingston Memorial Emergency Room with c:ompla:ints of abdominal pain 1 right flank pain and hematemesis. He has a past medical history significant for nonalcoholic liver cirrhosis, generalized anxiety disorder and depression. Hemoglobin level at Livingston ~R was stable at 12.S and hematocrit was stable at 33.3. He was transferred to Conroe ICU. In the hospital, he was started on octreoti de drip and was fo 17 owed by f bl/6\: /b\/ 7\/C\ I from GI and underwent EGD that was consistent with hypertensive portal gastropathy in the fundus, body of the stomach and antrum; pa.tc:hy erythema. in the bulb and second portion of the duodenum was seen. He was recommended to avoid any use of NSAIDs, recommended low-salt diet and continue medications, PPI 20 mg daily. He had mild =repone~a with a troponin level of 0.076 and 0.027. He was followed byl~j ib~)(~6)~; __ ~J Siddiqui. He underwent stress test on 09/16/2017 that was read as no~mal. No reversible ischemia was seen. He had normal left ventricular systolic function, calculated at 72% on stress imaging. He was fairly stable for discharge; however, a call was received early in the morning saying that the patient was hypotensive and code save had to be run. Stat labs revealed a drop of hemoglobin to 5.9 from 9.4 yesterday on 09/16/2017. The patient immediately went into respiratory failure. He was intubated. code blue was called and he was unable to be resuscitated, and then he was pronounced dead early in the morning. DIAGNOSESLEADINGTO EXPIRATION OF THE PATIENT: 1. Possible gastroint_eslirial bleed with a massive drop in hemoglobin/hematocrit from 9.4/26.3 on 09/16/2017 to 5.9/18.4 on 09/17/2017 in setting of severe thrombocytopenia due to nonalcoholic liver cirrhosis. 2. Nonalcoholic live~ cirrhosis, status post esophagogastroduodenoscopy consistent with hypertensive portal gastropathy. 3. severe thrombocytopenia secondary to nonalcoholic liver cir~hosis. 4. Abnormal liver function tests seconda~y ro nonalcoholic liver cirrhosis. Of note 1 at the time of admission, his total bilirubin was elevated at 6.56, this morning it had normalized to 0.99. 5. sudden respiratory failure requiring ventilator support. 6. cardiac ar~est, the patient was then pronounced dead . .,,..,..=""~---~ kb)(7)(E) ACCOUNTf; PATIENT NAME: RUIZ,FELIPE ~l_____ l(b)(7)(E) Patient:RUIZ, FELIPE MRN: B H008618902cJ00:lffl...~QQQ6 4167 Page 1 of 2 __. 9/19/2017 Fax Server 10:49:08 C0N-,..,. 100 H Tidal Voh.ime(Mtj_-!..:._ ________ --+---=-=,,-------,--;=-500 :iOO 5 5 PEEP (0.0 - 99.9 cm H20) 0.0 Pressure Support (0 cm H29) _______ _,_________ _ 18.5 L -8.2 I mmo~, ~ I aboratory Te_s_ts __________________ Chemistry Sodium (133 - 144 mmol/L) ··-Potass1um(3.5 - 5.1 mmo L) one( .:i-105mmo L) Carbon Dioxide (21 - 32 mmol/L) ~'-------4------~---+---A n ion Gap (4.0 - 1 5.0 GAP-cac) BUN(7-18M DL Creatin,ne 0.35 - 1.3 l'v1 DLJ G lomerular Filtr Rate ( > 60 cstGFRT Glucose (70 - 11 O MG/DLJ ·-Lactic i\cid-(b.4 - . mmo L Calcium (8.5 - 10. 1 1\1G/DL) Tota 1 1ru in (0.00 - 1.00 IV1GLJL) Direct 13il1rub1n(0.00 - 0.30 MG/DL) ---- · Indirect Bilirubin (0.2 - 13 /'v1G/DL) AST (15 - 37 Unit/L) Page Patient:RUIZ, FELIPE 3 of 09717 - 09/fT 0330 0200 148.0 H · 5.4 H 105 25 18.0 H 15 - l.49 H 50 87 0.!J2 114 H 9 Page 3 of 9 Server 8/18/2017 Fax Server 10:49:09 AM PAGE Fax Server 19/049 Pa~~ent: RUIZ,FE~IPE Unit#:BH0OB61890 Pate · a9 /J 7 / 1 1 AccL#: I l(b)(6); (b)(7)(C) -ALT (1 2 - ·18 Unit/L) --Total Ark Phos 54 [45-=-117 4 A umIn ( .4 - 5. U Albumin/Globulin Ratio (1.2 - 2.2 RATIO) S . 2.6 L 7.2 L 0.9 L DL) 1 NORMAL < 2 1\/tG, 1 NOR1V1AL < 10 MG ; 09/1 7 09/1 7 0127 0027 133-144mmo L Potassium (3.5 - 5.1 mmol/Ll Chloride (95 - 1OS mmol/L) Carbon Dioxide(21 -32 mmol/L) Anion Cap (4.0 - 15.0 GAP ca c) BUN (7 - 18 .f\\G DL) Creatin ine (0 ._5-_,? __ :__~1 ~· 3-0~i\=~•~G_/_D_L,_) ------1----------'-1 143.0 3.4 L 114 H 13 *L 16.0 H 13 .....,.0~1-+_ __, 92 110 DL 6.1 "'L G asp orus 2.5 - 4.9 • 3.8 Ma nesiurn (1-.6 - 2.6 ."v\G/DL 2.1 · Chemistry Sodlum (133 - 144 mmol/L) 136.0 Potassium (3.5 -· 5.Tmmol/L) Chloride 95 - 105 mmol/U 4.0 701 ucose (70 - 1 10 M Ca cium (8.5 - 10.1 i 700 ··fi.TL (1 NORMAL Index/OU 1 NOR1viAL <2 MG Specimen I leffiolysi? (1 NOR1\.~AL fr1iJe.~D=L~l-'-+~1 ~N~=R~M~A~L-<~1~0~f\~ ,\......., Specimen Arrearance Laboratory Tests .... 09/17 ---------------- Page 4 of 9 ~b)(7)(E) Patient:RUIZ, FELIPE MRN:BH00861890 ie2'tf-l~fi.oooo64174 ~age 4 of 9 Fax 0/19/2017 Server 10:49:09 AM PAGE Fax Server 20/049 Patient: RUIZ,FELIPE Unit#:BH0086l890 Date:09/17/17 Acct#: BH9023078383 0127 CClagulation PT (9.4 - 12.5 SECON OS) 22.6 H 1 1 INRUnit) INR(0.85-l. 1.96 11 PTT (Dade) (24 - 3 7.7 SECONDS) 60.4 H Laboratory --'--r--'-'es--'-'ts'--------------- 09/17 0330 Hematology WBC (4.1 - 12.1 k7nm3) RBC(3.8 - 5.5 ,\Vmm3) 12.4 H 1.70 ,.-:-c Hgb (10.6 - 15.8 G/DL) 5.4 *L Hct (36.0 - 47.4 %) }'v\CV(80.1 -101.1 fU ,~v\CH(25.3 -35.3 pg} rv\CHC (32.7 - 3.5.1 G/DL) 16.5 ,.L RD\V (12.2 -16.4 %) Pit Count (155 - 33 7 K/mm3) .1-,/\PV (7.6-10.4 fl) Gran% (37.8 - 82.6 %) 0 I ymph o/_oIAuto) (14.1 ~-4=5~.4~ -~o..:...) ___________ l'v1ono % (Auto) (2 .5 - 11. 7 %) Eos % (Auto) (O.O- 6.2 "lo) Baso % (Auto) (0.0 - 2.6 %) Gran# (2.0-13w7 K/mm3) 16.2 24 *I. 11.2 H 97.1 11.8 32.7 · 59.3 2~0.:.;,-.5 6.2 1.4 0.1 ······-··-·-·--·-··7w34H lymph# {Auto) (0.6 -J.8 K/mm3) 2.54 Mono# (Auto) (0.11 - 0.59 K/mm3) 0.77 H Eos # (Auto) (0.0 - 0.4 K/rnm3) 0.17 Baso # (Auto) (0.0 - 0.1 KTmm3) 0.01 Add tv\anual D'iff (CRITERIA DI r~r/~S~C~N~) --M~A~N~D~IF=F~I-N~D~I-C_A_TE~D~ Total Counted (100 #CELLS) 100 lmmdture Gran % (0.0 - 2.0 %) 12.5 ~ Seg Neutrophils % (40 - 7S %}_ ·· 82 : l Lymphocytes ''lo (Manual) (12.b- 43.5 % ) 12 L lvlonoc·;fes % (Manual) (4.2 -12.7 %) 4 L Eos1nop1·Ls % IManua (0. - .), % 2 Nucleated RBC % (0.0 - 1.0 /1 OOWBC¾) 1.1 H Nucleated RBCs# (0.00 - 0.05 K/mm3) 0.13 H . ..;:....::_:_::~-'-'-"-'-~~------'--~ TUXIC Granulation (NON E ON SCAN) SLIGHT -·--Platelet Estimate(ADEQOAIE ON SCANl MRKDf:CR L 09/17 Page:, of I 09/16 I 9 b)(7)(E) Patient:RUIZ:, FELIPE MRN:BHooss1s 9o 282~!Jet,'D0006 4175 Page 5 of 9 Fax 9/19/2017 Server Patient: AM PAGE 10:49:09 Fax Server 21/049 RUIZ,FELIPE Unit#;BH00861890 Date!09/l7/17 Acct#: BH9023078383 0127 Rematolog}'. \VBC (4.1 -12.1 k/mm3I Rt3C (3.8 - 5.5 MTmm3) Hgb (10.6 - 15.8 G/DL) Hct (36.0 - 47.4 %) MCV (80.1 - 7 01.1 fl) . MCH (25.:f~ 35.3 pg) ......... ... '% (Auto) (O:Cl-2.6 SI.ti ... 1.81 *L . - . ···- ,\KHC (32.7 - 35.1 G/DL) RDW (12.2 - 16.4 ¾l Pit Count \155 - 337 Kfmm3j t\-WV (7.6- 10.4 fl) Gran % (37.8 - 82.6 %) lymph % (Auto) (14. l - 45.4 ¾l .rv1ono % (/\uto) (7.5 - 7 7. 7 %) Fm % (Auto) ((i.0 - 6.2 %) Baso ,_ ····-·-- ..... 2.9 L 2.89 L 9.4 L 26.J L 5.9 *L 18.4 *L ·7·01.7 H 91.0 32.6, 32.5 32.1 L 3.S.7 H 15.0 H 17 .6 ! 1 • 35 *L :26*[: 11.5 H 10.0 49.8. 63.L 33.7 6.0 2.4 23.3 9.0 3_j 0.0 1.82 L 3.29 ..0.67 0.59 0.26 0.10 0.23 0.01 0.00 0.1 %) 4.87 Gran# (2.0 - 13.7 K/mm3) LymQh # (Auto) (0.6 - 3.81Vmm3) fv\ono # (Auto) (0.17 - 0.59 K/ni~3) t::os 1t (Auto) (0.0 - O)l K/mm3\ · ·saso # (Auto) (0.0 - 0.1 K/mm3) Aaa Manual 15\ff(CR:ITFRIA 81FF/SCN) ---Total Counted (180 #Cf-11 S) Immature Gran % (0.0 - 2.0 %) --?~~eutroohHs-% 05}:'5_ ····-··-· i\·\AN ·----Dlf-f- INDICAH-0- {40 - 75 ¾l Lymphocytes% (l'v1anual) \12,6 - 4J.5 %) (lv\anual) (4.2 - 12.7 %) Fosino_phils % (f\.fanual) (0.0 - 5.2 %) N t.icleated RBC % (0.0 - 1.0 /100Vv'8C%) N Licleated RBCs # [0.UU - O.D.5 K/mm3) Platelet Estimate (ADEQUATE ON SCAN), MRK DECR L '$DGI IT fv\acmcytosis (NOt,JE__ SCAN) /\1onocyte.s% 100 8.0 H 72 23 1.0 4 L 1 0.4 0.04 0.0 o:oo p \J Radiologydata: Recent Impressions: NUCLEAR MEDICINE - NM MYOCRDSPECTR/SMULT 09/16 0730 *** Report!mpres5ion-Status: SIGNED Entered:09/16/20171256 l.'VIPRESSION: 1. Normal myocardial perfusion imaging stress test 2. No reversible ischemia Page~ of .9 b)(7)(E) Patient:RUIZ, FELIPE MRN :BH00861890 te~'o~'ffl!FOOOOG 4176 Page 6 of 9 Fax Server 8/19/2017 10:49:09 PAGE AM Fax Server 22/040 I . Pacient: RUIZ,FELIPE Unit-#:BH0086l890 Date•09(17/17 l(b)(7)(E) Acct#: I 3. Normal left ventricular systolic function, calculated EF 72% on stress imaging Kb)(6); (b)(7)(C) Impression By: t.SDR.RM20- I L.l______ _,_ RADIOLOGY - XR CHEST 1 V 09/17 0127 *** Report Impression - Statl.l~: SIGNED Entered: 09/17/2017 0147 IMPKtSSION: ETT in the right mainstem bronchus. It should be pulled back 7 cm. ******"**"'***..,***"*FOR INTFRI\AL COOING PURPOSES ONLY***"'***'""'*"***"'* RFSULT CO'.JE: CVR Impression By: t.SDR,M.ASOl (b)(B); (b)(?)(C) 1,/\--\.D. RADIOLOGY - XR CHEST 1 V 09/17 0222 *** Report Impression - Status: SIGNED Entered: 09/17/2017 0248 ll'v\PR[5SION: Readjusted endotracheal tube now with tip terminating arproximately cm above the carina in aopropriatc appearing position Impression By: t.SDR.SR31 b)(B); (b)(?)(C) M.IJ. RADIOLOGY - XR CHEST 1 V 09 17 0222 **"' Report lmrire.ssion Status: SIGN[D Entered: 09/17/2017 M 3 0248 IMPRESSION: Readjusted endotracheal tube now with tip terminating approximately 3 cm above the carina in appropriate appearing position Impression ____.I M.LJ. By: t.SDR.SR31 - .... l(b-)(B-);- (b-)(-?)-(C_>___ Results: labs reviewed, vital signs stable, x-ray personally reviewed, rnrrent med profiic rev'd Treatm~nt & Prophylaxis Treatment & Prophylaxis VTE Prophylaxis VTE prophylaxis initiated: Yes Oxygen: ventilator Page 7 of 9 J b)(7)(E) Patient:RUIZ, FELIPE MRN:BH00361890 ~b~'a!F--0006 4177 Page 7 of 9 Fax Server 9/19/2017 10:49:09 AM PACE Pac~ent: RUIZ,FELIPE unit#:BHOOB6~s90 Dac.e:09/17/17 Fax 23/049 Server Acct#: BH9023078383 Ventilator: assist control Lines:CVC, P.A Tube feeding: No Anti-infective5: aztreo nam, ceftriaxone IV fluids: NS Pressors and inotropes: norepinephrine Ulcer prophylaxis: pantopra.zole Diagnosis. Assessment & Plan Diagnosis, Assessment & Plan Problem List/A&P: 1. Respiratory failure 2. Lactic acidosis 3. Cirrhosis 4. GIB (gastrointestinal bleeding) 5. Hemorrhagicshock Free Text A&P: 9/17 AT THIS POIN THEP T SEEJ\,,S TO BE DOING POORLY DESOPITEAGGRESSIVEtv1EDICAL tv1ANAGE1\-1ENT. I A,\,1 CONCERNED AOBUT HIS SEPTI SHOCK AND HEMORRHAGIC SHOCK ASSOCIATED WITH CIRRHOSIS AND GIB.L CERTAINLY THE PROGNOSIS ISX QUI 11::PIOOR. WILL PU\N D\A/ RN/FP Vl[\.\TD C Ll~E CXR Allt\E NGT TO SUCTION PRBC FFP Pl ATFI FTS PRl:.SSOR SlJPPORI /IV rllJ IDS ALBUMION COAN ULT H EJ\.·\E/G I ATX NEBS THIAMINE Page Patient:RUIZ, FELIPE 8 of 9 b)(7)(E) MRN:BH00861890 2Cffif-~fU 00G 4178 Page 8 of 9 Fax Server Pat~ent: 9/19/2017 10:49:09 AM PAGE Fax Server 24/049 RUIZ,FELIPE Unit#:BH00861890 Acct#: Date!09/17/17 NUTRITION CONSULT PHARr\ltCONSULT PAN CULTURES lj( b)(6); (b)(7)(C) Electronically s·1gned I.___________ I MD on 09/17/1 7 at 0502 RPT #:0917-0019 ***END OF REPORT*** Pa9"P. 9 of. 9 i b)(7)(E) Patient:RUIZ, FELIPE MRN:BH00861890 ~26~~~·os 4179 Page 9 of 9 9/19/2017 Fax Server 10:49:09 AM PAGE Fax Server 25/049 CONROE MEDICAL CENTER (COCCR) GE Consultation Note REPORT#: 0912--C667 DATE:09/12/17 PATIENT: REPORT TIME: STATUS: Signed 2041 UNIT#: BHOO861890 ROOM/BED: B_ICUlB-W RUIZ,FE~IFE ACCOL"NT# ; l(b)(7)(E) 06/2~6~/-6~6~A-G-E_:_5_1~ ADM DT : 0 9 / 12 / 1 7 DOB: * ALL edits or amendmer_ts SEX: M ATTEND: l(b)(6); (b)(7)(C) AUTHOR: L----------' must be made the on electronic/cornp·J.ter document* History Medications: I lome Medications: .rv\e 1cat1on Dose Rte Freq ,V1axDai I Dose 100 MG PO DAILY SERT RAUNI::(LOLOI: i) Stren8h: 100 /\·1GTAB traZ Done (OF.SY ) 50 .f\.·\GPO RF8Tll\1F. Strength; 50 /\-1G TAB 1-01 IC ACIIJ Strcn h: 1 1\-\G TAB 1 MG PO DAILY :\rlEPRAZ LE ER ( ril S C Days ·Qty Entered [ Last: 1 Revewed 09/12/17 09/1 2/17 1103 1104 09 12 17 09 127T7 1101 1104 09 12 1 7 09 1 2 1 7 1103 . 1104 oq 1 2 1 7 ! 09 , 2 1 7 1104 i 1104 .. 09 12 17 09 12 1 7 1104 1104 40 lv\G PO DAILY Stren th: 40 MG CAP_DR SPIRO~OLACTONF (ALDACTONE) Stren th: 25 1\-,GTAB Current Hospital Medications: Anti-Infective Agent:r. Sig/Sch Start time Last Status Adriin Stop I ime ~1_-e-vo---.,-o_x_a_c-,-in----,~o=o,--,/\--,1-,-1 ~Q~2~4~H~09/i2 1530 .AC 09/12. (l.FVAQUIN 500MG/ IV 09/19 1531 1€24 1OOML) 1v\edication Dose Route Cardiov.iS£ular Drugs Sig/Sch .. - I I · 1V1edication Dose Route 12.5 1V1G DAILY 1V1etoprolol Succina·1e PO (TOPROL XU Tabetalol HCI (TRANDATEl Lisinoprll !PRINIVIL) . Nicardipine]Sodium j Chloride ·· · Start time I Last Stop Time · Status Adm in 09/7 2 1 700 AC 09/11 10/121707 101\iC Q4H PRN PRN 09/12 i 530 AC 10/12 1531 IV 09/1 2 1100 DC 20 MG DAILY 10/12 1101 PO 250 ML ASDIR09/12 1000, AC IV 1011210011 Page 1 of 1626 09/12 1133 8 l b)(7)( E) Patient:RUIZ, FELIPE MRN:BH00861890 ~'C)~~F- QQQG MBQ Page 1 of 8 Fax server 9/19/2017 Patient: 10:49:09 AM PAGE Fax 26/049 RUIZ,FELIPE Unit#:BH00861890 Date:09/17./17 Acct#: I ij'.b)(7)(E) (CARDEN E-NACL 50 ,\·\G/ I I 2 0 1 .....,: N....,.i~c-ar--.-.-1p ..... 1-ne-.=o..,.,;~u -:- -L_I_V---1) i-----,,;2=5=0....,./\-.;,tL,--.,..T.-.-,-K~/\;ffD ONE 09/":2 09~3TOC:: ___: 09 12 Chloride IV 0959 (CARDENE-NACL 50 -~·IG/ 250 ML IV) Central Nervous System Agents Medication 1-:T-r-az-o~o-n_e_H_C~. ____ Sig/Sch Route Start time La~t I Stop Time Status Admin S_O_M_G~=R-F D~T-1 !\-\E~ __ ---0~911 2 21 DO AC 09/12 Dose (Dt--SYRt--l:1 PO Sertral ine HCI 100 /\AG DAILY (ZOLOFTI i ro tv\orphine Sulfate i 1 tvlG; Q4H PRN PRN (MORPHINf--?LJIFAllll ]1'{ Electrolytic 2015 10/1221D1 09/12 1 700 AC 10/12 1 701 09/12 1515 AC 10/121516 09/12 1626 Caloric And Wat RouteBl D Start time ___ tg p... 0 9712 PO 10/1 2 2 101 I Medication -L-ac_t_u~o-sc-,. -------+--~30ML Dmr 20 G1\V30 (CHRONULAC . C s , Last I~~~o Status· Admin CKD 09712 201 5 ML) 09 f2 1oOO AC 09/1 3 1555 250 ,\r\l ASDIR IV So ium C en e (NORi'AAI SALINE 250 ; MU "SodiumChlcr1ae· 2 1515 A 10/12 1 516 (NORM.AL SALINE 250 ,tvR) -vi'dium Chlorlde··--··· (SOD1 U.t-..-1 Ct ILORIDE 0.9% 20ML) · 1 151 5 AC 10/12 ·,516 IV Sodium Chloride (SODIUM CHLORIDE 0.9% 1000 1\-\l) 1 lOMLADIR 1,000 ML .Q13H20i'vf 09/12 i 515 IV 1 0/1 2 1 51 6 1/1,C ------··09(12· 16 24 Gastrointestinal Dru s tv\cdication Dose Par1toprazo e 40 1\1 (PROTON IX) Ondan5<'trnn He! (ZOFRAN) Sig/Sch Route Stop Time Status Admin C9 12 09 12 2100 J\C 1 2015 10/12 2701 IV 4 1\!IG Q4H PRN PRN 09/12 131 5 AC IV 10/12 151 6 Page ;, of MRN:BH00861890 09/12 1625 8 J Patient:RUIZ, FELIPE Last ~tart time b)(7)(E) 2'526!f~,-ooos 4181 Page 2 of 8 Server Fax Server Patient: 9/19/2017 10:49:09 AM PAGE Fax 27/049 RUIZ,FELIPE Unit#:BH00861890 Date:09 12 17 Acct#: (b)(7)(E) Vitamins S1 C Medication Dose Route Folic Acid 1 fv\G DAILY (FOLVITE) ro tart time Stop Time Last Status Admin 09/13 0900 AC 10/13 0901 Allergies: Coded Allergies: No Known Allergies (09/12/17) Objective Physical Exam VS/1&0: Last Documented: Pulse Ox Temp 02 Flow Rate -T6-.8 09/1 2 1838 2 09/12 1447 Medications: Active Meds + DC'd Last 24 Hrs Folic Acid 1 J'v1G DAILY PO I actulose 30 Ml BID PO (CKIJ) Pantoprazolc 40 MG Ql 2HR IV Trazodone I ICI 50 MG B[DTl.lv\[ PO Metoprolol Succinate 12.5 MG DAILY PO Sertral:neHCl 100/v1G DAILY PO Sodium C1lorirlP 2SO Ml ASrJI R IV Labetalol · lCI 10 .'v\G Q4I1 PRN PRN IV Levofloxacin 100 ML Q24H IV Morphine Sulfate 1 MG Q4H PRN PRN IV 0ndansetron HCI 4 f\,,G Q4H PRN PRN IV Sodium O1loride 250 /V1L ASDI R PRN IV Sodium C1loride 10 tvtl ASD!R IV (b)(7)(E) Patient:RUIZ, FELIPE MRN:BH00361890 ~26~~1f- 000G 4182 Page- 3 of 8 Server Fax Server Pacient: 9/19/2017 10:49:09 AM PAGE Fax Server 28/049 RUIZ,FELIPE Unit#:8~00861890 Date:09 Acct.#: 12 17 (b)(?)(E) Sodium C::hloride 1,000 1\~L .Q13H20M IV Lisinopril 20 ~v1G DAILY PO (DC) Nicardipine/Sodium Chloride 250 1'v1L ASDiR IV Nicardipine/Sod1um Chloride 250 ML .STK-1\'\ED ONE IV (DC) General appearance: alerL, awake Results Findings/Data: Laboratory Tests 09/12/17 1200: ---+--~< 09/12/17 1155: >----< 133,0 1CJ2 24 4.2 Lal:Jorator, Tests 09 12 1510 09 12 09 12 1530 1530 Chem!str -Ammonia (11.0 - J2.0 mcM ___ I_r_oponin I (0.000 - 0.045 NG ML) B-Natriurf'.tic 9 L) PP.ptidP.(0.00 - 100.0Q 0.270 *H PQ/~·.1!J. . 226.59 11 09 12 1155 Chemistrv 1---,~o~,u-m---'-,~1=33~~1~44~m_m_o~L --- Fage,;, 1JTO - - •· - of a J b)(?)(E) Patient:RUIZ, FELIPE MRN:BH00861890 zo~6~tltr-OOOG4183 Page 4 of 8 le§)~ ~132H Fax 9/19/2017 Server 10:49:09 AM PAGE Fax 29/049 Patient: RUIZ,FELIPE Unit#:BH0086~E90 Date:09 12 17 Server Acct#: (b)(7)(E) Creatin,ne (0.5.J - 1.30 MG/DIT .... 1:3G H omeru ar Fi tr Rate ( > 6 est F } Glucose (70 - 11 o-~1C/DL} 132 H Calcium (8~5 - 10.1 rv1G/DD---------1-------~7~.8~L Tolal Bilirubin (0.00 - 1.00 .~AG/rn) Direct Bilirubin (0.00 - 0.30 tv,G/1)1) In irect B1 iru 1n((L2 - 1.3 .'v1 DL 3.21 H 55 L 6.56 H 3.35 H AST (15 - 3 7 U nit7[l-·------'-----------~8~1~H----,--I ALT (12 - 78 Unil/L) 49 107 Total Alk Phos hatase (45 - 11 7 Unit/I) Iota Protein 6.4 - 8.2 ffLT -- 5.4 L 3.4 - 5.0 G/DU Albumin/Globulin Ratio (1.2 - 2.2 RATIO) Spedmen Appearance ( 1 NORJ\AAL lndex/DL) A umIn 2. l 1.2 3 SMALL 5-10 MG S ecim~n Hemolysis (1 ~O_R1_Vl_A_L_l_n_de_x/_D_;L)'---'-_2_T_R_A_C_E_. 1_0:;_-_2.::...5_/\_'lG.::...., Laboratory Tests 09/12 1200 Coagulation·-· --PT (9.4-12.5SECONDS) 17.3 H INR(0.85-1,11 INRUnit} 1.52H PTT (Oade) (24 ~ 3 7. 7 SECONQ~S) __ 2_9_.4_ I ahor atory Tests r-- -- . ·-·-·· 09/12 1200 Hematology 15. 1 H 3.50 I 11 .2 vVBC (4.1 - 12.1 k/mm3) RBC (3.S - 5.5 M/mm3) 11gb 1,10.6- 15.8 G/UL) Hct (36.0 - 47.4 %) .f\.\LV (80.1 - 101 .1 fl) 30. l L 8t'>.TI . • ·· --- MCHT2S.3 - 35.3 PgT MCHC (32:7 - 35, l u/Dll 37.0 J7.2 H ROW (12.2 - 16.4 %) Pit Count (155 - 317 _K/'!'::i,3) .MPV(7Xl-- 10.4 fl) Gran % (37.8 - 82.6 %) Lvmph % (Auto) (14.1 - 45.4 ~'u) f\-1ono % (Auto) (2 .5 - 11 .7 %Y Eo~ % (Auto) (0.0 - 6.2 'Yo) Baso ¾ (Auto) (0.0 - 2.6 ''fol · 11.2 TT ····· 27 * L 10.3 65.8 lZJT ··-. 0.5 ;=age 5 of 12.7 H 1.7 -----· 8 (b)(7)(E) Patient:RUIZ, FELIPE MRN:BH00861890 ~~6~~~6 i00G 4184 Page 5 of 8 9/19/2017 Fax Server Patient: 10:49:09 AM PAGE Fax Server 30/048 RUIZ,FELIPE Unit#:BH00861890 Date:09/12/17 ~b)(7)(E) Acct#: I ran# (2.0 ~ 13.7 K/rrim3) 9.95 H m Auto 0.6..: 3.8 Kimm} 1. IV1ono 1f (AuloJ (0.11 - 0.59 K7mm3) 1.91 H [os # (Auto) lO.O- 0.4 1<7mm3) 0.25 Baso ./f. (Auto) (0.0 - 0.1 k/mrr3) 0.08 Add Manual rJiff (CRl~T~ER_:..l_A_D'--I_F_;_F/_SC-=--N-'-l ______ J\,\AN DIFF INDICATED Tota Counte (100 #CELLS) 100 -lmmature Gran % (0.0 - 2.0 %) 7.2 H Seg Neutrophils "/o(40 - 7.'l %) 73 Lvm hoc tes % (.V,anua!) (7 2.6 - 43.5 %) 12 L Monocytes 0/o {Manual) (4,2 - 12.7 %) 14 H 1-osinophils "lo(.rv1anuali(0.0 - 5.2 %) 1, Nucleated RBC % (0,0 - 1.0 /100WBC%) 1.7 H Nucleated RBCs ft (0.00 - 0.05 K/mm3) 0.25 11 Toxic Granulation (NONE ON SCAN) SLIGHT P iifr•lr.tFstimate (ADFQUATF ON SCANf ---+,-.._,;:...:1=.aRc;:;K,:.,.;..:..,..,C""' __ R.....-,-1 ___ ___, Plti\~orphology Comment (NOR1\AALPl TS ON AN) U\RGE RARE PoIychromas ia (NONE O,;.,,N.,.-.-;SC,;::,A.....:.N~) ,----------+~S.;::..;LIG H oc romasia (NONE" .. NS AN) Poi I OC);tosis (NONE ON SCAN) An1suc tos1s(NONE ON SCAN) va ocytes (NONE ON S AN) Acant ocyt__ cs . J2Ur) N -NE ON SCAN) Schistocytr.s (NONE ON SCAN) HT LIGHT S~Ll~\~t---------1 LI H FE\.\' RARI:. j RARE Laboratory Tests ~-------- 09/12 1530· s NonReactive _i NEG-NONREAC Hep B Core lgi\-1Ab (Nonreactive SCREEN) Nor,Reactive ·· Hepatitis C Ant1bod (Nonreactive S_C_R_t_E_N....:.. )_· _ N_R ____ (NonrcacC RE:ENJ nreacttve N) ___J Radiologydata: Recent Impressions: ULTRASO.UN0· US ABDOMENLTD09/12 1637 *** Report lmpres~ion - Status: SIGNED Entered: 09/12/2017 1913 Impression: 1. lv\arkedly limited examination due to poor beam penetration. The liver, gallbladder, common bile duct and pancreas are inadequately Page 5 cf 8 l(b)(7)(E) Patient:RUIZ, FELIPE MRN:BH0Oas1a9o 2526!J~t~ 00006 4185 Page 6 of 8 Fax 9/19/2017 Server Patient: 10:49:09 AM PACE Fax 31/049 RUIZ,FELIPE Unit#:BH0O861890 nate:09/12/17 l(b)(7)(E) Jl.cct#: I visualized on this examination. 2. Unremarka::ile right kidney and visualized portions of the abdominal aorta an,d IVC. l(b)(6); (b)(?)(C) ...J Impress ion By: t.SDR. RH 16 .__ _______ Diagnosis, Assessment & Plan Free Text A&P: Consult: Hematemesis HISTORY OF PR~S Er-.T I LL!\ESS: The patient is a 51-year-old Hispanic incarcerated male, who was taken to Livingston Memorial Emergency Room with complaints of abdominal pain, and hematemesis He has a past medical history significant for ronalcoholic liver cirrhosis, genernl iT.edanxiety disorder, and depression He hcls been cia.gnosed with cirrhosis 7 years ago He is currently in the Department of Corrections. PAST MEDICAL HISTORY: As mentioned above, which includes, 1. Nonalcoholic liver cirrhosis. 2. Depression. 3. Generalized anxiety disorder. SURGICAL HISTORY: None. ALLERGIES: NO KNOWN DRUG ALLERGIES. MEDICATIONS PROM JAJL: Reviewed. SOCIAL I IISTORY: The patient is incarcerated. He is originally from Florida; however, because of the flooding, he was tnmsfcrrcd to Texas Jaii. F AMrL Y HISTORY: The patient is unaware of any medical problems running in the family. REVIEW Of SYSTEMS: Otherwise negative. GASTROJl\.TTESTTXAL: He presents wtth right upper quadrant abdominal pain and Page 7 ot 8 b)(7)(E) Patient:RUIZ, FELIPE MRN:BH00361890 29~5fel!1 00006 4186 [ ~age 7 of 8 Server 9/19/2017 Fax Server 10:49:09 AM PACE Fax Server 32/049 Pa~~ent: RUIZ,FELIPE unit#:BHOOB61890 Da:.e:09 12/17 Acct#: (b)(7)(E) hematemesis. PSYCH: depression. Vitals as above: General appearance: alert, awake, oriented Head/Eyes: atraumatic_, EOMl, icteric ENT: moist mucosal membranes Cardiovas~ular: regular rate & rhythm, normal heart sounds Respiratory: clear to auscultation. no distress, no tenderness, aerating well Abdomen/GI: active bowel sounds, soft, non tenderness Extremities: moves all, no edema-all extemities Musculoskeletal: full range of motion Neuro/CNS: alert, oriented X 3 Psychiatry: unable to evaluate LABORA ..TORY ANDDL\G~OSTIC DATA: Reviewed ASSESSl\.fEl\if AND PLAX A 51-year-old incarcerated Hispar.ic male with history of nonalcoholic liver cirrhosis, now presents with hematemesis Possible varices though PL Ts are low will t:--ansfusethen have EGD possible banding Agree with octreotidic and PPI drip with abx EGD planned tomorrow .'.\JPOfor now Follow up CRC in the AM . Electronically j l(b)(6); (b)(7)(C) _,pn 09/12/17 Signed by1... _______ at 2054 RPT #:09l2-0667 ***END OF REPORT*** rage 6 of 8 (b)(7)(E) Patient:RUIZ, FELIPE MRN:BH00861890 zo~6~~ 000G 4187 Page 8 of 8 Fax Server 9/19/2017 0918-0005 10:49:09 Conroe, PATIENT NAME· R!!Il Blvd. Center 77304 Texas ADMIT FEI lPf 09/12/17 B.CCU36 DATE: ROOMNO: AGE: ~~~~~~:~~~ (~~~-:_B_H_O_O.......J861890 REPORT TYPE: ADMITTING Fax server 33/049 CONROEREGIONAi MFDTCAI CENTER 504 Medical ~~~~~~~ AM PAGE ELECTROCARDIOGRAM 51 SEX: M PI-IYSICIA¥ b)(5); (b)(l )(C) ATTENDINGPKYSICIA~l________ _. order: 20170917-0006 Test Reason : C~EST PAIN Test Date/Time Stamp: sun Sep 17 2017 04:56:16 Blood Pressure : •**/*** mmHG Atrial Rate Vent. Rate 055 BPM P-R Int 000 ms QRS Dur QT Int : 408 ms P-R-T Axes QTc Int : 390 ms 081 BPM 140 ms -18 151 147 degrees rhythm with 2nd degree AV block (Mobitz 1) Right bundle branch block ST elevation, consider inferior injury or acute infarct Sinus icic ir'I< ACUTE MI icf< 'let, Abnormal ECG When compared with [CG of 17 sinus rhyth~ is now with 2nd venr. rate has decreased BY Right bundle branch block is Confirmed by !(b)(6); (b)(7)(C) Referred SCP 2017 00:33, (Unconfirmed) degree AV block (Mobitz I) 67 BPM now present sy: Ali Abbas Ion9/18/2017 Confirmed signed AM 6)_;(_ by: .... rb_)(_ b)_(l _)(C _ )____ ____. I (b)(6); (b)(7)(C) Electronically 7:42:l6 l by~---------~ on 09/18/17 at 0742 ••l(b)(7)(E) PATIENT NAME: ACCOUNT ft- _ RVIZ,FELIPE b)(7)(E) Patient:RUIZ, FELIPE MRN:BH00861890 f 2 ~-ft!r ~0000S 4188 Paga 1 of 1 Fax Server 9/19/2017 09l8-0002 AM PAGE 10:49:09 Fax Server 34/049 CONROEREGIONAL MEDICAL CENTER 504 Medical center Blvd. Conroe, Texas 77304 PATIENT NAME: RUIZ,FELIPE ADMIT DATE: 09/12/17 ROOMNO: ACCOUNTNO:~h= )f~7)= fF~)~~~~~__._~ MEDICAL RECORD NO: b)(6): (b)(7)(C) REPORTTYPE: ELECTROCARDIOGRAM ADMITTING PHYSICIAt-. f b)(6); (b)(7)(C) All E:.NDLNG PHYSICIAN! B.CCU36 il AGE: SEX: M 1 ._ _________ _, Order: 20170917-0050 Test Reason: UNKNOWN Test Date/Time Stamp: Sun Sep 17 2017 00:33:17 Blood Pressure : •••;••• Vent:. Rate 122 BPM P-R Int: 158 ms QT Int : 298 ms QTc Int : 424 ms rnmHG A.trial Rate QRS Dur P-R-T Ax:es 122 BPM 072 ms 022 114 026 degrees sinus tachycardia Left posterior fascicular block Abnormal ECG when compared with ECG of 12-SEP-2017 17:17, vent. rate has increased BY 52 BPM Left posterior fascicular block 1s now present T wave inver · · nterior 1eads confirmed by b)(5);(b)(7)(C) on 9/18/2017 5)"""" Refer red By: ~(b.,.., )(= ; (,...., b)""" (7""l(= c ,) --.-------c-o Elect~onically ..... nfi rmed by kb)(6); (b)(7)(C) Signed by .... l ________ I __,on 7:41:06 AM f.... b_J<6 _l_;C_bl_<7_l<_cJ____ 09/18/17 at 0741 ,. ••Kb)(7)(E) PATIENT NAME: RUIZ,FELIPE ACCOUN T ,,. l b)(7)(E) Patient:RUIZ, FELIPE MRN:BHooa61s90 2o~cr~er.looos 41a9 Paga 1 of 1 __, Fax Server 9/19/2017 PATIENT Fax Server 35/049 CONROE REGIONAL MEDICAL CENTER 09H-0004 ACCOUNT AM PAGE 10:49:09 504 Medical center Blvd. Conroe, Texas 77304 NAl~E: RUIZ, NO: kh\17\/ 1=\ 09/12/17 ADMIT DATE: ROOM NO: FELIPE I RECORDNO: BH00861890 REPORTTYPE: E!.l=(TROCAIWTOGRAM B. ICU18 51 AGE: SEX: MEDICAL M ADMimNG PHYSICIAN: ~b)(6); (b)(7)(C) ATTENDING PHYSICIAN:l order: 201.70912-0085 Test Reason : tropinemia Test Date/Time Stamp: Tue Sep l2 2017 17:17:29 Blood Pressure : •••;••• Vent. Rate 070 BPM P-R Int 182 111s QT Int: 416 ms QTc Int: 449 ms Normal sinus Nonspecific at outside eR mmHG Atrial Rate QRS Dur P-R-T Axes 070 BPM 078 1115 ··14 009 032 degrees rhythm n ST and T wave abnormality Abnormil 1 ECG pre vi o US,,.....i;;J...1.>. ..........i.:iu"-1...1..41,LLJ;::__ confirmed b (b)(6); (b)(7)(C) No R«ferred R.y: Electronically b)(6); (b)(7)(C) signed ~ _____ on Confirmed _~b)(6); (b)(7)(C) by 4,_ _________ 9/13/2017 7:14:36 AM 6 bf'-b-)(- )_; (-b)-(7_)(_c_i ____ I _,on 09/13/17 ____, at 0714 .,._•• r b)(7)(E) PATIENT NAME:RUIZ,FELIPE ACCOUNT.,. l b)(7)(E) Patient:RUIZ, FELIPE MRN: BH00861890 20216-Y~~l 00006 4190 Page 1 of 1 Fax Server 9/19/2017 10:49:09 AM PAGE 36/049 Fax Server CONROE REGIONAL MEDICAL CENTER 09l7-0008 504 Medical center Blvd. Conroe, Texas 77304 PATIENT NAME: RUIZ.FELIPE ACCOUNT NO: ADMIT 7 [ b)(7)(E) 09/12/17 B.CCU36 51 DATE: R00:'-'1 NO: MEDICALRECOko NO. BAvoo-61890 REPORTTYPE: eECHOCARDIOGRAM REPORT AGE: SEX: M ~b)(6); (b)(7)(C) ADMITTINGPHYSICIAN ATT~NDINGPHYSICIAN Kb)(7)(E) BH00861890 ECH02DDOP Echocardiogram Name: RUIZ, r[LIPE Patieni: Location: B.ICU4 8.ICU18 IV MRN: BH00861890 URN: BH 54 (b~)(% E) Account ft~1 Gender: M.._a~e ____ __, DOB: Report Study Date: BP: 89/50 SSA: cardiac Measu~ements with diam: 3.1 cm LA dimension: 4.1 cm LVIOd: 4. 6 cm LVIDs: 2.& cm RVDd: 3.0 cm MMode/2DMeasurements Normal Values: area: 7-23 mm calculations FS: 39. 2 % cm EDV(Teich): ESV(Teich): 81.6 cm/sec Ao VZ max: 161.9 cm/sec Ao max PG: 10.5 mmHq AVA(V,D): 3.0 cm2 PA V2 max: 111.5 cm/sec PA max PG: 5.0 mmHg 98.9 ml 29.9 ml 69.7 % dia.m: 2.1 LVOT area: 3.5 7.7 cm2 LVOT Doppler Measurements Calculations MV E max vel: 86.3 cm/sec MV A max vel: MV E/A: 1.1 1. 9 m2 20-37 mmACS: 2.4 cm 15-26 mm 19-40 mm 37-56 lllm rvsd: 0.94 cm6· 11 mm EF(Teich): Ao root mmHg 66 in 171 lb Gender: Ma.le CHEST PAIN Ao root LVPWd: 0.87 cm cm2 MV dee slope: 461.6 cm/sec2 MV dee time'. 0.19 sec LV V1 max PG: 7.6 mmKg LV Vl max: 137.9 cm/sec TR max vel: 240.2 cm/sec TR max PG: 23.1 mmHg -------- ··rb)(7)(E) ACCOUNT# - PATIENT NAME: RUIZ,FELIPE (b)(7)(E) Patlent:RUIZ, FELIPE 01:38 Height: Weight: 06/26/1966 Age: 51 yrs Ethnicity: other Reason ror Study: 09/13/2017 MRN: BH008618510 2~-ft!rf~ 0006 4191 Paga 1 of 3 PM Fax Server 9/19/2017 10:49:09 AM PAGE Fax 37/049 Server RVSP(TR): 33.1 m~Hg RAP systole; 10. 0 mmllg conclusions A complete uvo-dimensional transthoracic echocardiogram was performed (2D, Mmode, Doppler and color flow Doppler). The study was technically adequate. The left ventricle is normal in size. There is normal left ventricula~ wall thickness. Ejection Fraction; >65%. Left ventricular systolic function is nor~al. The t~ans11itral spectral Doppler flow pattern ,s normal for age. The left ventricular wall motion is normal. Left Ventricle The left ventricle is normal in size. There is normal left ventricular wall thickness. Left ventricular systolic function is normal. Ejection rraction >65%. The t~ansmitral spectral Doppler flow pattern is normal tor age. The left ventricular wall motion is nor~al. Right Vent ri cl e The right ventricle Atria ·1he left atrium visualized. is normal in si2e and function. is mildly dilated. atrial Right Mitral Valve The mitral valve is norMal in structure Pulmonic valve The pulmonic valve regurgitation. The aort·ic is not well is normal. IAS not well and function. Tricuseid valve The tr1cuspid valve is normal in structure not suggest pulmonary hypertension. Aortic valve The aortic valve opens well. valve is not well visualized. size and function. valve 1s mildly visuali2ed. Doppler findings sclerotic. do The aortic Trace pulmonic valvular Great Vessels The aortic root is normal size. Pericardium/Pleural There is no pericardial effusion. Fl P.,t roni call y signed b : (b)(6); (b)(?)(C) ordering Physician: b)(6); (b)(?)(C) , MD09/17/2017 PATIENT NAME: RUIZ,FELIPE 12:35 PM ACCOUNTi:~f b-)(-?)-(E_) _____ b)(?)(E) Patlent:RUIZ, FELIPE MRN:BHO0861890 2~~~- 00006 4192 Page 2 of 3 _, 9/19/2017 Fax Server Referring Performed P B 10:49:09 AM PAGE 38/049 Fax Server )(5); (b)(?)(C) (b)(6); (b)(?)(C) Electronically on 09/17/17 at 1236 Signed by PATIENT NAME:RUIZ,FELIPE Patiant:RUIZ, FELIPE MRN: BH00861890 ACCOUNT 2~-~N #~rb_)(-? )-(E_l ____ (b)(?)(E) 00006 4193 age 3 of 3 ~ Fax Server 9/19/2017 Patient Name: EXAMS: 020699234 10:48:09 AM PAGE Unit RUIZ,FELIPE Fax Server 39/049 No: BB00861890 CPT Pharmacologic Protocol Myocardial CODE: 78452 NM MYOCRD SPECT R/S MULT Perfusion Imaging Rest/Stress test; 1-day INDICATION: Diagnosis pain of coronary artery disease in patient with cardiac with atypical chest history: Clinical Patient chest is pain a 51-year-old male risk and atypical factors PROCEDt)RE : Pharmacological stress testing was performed with Lexiscan 0.4 rng/5 rnL from a prefilled syringe tha.t was discarded after single use. The heart rate increased appropriately during Lexiscan infusion. Following Lexiscan injection and saline flush, the patient was injected with 32.0 mer of sestamibi and stress gated tornographio imaging was performed. Prior, resting imaging was also performed following the injection of 14.7 rnCI of Sestarnibi. FINDINGS: The EKG portion quality of the the raw images, amount of of the stress test shows no acute ST changes. overall study is fair. The left ventricle i~ normal in size. there is no motion artifact. There is significant uptake noted on both stress and rest images. gut On Stress; The stress SPECT images demonstrate hamagenous tracer distribution throughout the myocardium. The gated stress SPECT imaging reveals normal myocardial thickening and wall motion, The calculated left ventricle ejection fraction of 72%. Rest: The rest throughout SPECT images again the myocardium. In comparing ischemia. 1.00. the There is demonstrate stress and rest images, no transient ischemic IMPRESSION: Normal rnyocarctial perfusion 2. No reversib1e ischemia 1. 3. stress (Y'lm:>n~ Patient:RUIZ, FELIPE Normal left imaging Mli'n r,'T't> ventricular T'IJ fr-,~~ MRN:BH00861890 inaging systo1ic ~ i(7)(E) homogenous there is dilatation, stress function, =~ • tracer no reversible calculated TID is test calculated Li;'l<'.T.Ttr~ 202'6-Yt!~l~funG 419.4 r distribution Page 1 of 2 EF 72t on Fax Server Patient 9/19/2017 Name: 10:49:09 AM PAGE RUIZ,FELIPB Unit No: ** Electronically Signed by Reported MULT signed Nuclear Medicine Cardiology exams anoracriate software far nrocessioa cc =l(b)(6); (b)(?)(C ) n 09 (b)(B); (b)(?)(C ) and BP.O0861890 CPT CODE: 78452 EX:AMS: 020699234 NM MYOCRD SPECT R/S Fax Server 40/049 by; 16 2017 at 1253 performed on dual and renoctiocr head cameras (b)(?)(E) Patient:RUIZ, FELIPE MRN:BH00861890 2~-~~r.l-0006 ** (b)(6); (b)(?)(C ) 4195 Paga 2 of 2 with 9/19/2017 Fax Server 10:49:09 AM PAGE (b)(6); 9 3 6-5 B (b)(7)(C) 936-58 M 936-75 FAX: FAX: FAX: Patient Name: EXAMS: 020699688 Campus: Unit RUIZ,FELIPE No: St: C ADM BHC0861890 CPT CODE: 71010 XR CHEST 1 V AFTER HOURS SERVICE ON: 9/17/2017 AP Portable Fax Server 41/049 5:06 AM Chest Location Cade M12 HISTORY: POST LINE PLACEMENT FINDINGS: Inspiration is n.idway iliove the effusions. is shallow. NGT remains in the d.isLdl stomach. The ETT between the clavicles and the oarina, appi:oxirnately 3 cm carina. There are no infiltrates. There a.re no pleur~l The~e is no pneumcthorax. Cardiac silhouette and rnediastinum appear within normal limits. IMPRESSION: 1. 2. No active intrathoracic ETT and NGT in place. ** Electronically ** CC: findings. by ~l (b_)< _5> _; _ (b_)(?_)_(C_)_________ on 09/17/2017 at 0507 Reported d.lld signed by: j-(b-)(6-)-; (-b)-(7-)(-C_______ ) Signed icb)(6); (b)(7)(C) Dictated Date ~~~,,.,¥z...L...-....L..t....-...l,!..,....J...._~05 O 7) Technoiogist: - Agency Transcribed Orig Print l"'/"\M'Or,'ll' Patient:RUIZ, FELIPE D D/T: 1,flH1 S: 09/17/2017 (0507) (0510) By: t.SDR.MASO PPI TU,.. IPage 1 of 1 _. _ Fax 8/19/2017 Server 10:48:08 b)(6), (b)(7)(C) FAX: FAX: AM r Name; EXAMS: 020699673 __ RUIZ,FELIPE Report P.a3 Fax Server Been C St: No: BH00851890 Amended** CPT CODE: XR CHEST 1 V 71010 Addendum ADDENDUM: 020699673 - 09/17/2017 SIGNED 09/17/2017 RAD/CXRl (b)(6); (b)(7)(C) Addendum: Results (b)(6); /h\/ ADM _. UniL ** 43/049 Campus: 936-58 936-58,__ Patien~ PAGE were at 7 \/r"'\ ** ** verbally communicated 1: 53 AM by WHRA on-call. Electronically by telephone to nurs ~I** 5 7 byf~ b_H_ l_; (_b_)C_lC _C_) _______ Signed on 09/17/2017 Reported and signed Dictated Date/Time: at ** Dl (~)(i )(b)( ? )(C) byl~.--' ----------~ 09/17/2017 (0154) Report AFTER HOURS SERVICE ON: 9/17/2017 AP Portable Location 1:41 AM Chest Code M12 HISTORY: ETT PLACEMENT FINDINGS: Inspiration located in effusions. mediastinum is shallow. NG tube is noted in the stomach. The the right mainstem bronchus. There are no pleural There is no pneumothorax. Cardiac silhouette and appear ;.,ithin normal ETT is limits. IMPRESSION; ETT in the right ma.instem bronchus. It should be p·J.lled back 7 cm. INTERNAL CODING PURPOSES ONLY**************** *******************FOR RESULT CODE: CVR ** Electronically ** on l 09/17/2017 Signed Reported t"'f"'INC>t"l'li' Patient:RUIZ, FELIPE M'li'I"\ 1"'"'1'0 n1 /l"li::i~ MRN:BHooss1ssio and I (b)(6); (b)(7)(C) by~=---,----=..,....,=--=--------~• signed at 01~3 u by:~fb_)(_6)_; (_b_)C7 _l_C_Cl _______ l(b)(7)(E) 25~6~~r.l!baaas 4197 rPage 'Cli' 1 of 2 ~ Fax Server 9/19/2017 10:49:09 AM PAGE b)(6); (b)(7)(C) (b)(6); (b)(l )(C) 936-58 FAX: FAX: Fax Server 44/049 Campus: C St: 936-58 ADM ------=====~-==-==-==-==-====------------------------------------------------------- Patient Name: RUIZ,FELIPE ** Unit Report Has Been No: BH00861890 Amended** CPT CODE: EXAMS: 020699673 XR CHEST 1 V 71010 cJ (b)(6); (b)(7)(C) Dictated Technologist Transcribed Orig Print DatjiLTirne· (0143) 09(11i2Dl7 Cb)(6); (b)(l )(C) I b)(6); (b)(7)(C) Date/Time: 09/17/2017 (0143) D/T; S: 09/17/2017 (0147) ____ By .__ ~-~~r_, t b)(7)(E) Patient:RUIZ, FELIPE MRN:BH00861890 2 000G 4198 ___. Page 2 of2 Fax Server 9/19/2017 10:49:09 AM PAGE b)(6); (b)(7)(C) FAX: Campus: r FAX: Patient Name: Fax Server 45/049 Unit RUIZ,FELIPE No: C St: ADM BH00861890 CPT CODE: EXAMS: 020699673 XR CHEST 1 V 71010 AFTER HOURS SERVICE AP PorLable Location ON: 9/17/2017 1:41 AH Chest Code M12 HISTORY: ETT PLACEMENT FINDINGS: Inspiration located in effusions. mediastinum is shallow. NG tube is noted in the stomach. The the ~ight m.ainstem bronchus. There are no pleural There is no pneum0thorax. Cardiac silhouette and appear within normal limits. ETT is IMPRESSION: E~T in the right mainstem bronchus. It should be pulled back 7 cm. *******************FOR INTERNALCODING PURPOSES ONLY**************** RESULT CODE: CVR b)(6); (b)(7)(C) ** Electronically Signed b on 09 /1 7 / 2.......,_ __ a~~~~---------' ** Reported and ._ <_ b)(_6)_; (_b)_(?_)(_C_) ________ by: signed (b)(6); (b)(7)(C) CC: l~-----------------' Dictated Time: Date 09 17 Technologist b)(6); (b)(7)(C) Trdnscribed Orig Print de D/T: l""f'I-..T0,....,1:1Ml:'li Patient:RUIZ, FELIPE l"''T'D me: S: 09/17/2017 T 't.T I t"\'Q (0143) 201? (0143) (0147) NZ. t..n,_· ~ MRN:BH00861890 By: 2~-f~rl~JJ (b)(6); (b)(7)(C) OTTT ~~(E~199 !;t 'l.'RT. T 'D"IfTT'7. 2U~6~'ffl.f-~ b6~~ ~ 4202 'i<'l<'T.T'O'li'. I Page 1 of 1 ** Fax Server 9/19/2017 0913-0070 10:49:09 CONROE REGIONAL AM PAGE MEDICAL Fax Server 48/049 CENTER 504 Medical Center Blvd. Conroe, Texas 77304 ~ig~~~~ ~~~~ci~~:~ ::~:::11~90 REPORT TYPE: E.NDO\IIORKS REPORT ADMITTING PHYSICIAN AllENDlNG PHYSICIAN Indications: 09/12/17 ADMIT DATE: ROOM NO: AGE: SEX: B.ICU18 51 M f b)(6); (b)(l )(C) ~------------~ Hematemesis (578.0). Consent: The benefits, risks, and alternatives to the procedure and informed consent was obtained from the patient. were discussed Pre-sedation Assessment: Hand P completed, I have examined the patient on this date and have reviewed the medical history, drug history, and previous anesthesia experience. Results of the relevant diagnostic studies have been reviewed. Planned choice of anesthesia, risk, complications, benefits and alternatives have been discussed. Preparation: EKG, pulse, throughout the procedure. kept IIIPO. Medications: pulse oximetry, An intravenous see anesthesia and blood pressure line was inserted. were monitored The patient was report. Procedure: The gastroscope was passed through the mouth under direct visualization and was advanced with ease to the 2nd portion of the duodenum. The scope was with drawn and the mucosa was carefully examined. The views were good. Findings: Esophagus: The proximal third of the esophagus, middle third of the esophagus, and distal third of the esophagus appeared to be normal. Stomach: Hypertensive portal gastropathy was found in the fundus, body of the stomach, and antrum. Duodenum: Patchy erythema in bulb and 2nd portion. Specimens Sent: None, unless othe~wise Estimated Blood Loss: Insignificant. noted. Unplarmed EvenLs: Ther·e wer·e no unplanned evenls. summary: No~mal proximal third ot the esophagus, middle third of the esophagus, and distal third of the esophagus. Hypertensive portal gastropathy was found in the fundus, ~ody of the stomach, and an~rum (S72.8). Patchy erythema in bulb and 2nd portion. Recommendations: including but not Return to floor. medications. PPI Avoid all non-steroidal anti-inflammatory drugs (NSAID's) limited to Aspi~in, Ibuprofen, Advil, Motrin, and Nuprin. Resume low salt diet as tolerated. Continue current 20 mg daily. (b)(7)(E) ACCOUNT#:. PATIENT NAME: RUIZ, FELIPE l (b)(7)(E) Patient:RUIZ, FELIPE MRN:BH00861890 2~6-~~r.l~ 1006 4203 Page 1 of 2 Fax Server Assisted 9/19/2017 By: The procedure 10:49:09 was assisted Procedure codes: [432 35] EGD Version 1, electronically signed 07: 47 AM ~lectronically signed AM PAGE 49/049 Fax Ion 09/H/2017 by ~/A. byl (b)(6); (b)(7)(C) l(b)(6); (b)(7)(C) b ~~-_______ _ .__________ ___. 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Ir 7 Y:'~ ½ti-<.____-...--_ fr 1 ~-6J5x\~-\-o , 9 sxl C-~ 3 / '. • -- -~ (b)(6); (b)(7)(C) Glb -fruvn-rfE_ cou/l-r 6t3 r;;:/, x t _C--~~) g 5x· 3 c-~\ o 1\ ..fc) v ~ coue;r by v/o: Cj0 -e·'r;-1:-=--- (b)(6); (b)(7)(C) ' -f~//')")_ +ru }I,) b)(6); (b)(7)(C) s X :!JL--...,,.t)-v ---,Y-,Y'\l ' ----==<1\ ;----'¥M U)1,J 1 b)(6); (b)(7)(C) 2020-ICLl-00006 4227 r5 ~ Ca.__,uz__ 1 ' ----:--~ - ,.:·~ _-- - ' 1 ...,,. .,,,. b)(6); (6);(b) (b)(m!7 )(C G) ---- r l(b} 1~)(6;),,X7>- ~ (b)(6); (b)(7)(C) bt) olo·'._-r,:-rr-__J 4 5~t ft ~lfW , covt/Jf +·;ht .~ - . .. ---,..., f-1-1(( ~ A IL IJ21'"bitcv.1 .C:?# rc/vdd17 1 ·iv t!-/C ;.:,,,, fl r---eeY(/tr'Ci,_-eefc-- A ({ ~ ecL-f/'-{:. feC-41'-f._ : C:o 4 llf Z::.j,-ecrf 'f0 5f .?f{v/;f S--ecvrr, :-1r _(t,,-eC/t- kl{ 7---tCLl(-e, r~c-r..tr/t( r1-ec/e- ~[( 1<.fcC-tr..z , 10;ff : ! __ (b)(6); (b)(7)(C) lf}v@ i59f . : fr'-{r·..h---,,-------::=-=--r.,-,r. f Ce lf (} f--- 'f _ //VJ'( : ~_5 b)(6); (b)(7)(C) . 'C.?ut?. _cf'½~C(c_ ~/ ( 7 '-f;C '-r/~ _ _ e,,,.,,,,____,.v.,.,,.,,_,/ _/20--.6- J / --MJ 4_ /~\\o..w~no__\\ ci{\-<.2~li-01 11\'~~oo~ \oq.A. : t;--ec 14 (/f ( i , frr: vtf/f( (bl< 5 !Oh'5 't ~ v /1.cf.o S~ c Gt f/ '[c/L -A-II 7e z:- w /'7-___ (b)(7)(C) tr C h -et'/c- ft/ ( >'f.LL/f'f :'.•: · ~:.; . } . , ... • . ...f , ... · M:anagement .; & Training Corporatio ,n -..~•:.\ ::;, IAH Secure Adult Detention Center Date.: Hospital Activity Log 3-//✓ J /ttiU()E-JLHA~ InmateName: -z_'-;!.D Shift: / Location (Hospital/~#) : . TIME -f.i/Jz ctJ1 - ID#: U tJ ({uhS-WAJ· t Cfl~§{{Az8 ACTIVITY 1--~--+-,-...........- --,-~ l-- ~d-L.--~~ ~e_~___J.,,~~~~=~~-!e.-=:...::~1:c::.._-- Handcuff Serial#:- OFFICERS! -;:----;;-i-;----,--:---;--:------:1----:;----:,--:---- ------ ~ ~ Leg Restraint Serial#: #:J)AUl CJ · Weapons Serial ,.-- (b)(6); (b)(7)(C) OfficerN '----l Officer (TWO) -- ----- (b)(6); (b)(?)(C) s· - --· - ------------ ---- ----· 2020-ICLl-00006 b)(6); ---l b)(?)(C) -- ·-··· 4232 . -·- - •-·· ·--- · ·--- · - ---- 1Y1 :anagemen;t & Training Corporatio,n IAH Secure Adult Detention Center Hospital Activity Log /27.. /n I~ Shift: Date : CJ ID#: Aoz_~ott Y?~ •, RM.#): ~ L-•.v_l'.1.)-;J'S.~~~ ----- Locati on (Hospital/ -- --/_ /._~_A _""-.c.lf _____ ACTIVITY TIME 0~6~ "-' (.. , 6/,oq ~ , t. ' or,z1 ..,. o<.3r.; - . I J. h~ _.JI O'V' _.i _ __1 ., j .I. ', ,. O- v,!,f- _,A'-'------'--\ o________ . · Wea.pons Serial #: .ALt:! u '....1.h ...Al\ _\ ,.1. . 1 - 11'1~1 1· ( ,_ -rv - --......,. _ - • .... 1 i .\ .,:,-\.. V\"\U. - ,l,, • I ~ OFFICERS! r---"G ___ r~- LJ ;_ ,.:dl cL...., l -•., i..J_/ .,,\....11-IJ-{,, ~~')"\.. l::,_.i,, O'IS1 .. ...1 _ :..___ (b)(6); (b)(7)(C) --¥.. ,I. ,. ~ ..... I tL;,.;--.u sl,~:_, / .,.__, l .__.\, OH3. _ Leg Restraint Serial#: 'f.-\o . ----:------- / lj Au '7:49 6 ~ (b)(6); (b)(7)(C) Officer Nam -- I n........, .,te: 'T/rz/11 1--------------- '--------.,- ..,......,.,~11 ,) (C) Officer (TWO) Signamres Superviso r S~ - -=================================== ::________ _ 2020-ICLl -00006 4233 M:anagement & Training Corporation IAH Secure Adult Detention Center Date; Hospital Activity Log 1-{(--f T InmateNBfile : Shift: ~ £, i'J- 1J2/u ID#: uAnit 2. 1s k £I<._ i 1-o ------- ,(JR rnaz,,. O. Location (Hospital/ RM.#) = ACTIVITY . TIME OFFICERS? 22.S"D Handcuff Serial# : ~G-SJ.,;:p.,,+-\ Y. ...... ,S,,___ · Weapons Serial#: C)S °t] 3£) (b)(6); (b)(7)(C) Officer Nam.e: L---~~~-----1.. J _ Leg Restraint Serial #~ l [M n ~ I I _______ (b)(6); (b)(7)(C) Cf-//-/±: ..u n:.:i.p:.,,~· Officer (TWO) Signatures : Supervisor Signature: - ---======= == ========~- ----- 2020-ICLl-00006 4234 rJ(,tj.D[ @ f55"{) (b)(6); (b)(7)(C) ol-ftJ[Z('.lr~: IAH Secure Adult Detention Center Hospital Activity Log iJ- {Z----f1 Date: Inmate Name : /11iltflt/JL~ -f!.0~ /'1 Location (Hospital I RM.#) : _ Z ~ Shlft: ID#: .f7u,uJ~ill f fif!JZ3&-!h4zf3 . A R-lO Cl,eb . TIME ACTIVITY Handcuff Serial #: ---- @ I 0 t7 __,_ v~ · _t1~V_W=--' ~g~~~~~~r-·~a-Clll~L.:::'=-.:tJ'-'-"'/V'---=I=---·....... 45--=----, ----- ----- OFFICERS! Leg Restraint Serial #: /3,.... (() (b)(6); (b)(7)(C) · Weapons Serial #: ~===:;:::::::::======::::::z==:.::::::=====---~ I (b)(6); (b)(7)(C) Officer Name: -====r,::-~=e:-:---------.....__-----, b)(6); (b)(7)(C) Officer (TWO) Supervis or Date: CJ ._( Z' s· Signatur ~=======;:::::::::====:;=:;::::========~ (b)(6); (b)(7)(C) 2020-IC 1-00006 4235 =------l (b)(6); (b)(7)(C) 7 [; •,r, Management ·,; ,,. -. & Training !::· ·;; t-- ? Corporatio !n IAH Secure Adult Detention Center Date: . H ospital Activity Log er- I;)_-I 9- lnmate NII.Dle : afl -R iu·z ~,:p Location (Hospital I RM.#): +.. F Shift: m #; ft 0-:)Bt; i~-{- ...,,Ji CJ~ I .. I I _,.J V \{)O :.., I .,_~ - ..tl ) ; ~• ,. ··- dt. /r k1.J ...-IL.. ~-1-I - ~II -- · ··.• L... . ~- /: .... J1 . .....1-l- ··- /L..Ll;... ,;,,:. r- ~ I .l~fJ,. ~ 17u, j ••~ ~ k.... di 'l - "L ..__, < .. I • I i. -1'lv j ~•- I I _J,....} "' O'ht, - OFFICERS~ 1NTI1ALS I - 'IL. l I b)(6); b)(?)(C) ~...... ~t<:.-.J \; .,- L •• ·- D..L..........l..i.... m1 67'0 ea.pons ---------- 1..- • ....u ,,-l ~· 070\ .W -- ACTIVITY TIME • -- J.1 .,.,..,_ ,J ··-· - ""' • _ I ..... Leg Restraint Serial #: 13-Yv ~'--------- - i --- - --- (b)(B); (b)(?)(C).fihiim~m -~-------< (b)(6); (b)(?)(C) -i- -- - ---.= =---b)(6); (b)(?)(C) D~a::!te~: _: ur.uLL __ __, _ Officer (TWO) Sign.a. Supervisor Signature: ______________ 2020-ICLl-0000 6 4237 _ __ _ _ _ ________ _ 1 :~ -.. l .:·: M:anagement & Training Corporation '; IAH Secure Adult Detention Center Date: Hospital Activity Log l\ ~ l~-1J Inmate Name: 'hl Shift: tllme(Z44'\ - a~·\]_ [eXipe. Location (Hospital/ RM. #): ID #: A0$'9;'.1.a{elf if? 1/)0fO c'.- Keg\()(\o..,l 'Rffi\~ \ C..,l\ ACTIVITY TIME Handcuff Serial #: 10 ~--- - Wea pons Serial #: --- ~b)(6); (b)(?)(C) b)(6); (b)(?)(C) Officer Name : (b)(6); (b)(7)(C) -- OFFICERS! lNITIALS Leg Restraint Serial #:-~_:.._:..=_ Ig~9~& __ l I I Date: Officer (TWO) Signatm Supervisor Sign ature: 2020-ICLl-00006 4238 0'JI1s(1ri _ _ M:anagement & Training Corporatio !n IAH Secure Adult Detention Center Date:Q 7l1,--\\ . InmateN~e: f+\~q~ 1°r Hospital Activity Log , I) , , ,ls) I K1J1L, ~J\ t-L1pt.. Shlib ID# : f f}-o ~ 6'(~ Location (Hospital I RM.#): _____________________ . TIME _ ACTIVITY OFFICERS! INITIALS • Leg Restraint Serial#: . l] .- L() ~e~ ' C ....J Officer Nam ,_______._ ___ Officer (TWO) Sign.a Supervisor Signature: 2020-ICLl -00006 4239 Da_te: ~ :j l.f- / ) •. anagemenl -:~M: ._-.17 : . . -· I·.,· r:,.,.,,.,.···.·< . ...· ' \ \ r; I ~o:~~1fon · t.-,, ....:.:._.·/• ·.·..... .:.:::;,;;-'; · IAH Secure Adult Detention Center Hospital Activity Log l O~ Q-rj-) '""\ lmnate Natlle : fr) MC'.; J_A\--, - fl; I\_ Y:-:e f1::_; ID#: /}{JrJ tt1,, ~f}-Y Shift: Date : Location (Hospital/ RM.#): Ci,A nl-C . TTh1E 1--r,~---= e,l.\- (D ACTIVITY --:-- -+-~ .----::-'---r----:---:-- - ~ -:-- OFFICERS! --r- - --:::; :--- - - - - --H.b)(6) ; (b)(7)(C) • Handcuff Serial#: ----J.-]~ _ -_( _ __ _ _ t/3 .- J{J ae!!) c- I Leg Restramt Serial (b)(6); (b)(7)(C) · Weapons Serial#! -;:::: (b::_;) (6,.::J ); (b =)(;;::: == 7)(:;::: C)==========:::!..., #f Officer Name Officer (TWO) Signa • Supervisor Signature: ------- -<------------- -· - --- --- -- -- - - ·- -- · -- - --- - ----- 2020-ICLl -00006 4240 ·-· -= =. - ·-- _, =;=: ===- - ·•··-- - · --- - ----- M:anagemen :t & Training Corporation IAH Secure Adult Detention Center Date: S- \'-1- InmateN~e : l :\ f}-:/r,4 Location (Hospital/ RM.#}: Hospital Activity Log Shift: mad,ru/ ACTIVITY OFFICERS? Leg Restraint Serial#: f0C\\... , · Wea pons Serial #: ~----L..;1--,-------(b)(6); (b)(7)(C) =- -------~ .:J ate: Officer Supervisor -· - bt- ~ febft Con ~ 2412 . TIME - - -- ·-·-- \ --- ·-------- -- --·---- ---- · 2020-ICLl-00006 4241 [a -:"f] C-l q.- I Lt-/ J tr ,,--, ~~ -,I ~~ :5 l· ~t:~~~ent Corporation IAH Secure Adult Detention Center Date : Hospital Activity Log ·g.- l'i -I l Shift: fr f Wl4 2..4,u . A.vI7- J~,ef~f t (Hospital t RM.#): COO roC f'Ykd t ,Ctc/ Inmate N~e : Location . 'lTidE !-------:1 ~=--,---,.- Handcuff ID w. . l >- - \ - ----- n-o:i-r-r1,, y;2.p ACTIVITY -t--7~--=- -;--- --::::-----:--:::--.---.:;;;::--=-------:=----,-------~ a-l O. Serial#: OFFICERS! (b)(6); (b)(7)(C) LegRestraint_Aerial# : (b)(6); (b)(7)(C) -------------- · Weapons Serial #: JJiO 1Je-1IJ,c_-/ (b) (6); (b)(7)(C) Officer Name : L.......o::.......,...--r-i=:-;;:-;-;=;=----------------, (b)(6); (b)(7)(C) Date : 9 -/ l/ --/_) Officer (TWO) Signa Supervisor Signature : ---- - ·---- ··- - ------- - ··-- - -----------::::""'"-====L -· - --- - -- -- - --- - ______ -- - --. - ---· -- . ..-- ---·- - ----·--- - -·-- 2020-ICLl-00006 4242 ---- - - _ - -·--- - -- : ,. ··:. :.:-:·:,...... J:. ..• ·,i:· :·· ~-- ::\ -'·"' '·? ·~- t :;·: M:anagemen ;t & Training Corporatio ,n '; IAH Secure Adult Detention Center Date: . Hosp ital Activity Log 9 ./ / 3/i,.J/7 Inmate N~e : Shift: 8/ma Z.u(l -£1-1, ·c:::_I Locati on (Ho spital/RM.#) : F'e1,/P e . TIME ~ /J -------- ID#: " fl.ozz 611f~oe.. Ke>qJt>/74/ /-lo5P/'-/4 7/ v 2 ?" ACTIVITY ~/n' 8'~(pt-llyL • I Weapons Serial#: 1Tti (b\/E )(6il'° ); (iiilb )i7'7 (7)m' ( :I) ____ ~ ....J._ _________ Officer Name '------ ---1__.,.a..._=l~~tt. ~ow::,~~~ I'-'~' ----------TIME - -- ACTIVITY <>1-'ft A.- . ....t I .• d1R .........~L.J.c ,_ 0$"1. e,L.1.. ,. ,j v75'&" I ' .L • ~ •.JL I \IQ) ,.L, I• - ..,._, ii. , 1 • 1 .,_ !4l'i c.W.. ,~ •.._ "-·~ ,I , I L 1-, t:.L., :~ <.J' J - A:-1- ~ II ~ /4I ... ·~ - .J ~u.:::::r. -1- .J -I. j ,..14 ....11 ~....,_ ,j .._JL 4 ;1.,'f. .:J - .,// /7f'S' ck.I.: 1,, ',-/J.. c..,., k~ .,.., l -" ,JL ..~,, ,.., ..... J,_ -4 II ~ , - _.,._ ,;;//5.,.,.- of..../cf I .,.,/-{; ""RG ..._ Handcuff Serial#: -=&:_.lo -. __ . Weapons Serial (b)(6); (b)(7)(C) 1;;..\.Jt - J ..:ril. 1,ti1 ~ ,.L. -1:. V 1,JC! ,.// ti&,.__.... ,J ..1. ,,,,. A. ,I #' . ,-L.L l'-n'I /flo O ...i-.,~ ' ......J... ::t..~ ,_ i-JL --u _ .JI - J J 1-~ ~ ~ ,u~l mr lt.ol .;ti J ~ .;,!.l ..klt. L ;~ l r ,.1.,. - ·J. -,.IJ -.1 mi (Zl'I ...l •- · L ..., , L.• •·- .. .ii. ,~'ff / OFFICERS~ INITIALS A,..t - '- -· "'"~\... J,.j - tJ'tIt O'ffJ ,1J 1 _ _____ #: Ll < _6)_; <_b>_<7_)(C _>___ _,____ _ Leg Restraint Serial# : g,- lo. -------- - ' _ (b)(6); (b)(7)(C) Officer Na.me : ~-----< .--.,----=~--------------(b)(6); (b)(7)(C) .....,......._ ----, r--..._. Office r (TWO) Signa Superviso r Signature: -·- - --- - - ---- - - -------------- --- - - . . - ---· --·--. - -- ·-- ·- . - ---- --------- -- 2020-ICLl-00006 4247 ___ _ M:anagament & Training Corporatio !n IAH Secure Adult Detention Center Hospital Activity Log Date: Shift: I~ 9 lu./ n -------- f;,I1[><= Inmate N~e : A\.-~-W:t, Location (Hospital/ RM.#): -=~==--'-''!aa-'t.=-=""'-----'r-"p=.,._~J'--'-!,_l;.._____ ACTIVITY TIME wz ::Zeei"I ___ - I -,;.,,, r<_i k J ......,,_ -~ 1 o ~' _____ _ OFFICERS! INITIALS (b)(6); (b)(?)(C) - ~ Leg Restraint Serial#: Handcuff Serial#: ....:....:..'--A- [D - ------ _ }5.-/t>. --'------- Officer (TWO) Signatures : Supervisor Signature : _______________ 2020-ICLl-00006 _______ 4248 __ _ Manag.ement &Training Corporation IAH Secure Adult Detention Center Hospital Activity Log Date: <> / 7/'l .S- DATE I TIME LEFT UNIT: o/'12---Z. I '-/-~ DATE/TIME ARRIVED @MEDICAL APPT ./HOSPITAL: DATE/TIME DEPARTED FROM MEDICAL APPT./HOSPITAL :a/ Total Hrs./Minutes For this shift () hrJ1L Count all time - leaving unit to retumin. g I DATE I TIME RETURNED TO UNIT: ood-. VEHICLE ~I;) (l" ; BEGINNJNMlLEAGE LEA YING UNIT D~ ~ ENDING MILEAGE UPON RETURN TO UNIT,S -~ C01\1JV1ENT{S): (PR.INT) RELIEVING OFFICE OT ABBREV/A (b)(6); (b)(7)(C) By your signature below, the officers on Stationary Guard D completed on this form is true (b)(6); (b)(?)(C) (b)(6); (b)(7)(C) (b)( 6 ); (b)(?)(C) n OFFICER SIGNATURES: CHIEF OF SECUR.ITY SIGNATURE **NOTE: T _ his form is due immediately, upon your return to the unit, and must be c~mpleted the officers stationed on hospital guard duty. Turn the form into the Chief of Security or Assistant t Warden, in their absence. ICE Ql'i:-CALL BILLJNG Print legibly, $17 34 x ---- __ $26 .01 -orr Mileage: 07- / except where signatures = $------'----hrs ..x 2 offic.ers- $. __ by are required. hrs. x 2 officers miles r/t x $0.535 2020-ICLl-00006 4256 __ _ _ _ _ _ ____ _____ __ = $_-+i.-#1-'-+--- II Management & Training Corporation A Leade r in Social Imp ac t /~;-?, STATIONARY GUARD ROSTER '.··:·:~/ IAH Secure Adult Detention Faci lity D (Complete separate line fo r each detainee on trip) OFFENDERNAME: fel1pe. OFFENDER NAME:____ OFFENDER NAME: OFFENDER NAME:_____ __ ID . #____ _ __ _ ID#_ _ _____ ___ _____ Office): aJ,:0,17 ~ ~·r1/'-·1 SHIFT ~ :,...;:;; ~ ~ I (Print) ID#UdX:fb~ t/eif ___________ TRAVELJNG TO LOCATION :_(Hosp ital/D octor DATE: · , {Jl.m81.1i&-:i\41:z. _ ____ ID #_______ l!J,o~kl {1,Jf.A.e., _ _ ROOM# /~(L- J 6 1\/i == {_=============--------~ (b)(6), (b)(7)(C) OFFICER(S) FIRST & LAST NA.iyt.E: ?~ 1 IS@ 3/(J?)pfY\ DATE I TIME L~FT UNIT: DATE/TIME ARRIVED @:MEDICAL APPT./HOSPITAL: DATE/TIME DEPARTED FROM :MEDICAL APPT./HOSPITAL: ( J (b)(6); (b)(7)(C) RELIEVING OFFICERS: f/2;,.I c)J. lf 7. /J.,:~~ ~. DATE I TIME RETURNED TO UNIT: (PRINT) /6 f);J, ~/ ,. _, •·•- . 1 """!/ AT E NAMES, J- Total Hrs./Minutes Forthis shift Count all ti.meleaving unit to returning t;JI J,.O aud,.D (b)(6); (b)(7)(C) By your signature below, the officers on Stationary Guard Duty are verifying that the information completed on this form is true and accurate. OFFICER SIGNATURES : (b)(6); (b)(7)(C) ~ATURE ASSL CHIEF OF SECURITY SIG NATURE ~ completed upon your return t • ** NOTE: T his form is 'd ue immediately, th e officers stat io ned on hospital guard duty. Turn the form into the Chief of Security or Assis tant Warden, in their absence. Print legibly, except where signatu res are required. ICE ON-CALL BILLJNG L2,o $17 .34 x $26.01 orr x Mileage: hrs. x 2 officers = $ hrs. x 2 officers=$ -miles r/t X $0.535 =-$-- /3_8'._· 2020-ICLl-00006 4257 4/,~ 2--< . ,iz-1-,-,-,-- by Management & Training Corporation Ill A Leader in Social Impact ,:~±:~": 1 .. IAH Secure Adult Detention Facility ...... "-.-✓ STATIONARY GUARD ROSTER (Complete separate lin e/or each detainee on trip) OFFENDER OFFENDER OFFENDER OFFENDER ¥ NAME:_..e__;!~tr¼ J.&'t: 6, L 7 ~ COMJ.\1ENT(S): ---------i( b)(6); (b)(7)(C) (PRINT) RELIEVING OFFICE By your signature below, the officers on Stationary Guard Duty completed on this form is , (b)(6); (b)(7)(C) ~ CHfEF OF SECURITY SIGNATURE * *N OTE: T_his form is due immediately, Assistant stationed Warden, on hospital ON::-CALL BILLING ASSIS upon your return to ........ ,......,n-riciro:z,rra-r...-a,:n-s:J'C""'l:;.Q'l'lrq:n=:v-'b guard duty. Tum the form into the Chief of Security or in their absence. ICE n I ~-- OFFICER SIGNATURES !~-------- the officers r1rr:..,,..,.,,'TT177Tn"~TT77~rrrrrr7"7TTTh Print legibly, except where signatures are required. & $1734 X J. c/0 hrs. x 2 officers = $ // 7. ___ $26.01 orr x.__ . hrs ..x 2 officers:::$ . __. 7~ --j=-,-!~2..:.......:.. ·- - - . -· ·-· -·.. Mileage: /38 miles r/t x $0.535 =-$- ..... 2020-ICLl-00006 4258 .. ■ Management & Training Corporation A Leader in Soc ial Imp ac t _/'-=;~-: ·"\ IAH Secure Adult Detention Facility ,...__,.,,.. ._ STATIONAR Y GUARD ROSTER (Complete separate lin e for each detainee on trip) OFFENDER OFFENDER 0 FFE ND ER OFFENDER NAME: A' ~ NAME : -------NAME : NAME: TRAVELING TO LOCATION: DATE: -f i-r.,, f:c,hl?'- 11 -- -- (Hospital/Doctor Office): 'Vl"!>_/n -- --- -- ID ID ID ID # ~O-Ur£.e, '-fz.r # -- ------- ------ # - #----- C""'vt>C. ------'--"---------- - --- ROOM # Tcv # /$ SHIFT : /1,l- (Print) b)(6); (b)(7)(C) (b)(6); (b)(7)(C) I OFF1CER(S) FIRST & LAST NAME: DATE I TIME LEFT UNIT: Total Hrs./Minutes Forthis shift DATE/TIME ARRIVED @ MEDICAL APPT./HOSPITAL: Count all time leaving unit to returning DATE/TIME DEPARTED FROM MEDICAL APPT ./HOSPITAL : 1/rs/nI u?l/ o/15/n , 7H"f DATE I TIME RETURNED TO UNIT: 1'7 / \:, VEIDCLE # 't7 /q,(, BEG~"l:NG MILEAG E LEAYING UNIT uitlf5 / ENDING MILEAGE UPON RETURN TO UNIT _;_;;. "l..f&'ft4'.J. COMMENT(S) : (b)(6); (b)(7)(C) (PRINT) ATE RELIEVING OFFICER (b)(6); (b)(7)(C) - - . By your signatur e below, the officers on Stationary Guard Duty are verifying that the information . (b)(6); (b)(7)(C) completed on this form lS b)(6); (b)(7)(C) OFF1CER SIGNATU RJ r CHIEF OF SECURITY SIGNATURE - - ** NOTE : This form is due -rmmedr -ately, A~ - and m-ost be completed upon your return to the unrt, I / the officers stationed on hospital guard duty . Tum the form into the Chief of Security or Assistant Warden, in their absence. Print legibly, except where signatures are required. ICE ON-CALL BILLING $17.34x q.13 hrs. x 2officers =$ 0/~ . lt,~ $26. 01 orr x hrs . x 2 officers=$ Mileage: /3 f--miles r/t x $0.535 =-$--'7c-'c3-.£.......,....3_ 2020-ICLl-00006 4259 by II Managemen t & Training Corporation A Leader in Soci al Impact IAH Secure Adult Detention Faci lity , -~~--., STATIONARY GUARD ROSTJfR ·· (Complete separate line for e~detainee on trip) OFFENDER NAME :-------------TRAVELING TO LOCATION: DATE: (PrintJ q-/3- /J ~octor Office): ~ ENDING MILEAGE UPON RETURN TO UNITZ,$7, 9-°'1\ , lo i35,. I i CO:MMENT{S): ________ 4 1 b)(6); (b)(?)(C) (PRINT) RELIEVING OFFICE By your signature below, -~....---~----:r---" completed on this form is tru e and accurate. (b)(6); (b)(?)(C) (b)(6); (b)(?)(C) OFFICER SIGNATURES: - - NATURE ASSI CHIEF OF SECURITY SI GNATURE 0 e completed upon your return t ** NOTE : This form is due immediately, the officers stationed on hospital guard duty. Tum the form into the Chief of Security or Assistant Warden, in their absence ICE ON-CALL BILLING . Print legibly, except where signatures are required. b,t/1 hr s. x 2 officers = $__,~-'--'-' ~-=--hrs . x 2 officers=$ _____ _ LJ.t miles r/t $0.535 = $ 7 6. f j3 $17.34 x $26.01 orr x __ Mileage: _ X 2020-ICLl-00006 4262 by II Management & Training Corporation .A.Leader in Social Impact IAH Secure Adult Detention Facility (?~\ STATIONARY GUARD ROSTER . _n (Complete separate line for each ddainee on trip) fl'-ltl, <[fr OFFENDER NAME=➔f'-.J-l-'\M~A"\-"1-. .< _7-)(CL) --=---L..-----------------. _ _ _ ROOM#-.,/,,_l.f-11--,_, __ OFFICER(S) FIRST & LAST NA1'1E: q-lS'1~~-u\_ ~ J. DATE I TIME LEFT UNIT : 1c:::. J J 7 // DATE/TIME ARRJVED @ MEDICAL APPT./HOSPITAL: ~ DATE/TI1\1E DEPARTED FROM lVIBDICAL APPT./HOSPIT~ - Count all time to lea;:g_;;t::; 8:Jl,frA 9-./5-/] d0/~..__~ DATE/TI1\1ERETURNEDTOUNIT: ~~=G Total Hrs./Minutes For this shift 1~' ~_. .... c:1,p&~0f#3 AGELEAVINGUNIT ENDING l\flLEAGE UPON RETURN TO UNIT 2-SC7 <./C/• £ COMMENT(S): b)(6); (b)(7)(C) (PR.INT) 1 NOT ABBREVIATE RELIEVING OFFICERS: - N, (b)(6); (b)(7)(C) - By you r signature below, the officers on Stationary Guard Duty are· completed on this form is true and accurate. (b)(6); (b)(7)(C) -:.,.,r-•-b r .. -- ..... ..,. ... --.J...., ••. b)(6); (b)(7)(C) OFFICER SIGNA CHIEF OF SECU TURE **N OTE: T _ his form is due immediate ly, upon your return .__....,,...-------,.-~ ompleted the office rs stati oned on hospital guard duty. Tum the form into the Chief-of Security or Assistant Warden, in their absence. Print legibly, except where signatures are required, ICE O:rs-:-CALL · BILLING 7. $17 34 x ~ __ _$26.01 0/T x.fl. Mileage: f,i ~ Jg .. f' q hrs. x I officers = $ ~ hrs ..x 1· officers-.$ . Ii't 1 iJ.__. miles r/t x $0.535 = $ 7J, a~ 2020-ICLl-00006 1k 4263 by - . I II Management & Training Corporation A Leader in Socia l Impac t lAH Secure Adult Detention Facility .- , STATIONARY -GUARD ROSTER ✓ OFFENDER N.Al\1E:/l!n1 t1z .,O - iZo ·z:r, (Complete ne::ctlin e for more than OIII! detainee on trip) OFFENDERNA.."l\1E: ___ 9/1.5/1?-:-~b1 (Print) ID # // _____________ TRAVELING TO LOCATION :eoctor DATE= k l>',oe 7 ID #_______ Office): C~1rt?e ~cV:,,/14 / sHIFT=~z~;1_of ___ ~I o Z88llrf/ Z8 _ _ ROO M# /£1/ _ 1----' r::b)=(6,,.... ); ("b)= "' (7)'"'"" (C,,.... ) --- 6 (b)( ); (b)(?)(C) OFFICER(S) FIRST & L~T NAME 1---~:iiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiaiiiiiiiiiiiiiiiiiiiiiii 4.'~SfMIJ''{-t/ DATE/ TIME LEFT UNIT : DATEffil\1E / DATEITIM:E:PEP AR _ TED FRO M MEDICAL APPT ./HOSPITAL:tjQ//, ' g:5~ ~TE/TIMERETURNEDTOUNIT: Count all time - p4a,lon1leaving to returning unit VEHICLE-# BEGINNING MILEAGE LEAVING UNIT -Z..2> 7 /3 ENDING MILEAGE UPON RETURN TO UNIT2a] "2... t4. 5°.] (b )(6); (b)(7)(C) TotalHrsJMinutes Forthis shift ,_0_ '_ Cj/J~{t7/o35!:5 ___ g7 ii;;;.;;. :4f?l//lf£ d7 f✓.5/J;:,//837 ARRIVED @M:EDICAL APPT ./HOSPITAL: __ 9 REV/A TEN. (b)(6); (b)(7)(C) ers on Stationary Guard Duty are verifying that the informati on . SIGNATURE hlrnrnediately, Ospital (b)(6 ); (b)(7)(C) ASSIS upon your · return guard duty. to ~ t -he_u _ni-t ,_a_n_d-,-7 s_ t_b_e _c o-m-pl-e-te_d_Jby Tum the form •bsenc e . Print legibly, except 2020-ICLl-00006 4264 into the Chief of Security where si gnatures or are required. Management & Training Corporation Ill A Leader in Socia l Impact IAH Secure Adult Detention Facifit-u "J' \}): '..:...._., .I STATIONARY GUARD ROSTER (Complete separaJe line for each detainee on trip) OFFENDER NAME:...LA.LJl....,,.,.,......,~ ...."-!l.:_:...!:41~·~-c.~ . .!....lfwo<1.l·1.p.,,.w:......__ __ ____ _ ____ OFFENDER NAME: 0 FFEND ER NA.ME: OFFENDER NAME: TRAVELING TO LOCATION: DATE: ~ --------- ROOM#_/ _'i..._/ __ (HospitaVDoctor omc e): _ ~~..___ ________ 1 ie,/n SHIFT: (Print) ID # A OL't ?'l' q'!..? ID# -- - -----ID# - -------ID# =(b)(6) /~ -=------ -- _ -- ; (b)(7)(C) OFFICER(S) FIRST & LAST N~ DATE I TIME LEFT UNIT : Total HrsJMinutes For this shift DATE/TI1\1E ARRIVED @MEDICAL APPT ./HOSPITAL: DATE/TTh1E DEPARTED FROM MEDICAL APPT.!HOSPITAL:'V 1'1n /\- o ~"'DJNG MILEAGE UPON RETIJRN TO UNIT $T.-\, ,. 'b COl\1MENT(S): (b)(6); (b)(7)(C) (PRINT) j rOTABBREV/A 7 (b)(6); (b)(7)(C) RELIEVING OFFICERS : By your signature below, the o zcers on Stationa completed on this for (b)(6); (b)(7)(Cl Guard Duty are verifying that the information (b)(6); (b)(7)(C) OFFICER SIGNA CHIEF OF SECURITY SIGNATURE AS **NOTE : T_ his form is due immediately, upon your retum L.__ ______ ~__ ____. pleted by the officers stationed on hospital guard duty. Tum the form into the Chief o Security or Assistant Warden, in their absence. Print legibly, except where signatures are required. ICE Ol'i:-CALL BILLING q $1734 x 1, J hrs. x 2 officers=$ ___ $26.01 0/T x_./7. I hrs ..x 2 office.ts=$ . Mileage: IJO miles r/tx$0.535=$ 1 2020-ICLl-00006 4265 /J..t/-. &9 - I 87,LJb -· . b9.,S-S '1·l'f -ry:t~ ... . -,q.3f ■ Management & Traini ng · Corporation A Leader in Social Impact IAH Secure Adu lt Detention Facility STA TI ONARY-GUARD ROSTER OFFENDERNAME:;4k 14µil1 h/;j;e., -2'u/z..7 (Complete n.ert liMfor more thanone detainee on trip) OFFENDER NAME :____ I' ____ ____ TRAVELING TO LOCATION:~octor ) lo DATE: (Print) fl7 . _ ____ Office) : C r,;:(b;-;;: )(6~ ); (~b)~(7)~(C~) -- :,r\fOt;. ID#_____ L2e5 10(\Q"\ __ ROOM# "~(\~ o,( ...;, "__________ _ I~ ( __:_ __ -, . . OFFICER(S) FIRST & L~T N 1//4/I? DATE I TIME LEFT UNIT: DATE/Tll\1E ARRIVED@MEDICAL A.PPT./HOSPITAL:~/' .?/j '8i0 DATEfTIME :PEPARTED FROM MEDICAL APPT./HOSPITAL :9 /;7 -------- ,l~'-}_f' Total HrsJMinutes Forthisshift Count all time leaving unit to returning /t7·o 7W I DATE I TIME RETURNED TO UNIT : VEHICLE-# °f 7 BEGINNING MILEAGE LEAVING UNIT Z->37 T.I 5, L ENDING l\1ILEAGE UPON RETURN TO UNIT .i '. _::./f:..·; ·:. ., . : - · -·.,-.:;;r... .:,,.,,", Shift Topics: Enforcing Dayroom Rules, and Rack Time Total Officers assigned to shift: 12 Absen (b)(6); (b)(7}(C) MLA) (b)(6); (b)(7)(C) 1----------------------------t Emergency I Response Assignment Response Team A& &Teams Duty/Equipment b)(6); (b)(7)(C) A Supervisor/Team Leader A iEvac A B Fire extinguisher Medical (b)(6); (b)(7)(C) Fire extinguisher B Emergencv Keys B 8 Outside Keys Transport Camera Officers Transport Restraints Van/Weapon Revised July 1, 2017 2020-ICLl-00006 4275 Equipment 1st Shift Roster Unit Total: 9/10/2017 Date: Category Position Category Category Position Position b)(6); (b)(7)(C) Lleutanan b)(6); (b)(?)(C) Sergeant [11 (2) Central Central Lobby .. :-_...~.. . .- ADISEG [1] [ 1] Rocroatlon [1 I [ 1] Recreation [1 I [1] Recreation [ 1) Visitation [1) Medical B Hall- [1] Front B Hall - A Hall - [ 1] Back Back C Hall• D Hall • [ 1) Front Front C Hall - D Hall• Back Utlllty ·._. [ 1 ] Back [11 I 21 Utility [2 ) Utility I 21 B Rover I2 I C Rover I 21 ··- •-•'TO• ..• :•- .. ' r21 A Rover .,,. [ 11 [ 1] l _. Front · -· [1l Control [1 A Hall• ' , (b)(6); (b)(?)(C) Control [ 1] :.=·· I 21 D Rover Shift Topics: Recreation for new Detainees Total Officers A9sglned to Shift: 1-----------------------------1 Absent: 10 1--------------------------1l (b)(6); (b)(7)(C) Emergency Response Team (b)(6); (b)(?)(C) Medical (b)(6); (b)(7)(C) Response Assignment A and BTeams Duty/Equipment A A A A Supervisor/T earn leader A Emergency Keys A Outside Keys Camera Transport Equipment A Transport I Evac Fire extinguisher Fire extinguisher Officers b)(6); (b)(?)(C) Restraints Van/Weapon Revised 7/1/17 2020-ICLl-00006 4276 2nd Shift Roster 299 Unit T otal : 9/10/2017 Dat e: Category Position Category Pos ition Sergeant Category Pqsition (b)(6); (b)(7)(C) Utility A Rove r [2] D Rover Shi ft Topics: Time man agement To ta l Officer s Ass gin e d to Shi ft: ( 6 t--------------- Absent : RDO: (b)(6); (b)(7)(C) -1 - ----------'- Emergency Response Tea m A and B Team s A l-- -----'------,---------A A (b)(6); (b)(7)(C) Response Assignment Duty/Equipm ent Su ervisor/Team Leader - -+----'---___;:_:-'-'- ___;:_:-'- --I Evac A A A Outside Ke s Camera Tr a nspo rt Equipmen t A Medical Tr an sp ort Offic e rs (b)(6); (b)(7)(C) Restraints Van/Weapon Revised 7/1/17 2020-ICLl-00006 4277 - -----1 3rd Shift Roster 536 Unit Total: 9/10/2017 Date: Category Position category Position Category Position (b)(6); (b)(?)(C) b)(6); (b)(?)(C) Lieutenant -..~t~.~:; .-_. -~.--· [1l .. . ·· ....... ·.. · .. ":"":,.~ :: [1l :~(~~-~-. . :',~.'-' . - .. Medical .,. .. . Recreation J ' :->~;~-!..;~\: 1 .. .. .. , - [1 Front .·.:"\~~i;:-~~ ..-~:-' D Hall• Back .. ., ... ::·•-:. ... [1 1 [1 l Recreation ( 1 J [1 l Perimeter [2] utility . -· ......: ., .. . :: .· -'..,-•"·l •·· ,. [21 AID Rover --::r:( ..-~:~-t-:"~:;-~-~-'."t~ ••:;-.r•;. .. I.;.;·:\_.-:·,,- ;~:-!~;:•::J~\Y.-.~'.f~· .. r• ·. ~. ; ~ ,< -, . Total Officers assigned ., [2) (b )(6); (b)(?)(C) Utility ._. -· BIC Rover \-~;:.;._.-.:, . •.-.:~~---·.: .. .... .......... ·.-_J:~~~:: .:-;;,.:•i. :! -\,:._.'}:,./:,.. , ;~-~ 12 [2} -- .. ~ to shift: ,. : : .... Situational -;•_--~. , .. .·... •" .. ~ ·' Awareness Absen~\~)\~);,,_, FMLA) b)(6); (b)(?)(C) Emergency Response Team b)(6); (b)(?)(C) Medical (b)(6); (b)(?)(C) Response Assignment A & B Teams Duty/Equipment A Supervisor IT earn Leader A iEvac A Fire extinguisher B Fire extinguisher B Emergency Keys B B Outside Keys Transport . .... 11 ] '• Phone Calls For New Detainees, Shift Topics: .. . ,. '. Utility .. J .•. -- [1] .. C [1 ... C Hall• Back . [1] Recreation ' Front . .. .. -, -C Hall• l [ 1 ] Baek .:..:-:S'./i,:.'_,i'.: , -·· .. ·---. ..... (b)(6); (b)(?)(C) [ 1] B Hall.· . .. .. Camera Officers ..,.- ·.·.,. .. , [1 ] Back -- .:·--,.= .:·-: ..·, D Hall . .. .. .. ..Front. ' - .. .. B Hall• [1 Front ,. .' ADISEG A Hall- .. ,. : .. . ~ [1 - ·. ' Control [1] . ·_·f: •. A Hall [2) : ->·.<·:··,. ,-,:,··;. Central Lobby ..... Sergeant Transport Restraints Van/Weapon Revised July 1, 2017 2020-ICLl- 00006 4278 Equipment [2] 1st Shift Roster b)(6); (b)(7)(C) Ueutenant [1] Sergeant b)(6); (b)(7)(C) [2] Central Central Lobby l [1 Category P~ition Category Position Category Position ..,._ 536 Unit Total: 9/11/2017 Date: (b)(6); (b)(7)(C) Control [ 1] Control [ 1] Medical [1] AD/SEG [ 1] [1] Recreation I1l [1] Recreation [1] [1] Recreation [ 1) Visitation [1] Utillty r2 I C Rover r21 .. Medical [1] A Hall• B Hall• [ 1] Front Front B Hall- A Hall • [ 1] Back Back D Hall • C Hall• [1] Front Front D Hall- C Hall- Back [ 1] Back [1J Utillty r21 Utlllty {2 A Rover r2 1 B Rover D Rover r2 1 Shift Topics: I r2 1 Counts Total Officers Assglned to Shift: 1-------=-----------------------11 Ab sen t : 10 Response Assignment A and BTeams Duty/Equipment A A A Suoervisor/Team Leader A Fire extinouisher A Emeraency Kevs A Outside Kevs Camera Transport Equipment (b)(6); (b)(7)(C) (b)(6); (b)(7)(C) Medical A Transport r I Emergency Response Team (b)(6); (b)(7)(C) I Evac Fire extinouisher Officers 2020-ICLl-00006 4 :m&traints 2nd Shift Roster Unit Total: 9/11/2017 Date: Position Lieutenant (b)(6); (b)(?)(C) Sergeant l [1 Category Position Category Position Category (b)(6); (b)(?)(C) (2) --- - Central Lobby [1] Control [1I Medical [ 1 Central Control [ 1l AD/SEG [ 1l [ 1] Recreation [ 1] [ 1] Recreation C1 I [1] Recreation [ 1] I1l Visitation ... _.... : .6": -\s:"i::' Medical [1] (b)(6); (b)(?)(C) I ., B Hall• A Hall• Front EMPTY [ 1] A Hall • Back EMPTY [1] Front B Hall Back -. D Hall • Front EMPTY [1 D Hall· Back EMPTY [ 1] C Hall Front J C Hall• Back /1} .. I (b)(6); (b)(?)(C) {2] Utility ; .. - Utility {2} . .. . A Rover ,:_ ...--- {2] D Rover [2] .. ' {2] B Rover [2] C Rover [2] .. Shift Topics: Enforce the rules !Total Officers Assglned to Shift: 7 Absent RDOf Emergency Response Team (b)(6); (b)(?)(C) b)(6); (b)(?)(C) I Response Assignment A and B Teams Duty/Equipment A Supervisor/Team Leader l Evac A A A Fire extinguisher Fire extinguisher A Emergency Keys A Outside Keys Camera !Transport 1:qu1pment A mea1ca1 1 ransport rb )(6); (b)(?)(C) Utlllly .. onrcers I Restraints Van/Weapon I Revised 7/1/17 2020-ICLl-00006 4280 3rd Shift Roster I Category Position (b)(6); (b)(?)(C) Lieutenant -. [1] (b)(6); (b)(?)(C) Sergeant .. . .. • Category Position Category Position [21 .. Contral · Lobby [1 -. ·.·•; 534 Unit Total: 9/11/2017 Date: l Recreation [ 1] ContTal i ... Madlcal [1 ADISEG 1 ~b)(6); (b)(?)(C) [ 1] . ... . [11 Recreatlan [ 11 l Recreation [11 Perimeter [11 ' B Hall• A Hall- (1] Front Front 1 l ... -- AHall B Hall - • [ 1 Back . -.. 1 1 C Hall - D Hall• Front • [ 1 Back v;•-..:.•7, ' [1] -. ,·. - [ 11 Front C Hall - D Hall- Back .·.-.·. l11 Back [1I [2] Utility {2] - Utility l(b)(6); (b)(?)(C) Utlllty : [21 AID Rover .. ' ·• ... ' : . ~--·.:-.. ·- .. . .... .,. - . . -,... .~:~. ·.:·· .. ... .. ' . .. . Shift Topics: Outgoing Chain Total Officers assigned to shift: 12 Absent: l(b)(6); (b)(?)(C) bnHospital Run I I Emergency Response Team A& Wyatt (FMLA) rb )(6); (b)(?)(C) I I I Response Assignment B Teams Duty/Equipment (b)(6); (b)(?)(C) Supervisor/Team Leader iEvac Fire extinguisher Fire extinguisher EmerQencvKevs Outside Keys Camera A A A B B 8 8 Medical Transport {21 [2] B/C Rover : I : Officers Transport (b)(6); (b)(?)(C) Restraints Van/Weapon Revised July 1, 2017 2020-ICLl-00006 4281 Equipment 1st Shift Roster Unit Total: 9/12/2017 Date: Category Position Category Position (b)(6); (b)(?)(C) Lieutenant ... ... ' Lobby {2] .. .... [ 1 ] Control [ 1] Medical [ 1J ADISEG [ 1] [ 1) [ 1J Recreation [1] Back [1] Recreation t1I C Hall• Front [ 1J Recreation [ 1] Back [1] Visitation [ 1] Utlllty r2 I B Rover r21 " A Hall - [ 1] - •.~ Medlcal •. b)(6); (b)(?)(C) Central Control Central .. .. . . B Hall - [1 ] Front .-·- Sergeant (b)(6); (b)(?)(C) [1] Category Position Front .. 4.'• B Hall• A Hall - [1 Back J ·;, -:.•. : :, ,~: __ D Hall • Front .. [1] .. ·:·ii· .. C Hall - D Hall - [ 1 Back . ... ... .. .. .. . . ... l2 l Utility . .•;•. J •··· r2 l - . -- A Rover .... . . -·-·· Hospital Utility [21 C Rover r2 1 . . r2 J D Rover Shift Topics: .. J(b)(6); (b)(7)(C) You are on call 24/7 answer the phone when the unit calls. Hospital Transport Total Offlcera Assglned to Shift: Absent: 10 Emergency Response Team (b )(6); (b)(7)(C) Response Assignment A and BTeams Duty/Equipment A A A A Supervisor/Team Leader A EmerQencv Keys A Outside Keys Camera Transport Equipment J Transport Evac Fire extinguisher Fire extinguisher A Medical b)(6); (b)(7)(C) Officers - Restraints Van/Weapon b)(6); (b)(?)(C) Revised 7/1/17 2020-ICLl-00006 4282 Facility: IAH SECURE ADULT DETENTION FACILITY ROSTER ID# Printed Name b)(6); (b)(7)(C) 2020-ICLl-00006 4283 IAH SECUREADULT DETENTION FACILTIY STAFFINGPLAN DAYS PER WEEK DAYS 5 1 1 RN- Director of Nurses 5 1 1 RNs 3 2 1 3 LVNs 3 4 2 6 Mental Health LPC 5 1 1 Pharmacy Tech 1 5 1 Medical Assistants 5 1 1 HOURS HOURS POSITION , RN- Health Services Administrator NIGHTS PER EVENING TOTAL 2 PERWEEK PER DAYS Psychiatrist 1 4-6hrs 1 Physician 1 6hrs 1 DAYS POSITION -I Physician's Assistant 6hrs 3 2020-ICLl-00006 4284 TOTAL 1 MEDICAL SUMMARY OF FEDERAL PRISONER / ALIEN IN TRANSlT U.S. Department of Justice I. PRISONER / ALIEN TB Clearance Name: Prisoner/ FELIPE ALMAZAN RUIZ A0288664 2 B Departed From: Date Dep arted: GCOC 09•07-20 17 Results: Destination: Reaso n for Tra nsfer: Negative FOLKSTON ATW District Name: District# 1) PPD Completed : Date Alien Reg# 0 .O.B . 06-2 6-1966 ResuHs: 2) CXRCompleted : 07-12-2017 Date ~b)(6); (b)(7)(C) <-t-Wr.,. J ·-l Date Note: Dateslisted above must within one year of this transfer Da tt Medicati o n l0l 7-08-22 2017-08-22 2017-08-ll :2017-09-06 2017.09-()(i :2017-09-06 2017-0.?.06 be Dosage Date in Cust ody : II. CURRENT MEDICAL PROBLEMS 300.02 GENERALIZEDAN XIETY DIS O RDER . 311 DEPRESSION, 571 .5 CIRRHOSIS OF LIVE R WITHOUT ALCOHOL Dir ect ion sN umb cr SERTRALINE R0..100 MG TAB 100 Take t Tablet by mouth 1 time per day for 60 days 60 T RAZODONE 50 MG TABLET SO 1 po q US 60 TRAZODO~E IICLSO MG 1/2 t11 b PO at bed,imc 1[ 60 day1 60 FOLI C ACrD 1 MG l 'ABLET l Take I Tablet by mouth l time per day Cot 90 days 9 0 OMEPRAZ-OLE 40 MG 1'akt I Cap sule by mouth 1 time ptr day for 90 dtlys 90 PREDN lSONE SO MG Take l Tablets by mo uth 1 time pe r day for 3 d11ys 6 SPIR ON'OLACTONE l!i MG TABLET 25 Take l Tablet by mouth :2times per day for 96 days 180 Addltlooai Comments: NKDA Ill. SPECIAL NEEDS AFFECTING TRANSPORATION Is prisoner able ta travel by airplane? y y Is prisoner medically able to stay o\ternight at another facilityen route to destination? y If not, W hy not? Is there any medical reason for restricting the length of time prisoner can be In travel status? N If yes, state reason: 0aes prisooer require any medical equipment while in Iransport stal us? N If yes, What equipment? Is prisoner medically able to travel by BUS; VAN or CAR? (b)(6); (b)(7)(C) If no, Why not? If no, Why not? Phone Number: 863-946{ Original - Upon Transfer Date Signe d : b)(6); (b)(7)(C} I Form USM-553 (Est. 6/98) 2020-ICLl-00006 4285 II I. Master Problem List Medical Date of Occ:urrence 0 ~ ~ ,ir ... I Date Resoved (b)(6); (b)(7)(C) / 00\l IA~\.Lo 1017 I Problem (Medical, Dental, Mental Health) ' .. ,_ I (b)(6); (b)(?)(C) C\ villl:'Ibf\- ) .....I ·- /h~f\ ........ _/ f'\o rrt'.,<., W r, a giIUJ q ~ 107 r, <"~hs1s I", f \\\ft t111 JJ\AlrN\i\ J I :.. - 1.... .,I f • ( I ....... - -~··-·-- -·--·-· ... --- ...... , .. Allergies: 028 866 428 ALMAZAN~RUIZ, FELIPE ADM 09/08/17 . . .. . ' . .......... ---·- .. - \.J¥,D\f, Medications: DOB 06/26/66 Revi=ed Sept 2016 / mb 2020-ICLl-00006 4286 II TREATMENT PLAN SPECIALNEEDS& RESTRICITONS Medical BUNK ASSIGNMENT: 0 No Restriction n Other housing needs _________________________________ _ Duration: ____________________ Expiration: _______________ Z RKl ROGRAM ASSIGNMENT: [! _ NO RESTRICTIONS OR □ Unassigned p-~~chiatry C No food service No reaching~:~~Y C No repetitive use of hands 0 Sedentary Work Only u □ Four hour work restriction :J No work in direct sunlight U Excuse from school thru _______ D Limited standing >______ No walking on wet or uneven surfaces :J No temperature extremes _ '.J No humidity extremes hrs D No walking> yds □ No exposure to environmental pollutants D No lifting > lbs □ No work with chemicals or irritants D No bending at the waist □ No work requiring safety boots D No squatting D No work around machines or moving parts D No climbing D No work exposure to loud noises D Limited sitting □ OR DISCIPLINARYPROCESS: n Consult repr No work requiring complex instructions entative of medical department before taking disciplinary action NEEDS: C On Dialysis C Adolescent in Adult facility Precautions required: _____________ , • Infected with serious communicable disease - _ :J Physically Disabled :J Frail or elderly ::::J Pregnant '.J Terminally ill □ Mentally ill or suicidal □ Developmentally disabled D Suspected victim of physical or sexual abuse ---11 b)(6); (b)(?)(C) een entered into ODS - . Initials -(b)(6); (b)(?)(C) i--::--____::c----"'"'--""-L----"! Date:_.___ ~ 7 DO D e ._.---·---. . -·-· d2J3o nme 028 866 428 ALMAZAN-RUIZ, FELIPE ADM 09/08/17 DOB 06/26/66 2020-ICLl-00006 4287 Reviewed May 201 7 / rnb 1111 Medical INTAKE SCREEN Translator available □ Yes Date/Time of Arrival at the facility:_. In the last 21 days what countries Have you been in contact have ou isited outside of the U.S,? -"--~~'-"--'-✓- / with anyone who traveled from these countries in the last 21-days and who is sick? Yes__ In the last 21-days have you been in close contact with anyone who has been diagnosed with an ir.fectious disease? Ye>_ NZ NoZ If yes please e,rplain: Do yo ave any current medical, mental health or dental problems that need attention now? NONE __ YES- explain: include any special health or dietary needs: *** Note Detainee should be Instructed on sick call processfor any non-urgent healthcare eeds. Do you have a family history of any Medical conditions? Yes o 6 a 10 Location .--'\-6.JJ..!...-'i.~~~6..l..i..~~~"---..1---~ uration ___ Do you ave any physical injuries, open wounds, cuts bruises or signs of trauma/violence? NONE NOTED/DENIES -~ YES(de5cribe) ____________________ . Do you have a past history cf seriousinfectiousor communicable illness (to includeTB)? (include ar.ytreatment _ __ YES or previous symptoms) Do yo, h,ve •nv meat oomm,a;cable maess symptoms, k lfye;, iadicate, :1 Chronic Fatigue □ Weight Loss/ Loss of Appetite :::i Night Sweats □ Bloody Sputum - •"'*If yes, cont.ct tile medTcaI pro11iderto determine lf the plltient requiresP. □ Frequent Productive *** □ Fever r: Weakness eme.nt in Respiratory isolation (Neg;,tiveAir Flow Fioom) until testing is completed ,rnd the patient ls cleared to be pla :ed in t~e general Do you have any Chronic Diagnosis? __ (\ YES !1.:tfil.,Note Diagnosis below NO If Diabetic - Blood Sugar____ HTN Cough DM SZR RESP H fer to Chronic Clinic\..:_.).\,-~" e · MENTALHEALTHDX:~~'H-l'--l-.."'-"':_: __ GS = ... =.·=YES~----~-~A ... C>--.·_-""_ .. Do you have a history of PhysicalIllness,Surgeriesor Dental Problems? , ~--·---..-~"""'--'.1-tMr-- (include past hospitalizations, surgeries and treatments) · / Do you identify yourself as a Transgender?-~_Nno ____ .,.YES (lf so, document history of trans ition- elated care and notify security supervisor) Are you currently taking a medications, Induding over the counter No and/or herbal? Yes /fyey V_ Current Medication listed on transfer paperwork - See Orders ,J.--...La.w.i..u....,.,.......,...1.1.1aL.WLl:...J,;Ufn the current medicatio ns, however they are no: k or tra b)(6); (b)(7)(C) received, 1--------'::-.,.....-+---------------------' ~ Time 028 866 428 ALMAZAN~RUIZ,FELIPE ADM 09/08/17 DOB06/26/66 2020-ICLl-00006 4288 Revised May 20:7 / mb i . .INTAKE SCREEN- Mental Health {Page 2 of 3) .Do you have a current or past history of Mental Illness or disabilities? Treatment: INPT Diagnosi ~:::t::A~<\--1~~~~~~-~..---,-:J.l~~~!C!~..::___--\------- Do you have current, recent or past history of Physical, Emotio ff yes • Perpetrator When _______ Have you been sexually assaulted prior to arrival at this facility? ~NO ~----------------------1 __ ~.,.L__~ _____ notified lmmediately ______ uSeCl.lrity Supervisor Victim or YES tfyes: Name _________ Date/nme ~-~Y~-n~e:i:~1#rify~~,~~rii~~k'.~~6~:s·~:·?~-~i61~-n~~-i _-7 ·~b-· · -··_·'f~s--· - -··-··· . •. , . h1Jui{ot'~oner if ap~ropr1ate ~i_ii.n Do you use Tobacco? __ YES If yes: Cigarettes Type: \ . I Method: -..P.~ IV Smoke \\ How Often?_______ _ Ingest S11orting Other Lastdrug(s) used? When? (if a female patient reports curre:,t Opiate use, make sure she was offered the pregnancy test. If positive she must be referred to the provider to avoid opiate withdrawal risk to \\ '. '(~~~'l)J'-"cs~~ ~ '. :"\ Cocaine Meth Heroin Inhalants LSD Opiate Other ty\\)~ How Much? ~ \ 0~~ \.\, 1[,~ ...... ~ -~~(L;'( NO Ty~ijuana o5Z:Y \O....~~ Oral =::::::::: Haw Oft~e~? ....-----=..-------i ~ If yes: ~ llfeg ~ How Much? Do you have a history of Alcohol or Substance Abuse? Pipe the fetus) Current or past illnesses & health problems r/t substance abuse: □ 't"' □ Hepatitis Seizures 1:; Trauma □ Liver Disease Do you get sick wher> you qu'rt usirlgthose drugs? ____ NO __ □ Infections YES (Le.: convul~Tons) If yes, what happens? ______________________ Any history of substance abuse hospitalization ___ _ NO ___ YES If yes, when and for? _______________________ _ Any history of detoxification and outpatient treatment? __ NO __ YES If yes, when and for? _____________________ Do you have any withdrawal symptoms? __ NO ~s Symptoms:_'o~~~~~'~~~~.,,__ ·Have you ever thought about killingyourself? _ /_N NOO __ If yes, when and why? _____ iHave you ever tried to harm yourself? ~o Do you want to harm yourself now? Do you want to harm someone else? YES _________ _ --J --,,.~---------------------..~~~-------i ···- __YES If yes, when, how and why?--l'e..:Q.&J==•...,,\-=\l...,,,_""'-'~~----- 0o __ __/_ ~ NNIO __ YES If yes, do you have a plan? YES If yes to what degree - explain?______________ _ b)(6); (b)(7)(C) ity who is a threat to you __ NO __ YES (If yes, notify Security SupeNisory Immediately 1) Time 028 866 428 ALMAZAN-RUIZ, FELIPE ADM 09/08/17 DOB 06/26/66 2020-ICLl-00006 4289 Rt!vised May2017/ mo ■ INTAKESCREEN Medical (Page 3 of 3) OBSERVATIONS Is this person unconscious, semiconscious, bleeding, mentally unstable, severely intoxicated, in alcohol or~ withdrawal or disoriented to person/place/time or otherwise urgently in need of medical attention? G-N6" u YES If yes, immediately refer to medical persormel for further evaluation & care. IS T~ATIENT DISPLAYING ANY SYMPTOMS or UNUSUAL BEHAVIOR? c YES ~ rt"¢pearance - appropriate o Weakness o Seeing visions 121""' ~ropriate behavior □ o tTN/4al ~lert gait responsive Slurred Speech :.i Unusual su5pidou,ness o Hyperventilation o Disheveled o o Body deformities o o □ o Loud / obnoxious Persistent cough Abnormal gait Yellowing of skin or eyes/jaundice o Rashes o Infestations (lice/crabs) Hearing voices o Evidence of self mutilatio n Bizarre/ insensible o Alcohol or drug withdrawal c, Communication difficulties u Disorderly u Other physical abnormalities n Sweating n Assaultive or violent behavior o other: __________________ o Tremors u Lethargy n NeedlF. Marks _ ls his~? o Crying/Tearful o Incoherent c.YWNL/ Cooperative □ □ Confused o 1~ted Any body piercings _/__ ;; N~O--__ Recent Tattoo(s) o Embarrassed □ Uncooperative o Passive o Depressed o Anxious Scared YES DISPOSITION Population with NO Immediate Health ServicesReferral r:::i ~ral Population with Immediate Health Servkes Referral to ¼).t::':\'°"'!1Lf=~zf~~~~~u~~~~~\-~:::'.:.l..L..:L!~~.2..Jh::, ~;.n;;al :J Transfer to Hospital for Emergency Treatment LJ Constant Suicide Watch - provider contacted for order □ Medical Observation / Isolation D Single Cell Housing If a female patient and pregnancy test is positive, refer to provider to avoid opiate withdrawal risks to fetus ,., ..- . · .. --··. -~- ··-· - .. -· .... -. :O .tf viol~nce, M~ta! Health referra!madewithin 72 hours: □ ars0°~r~~:y~tc1JJqrr1esti~al;l~_se or 7 b)(6); (b)(?)(C) ROUTI th Serv' ,:___l,J-J..-....._-rl! ~~'P/PA ~:acy □ / Order Meds Request Records/ Call MD E:r S~ ary Nee __ _,_,.,.,.,....,.""""°'"L ___________ _ B'ln.structed detainee to submit sick call request for non-urger.t health care need D Dental Clinic - . -·. - -- ... :t{~~~5~~aks: (b)(6); (b)(?)(C) __ ·_··_·_·_·__ ••:__· .-_~:_:.,.._~c~~a;1~~-f$:p_~~k;i~spanish/other:_··-,-,--------,-,.......,.·....,-,..,.·-_·,-_·--,-··_·· ----=------------ ......... ·_,·. tan_~~-~~e~_:_-· _.._... ___ ......, ........ _____ ...;..:.....;.__...c..;.;_----- C\\~:) Date P~tip,-.-4- t,.1- Time •. - - 028 866428 i: ALMAZAN-RUIZ, FELIPE ADM 09/08/17 DOB 06/26/66 2020 -ICLl -00006 4290 Revised M2y 2.01.7/ mb I Medical FORMA DE CONSENTIMIENTOMEDICO · PRO(iRAMADE CUI DADODE SALUD FORMADECDNSENTIMIENTO MEDICO El pro;i6sito de la clfnica es provcer a listed ,3tnecl6n me::!ica. Los inforrnes medicos que te obtengan seran niatenidos er. us expedientP. medico, confidem:ial. Se espen; usted que se someta a un examen medico para determinar su estado de salud al presente. Yo, par la presente c□nsient□ o aut□riio a una evaluaci6n o examen medico pa,a determinar mi estacio salud presente. ':"ambien corislento a cualquier otra evaluaci6n o procedimiento medico, cuidado rutiniariio, y tratamiento medico o dental o salud mental que el pl"rsonal medico de la clinica considere necesario, aconsejable o apropiacio. Yo .utorlz.o la divulgaci6n de mi historial medico a cualquier hospi~al er, case de que hospitalization sea necesari2 or recomendada. autoriza la divulgaci6n de mi informacl6n medica para el reporte a entidades federale~ y/o e5tales para la vigilancia y coritrol de enfermedades. Yo Esta forma se me has ex:i 1icado completa:nente y yo entiendo su contenido. Tambien entiendo que nose me han hecho garantia con respect□"' resuhado de tratamiemtos o examenes administrados en la clinica. He recibido instn,cciones sobre c6mo acceder a: • cuidado medico en esta unldad, dental y mental • el pmgrama de ,arifa-por-servicio :::i NA • el proceso de queja para las quejas relacionadas con la salud Pacientes se se.xofemenino: • Servicios di!' embarazo incluyendo pnuebas, nitina o atenci6n prenatal espedalizada, atencion en el posp,nto, Posparto seguimiento, servicios de l"ctancia y los servicio, de aborto como se indica • Asesor.miento y asii>tencia para las mujeres embarazadas de ac:uerdo con su expreso deseos en la planificacic\n de su embarazo, si desean aborto, servicios adoptivos o para mantener al nifio • Rutina, apropiados para la edad, ginecol6gica servicios de ateru.:i6n medica, incluyendo otretlendo cuidados preventives es;:ieclficos de las mujeres Solamente medicamentos basicos seran proveloos de a:::uerdo a los protocolos medicos. El Paciente podra obtener medi::amento y sern responsable para tomarse las pastllla.i cie acuerdc a las instrucciones para tomarse como en la vida libre. Este privileglo siars d.ido solamente a los Paciente que sean capaces y responsables. ElDetenido tiene q ue: 1. Tomar e, medlcamento como e~ sen,dado y no deben abandonar dosis ni tampocotomar dosis dob!es. 2. Cuidarel medicamento, nose d!"be vender, nose debe cambiar, no descuidar el rnedicamento para que sea extravlado o robado. 3. No acumular medicament□ en ei dormitorio. 4. Ser CU"'"lido todo el ti~(b)(6); (b)(7)(C) ·~a1 Date 028866428 ALMAZAN-RUIZ, FELIPE ADM 09/08/17 Spanish Consen, Form Time 1 ~lla-01 l Time DOB 06/26/66 July 2014 / mb 2020-ICLl-00006 4291 acidyour facility name t,,,n, Intake Screening and Testing Provid~rSpe~~~~/Spanisb/Other:._· ' - __.. :_~:;:_·__ - P~tientSpe~anish/Other._- !nterpre!er?, ~- Y N - ~a~e: □ TB - CLEAR D - - .-· · ------,----.------ ·_t?ngliage:_· ____________ __,_ __ AT PREVIOUSFACILITY- via (must have documentation of Negative PPD on file) Negative PPO- date completed ______ OR 0 TB - CLEARANCEREQUIREDAT THIS FACILITY D CXR required and scheduled b)(6); (b)(7)(C) Time Expiration-Date of Vaccine-::·._· Administered by (signature) ________________________ Date PPD Read __________ _ Results.____ mm lnduration Results Read by (signature) _________________________ _ Female Patients: Have you recently been Pregnant ___ Yes __ NO ( if yes, when): _______ Is there a possibility that you are currently pregnant? ___ Yes _ No --- * If pregnant PPD planted and read* Urine Pregnancy Test ___ Date Negative ___ Positive _____ Time Medical Staff Signature r 1 028 866 428 ALMAZAN-RUIZ, FELIPE ADM 09/08/17 DOB 06/26/66 Initials Date Allergies:~ Time '(.'{j~ 2020-ICLl-00006 4292 Rev1secMay2017/mb .• ·. . ; Facility: ALMAZAN -RUIZ,FELIPE ADM 09/08/17 DOB06/26/6G Patient Nar,.____ Da e Telephone Orders M e d ic al 028 866 428 Time _ _ __ __ Patient# _______ _ Signature Order: 1P\' K~~ r-.11t-O f: Qr} f d I J 111PdiOOh~ (J <; 0 ~ I) •• ~)(6 )~:!,,(C) - ~ ht1 nrl'.::>c)K\.okJ Neck Throat [! f C'\\ ({_I)/h--.;, ., 7:)O ~ \3:: CL:,;_V, Cv, cJ I' Abdomen Additional Findings REVIEWOF CURRENTMEDICATIONSc ___ _ VPc / ASSESSM ENT(DIAGNOSIS) :_----1r-t-L -=-------,~f--'--r-f-' -+-sf:i1-~t--?r~/Jfj---------,----------i=-:-_LL-+-· ~---..-.c---- ~ (.f) tJJf'cx "o5r iX PLAN:. _________________________________________ FOLLOW-UP: D PRN r:i 30 day n 60 Oay~ Medication (s) Order : r::90 days _ □ Referral □ 5-e..-t"cl ~, £((_ Other -L~ _eVc~( SJ;~7 (- tvftr· 9t1~ ./ Lab/Radiology Order: Other orders: Time Frame for any requested consults u within 2 weeks o within 30 days EDUCATION: □ Diet □ Signs and Sy □ Patient verba Provider Signature/ Title:__ □ lnterpreter\jl s s, benefits, and alternatives and agrees to the plan Date/Time: ---1 .-N Name: __ Prov id e r pea ks: ~_L__spanish 028 866 4~ --1 c7 /( / ,_ ___ Language: ~ /J·J/·?.Q ~~'°' J / ============; / Ot~======:::::a,====s:Pe::a:.:.:k:.:s:_.:E::.n~g.::.:lis:.:..:h:...'.../_:S_µ;~:..!./_:D::..:t.:..:_he::.:r...::: ALMAZAN-RUIZ,FELIPE DOB 06/26/66 r ADM 09/08/17 u Risk Factors and Reducers (b)(6); (b)(7)(C) ~l :::i other: Allergies: ~~',\-RevisedJuly 2017 / mb II Emergency/ Injury Assessment Medical Date/Time injury: Date/Time reported: Subjective: n~ (State wh;it occurred, who/ what/ where/ how) ca½\d::ta::tM1 !<-c,io "~n~ 'doo&. Pain Scale: (0-10) __ Objective: Date '1l . tt\n be1A1JS0 o\tto1rLQ.t ~ r~~ Time l~D Temp Pulse Resp t,\15 toll w Sa02 BP BG q_,;;.... ___ _ Narrative fOO'f. \'\1~-V\0l HVt. ?'l-c1ti ,L\'MY) f-\-umtrr!holrt:_af¾- nvrlot1A:tt ~r~ q~r; nu---c~W 6k-' "'l-l- .r) Y\' ~( ,~ --,. V1.•'"!!!,,.117_.r n /\ . -. ,~ Assessment Decision:· . ~urther D No Further CJ re Needed D Care-RequirE!d Other _____________ _ _ Plan: u Cleared lo Return to Current Hci.;sing in Facility per Provider: __ ...--------- Date/Time ________ _ > ::mer~ePcy/ Injury 1\sses~mert, Treatment 2020-ICLl-00006 4296 1111 Timeline / Checklist - Depart from the Facility Medicai Departing Facility Via: Transport via VAN· Date Time q\\\\t1 ~~,z (b)(6); (b)(?)(C) (b)(6); (b)(?)(C) ·omments ecurity SLperv ~AR notified of need to transport via VAN to o Progress notes 9#atient f11-tL S\-,LU.~';) left via van with security escort Transport via EMS: Time Date Initials Comments 911 / EMSActivated notif;ed of need to tra11s~artv·,a~MS to Security Supervisor o MAR Returning to Facility: Vital Signs: Temp Pain Scale: (0-10) Date Time □ Date/Time EMSarrived at facility Progress notes c Returned frcm ER ____ Pulse ___ Initials Comments Resp ~dm --- B/P itted to Hospital and returned ______ Sa02 (room air) ____ _ Patient returned to the facility Hospital Records o Continue previous orders 0 and Orders Received forwarded to medical provider for review New orders from provider noted □ New medication(s) entered into pharmacy system Assessment/ Notes: _____________________________________ _ Telephone Order: (b)( 6); (b)(?)(C) Date/Time rder per Provider Date/ Time 028 866 428 ALMAZAN-RUIZ, FELIPE ADM 09/08/17 DOB 06/lG/GG Allergies: Y\V-,,OA- Medications: ~ VY\~ Revised May 201S / mb Emerge1cy Tlmeliie/Checkiist 2020-ICLl-00006 4297 1111 Emergency Treatment Order Medical Date r------------t----i-.- Oi_ \ Time L\{\kj..,- Initials b)~(6-);----rl \l\\'1 \l!\'J'\ b)rJ(C) Transport Patient to----~-ER for f ~~ \f()\'V\\ rther eva[uatiqn and \rfatme11t(telat~d \?\bO(l C: tt )( fJ.\-"{A ( Per p.:~ei ,T;-av,- t (b)(6); (b)(?)(C) Date/Time p~~-----t Receiving staff l'!"b~)(Bf>l );~(b"!-' )(!=, ?)-+: (C,,.. ) ----------.. N.ime Printed: 1------Date/Tlme 1----Title: ~ l'\ I . C\ _______ .........,._~-- k'V Y\ When the Patient is Released form the ER/Hospital, please do the following: /\DC F/\CII.ITY 5Pf'CIFIC INFO~MATION HcRr If you should have any questions regarding this Patient, please contact: HSA Name Phone# & Extension 028 866 428 ALMAZAN-RUIZ,FELIPE ADM 09/08/17 DOB 06/26/66 ~m ergency ·reatme ~t Order 2020.1cu .oooos 4298 \\ 1 ,zof 1111 M,2L1ical UM call prep Chronic Care: Yes/ No Last Visit ____ Riskfactors: \\•'\' Current Medications: ~ ,,, Compliant: Yes/ No CCDiagnosis (s)_______________ 'l',B ~' ~o..-~c.,..i;,,oe _ , ---------------------------------------- Tests prior to leaving (i.e. EKG- labs} Yes/ No If yes results ____________ _ Facility: Vitals ➔ Time-!, Temp Pulse Resp BP Sa02 Recent CC results - i.e. Ale - PT/INR I I I I Tests in the ERand results: ---------------------------------Medications received in the ER/Hosp.______________________________ Sa02 Return Vitals Notes _ Medication changes at Hosp: \ Temp ?a Pulse \\Sh,,c :be,,,e,>,~\:i~. Resp BP Sa02 -~ Seen upon return - Date Time By: ~I'.'\\\ c;\,\s ~~..Jc UM call May 201S / mb 2020-ICLl-00006 4299 r )(6); (b){7)(C) Subject: HOSPITALDAILYREPORT DETAINEENAME: XXXXXXXXXXXXXX ALIEN NUMBER: XXXXXXXXXXXXX DATE OF BIRTH: 06/26/1966 COUNTRYOF CITIZENSHIP:MEXICO DATE OF ARRIVAL:09/08/17 RELEVANTMEDICAL HISTORY:Detainee with history of heavy alcohol use, last drank 3 months ago. Presented to medical reporting he was vomiting blood xS days, assessed by RN who noted blood in mouth. Reports history of this happening 7 years ago as well. Has history of cirrhosis of the liver with varices. DATE OF ADMISSION: 9/11/17 CURRENTDIAGNOSIS:q,1 RI Fm ATTENDINGPHYSICIAN~ b)(6); (b)(l )(C) CURRENTSTATUS:PT STABLEATTHISTIME. MOST RECENTVITALS B/P-99/58, P-75, R-17, 02-97% REMAINS AFEBILE. 2UNITS OF PLATELETSGIVEN DUE TO CRITICALPLATELETLEVELOF 27. POSTTRANSFUSIONLEVELIS 55. All OTHERLABSREMAIN WITHIN NORMAL LIMITS. DETAINEESCHEDULEDTO HAVE EGOIN THE MORNING. DETAINEEWAS PREVIOUSLYRECEIVINGCARDENEDRIPVIA EXTERNALJUGULARLINE, HASBEENSTOPPEDNOW RECEIVINGLISINOPRIL PO. DISCHARGEPLAN: NONE AT THISTIME REPORTGIVEN BY(b)(6); CONROEREGIONA""''t.a;., 'H~"~c;,, 'p=ff=A.,..,.,L (936) S39-1111t )(6); (b)(7)(C) AH-SADF-POLK _ivingston, Tx 77351 936-96 ~ b)(6); _. m 936-96 7-8846-Fax 11.1,c,c cal 3 2020-ICLl-00006 4300 r b)(6); (b)(7)(C ) (b)(6); (b)(7)(C) From: Sent: To: Cc: Wednesday, September 13, 2017 5:35 PM RE:HOSPITALDAILY REPORT Subject: Hospital Daily Report Hospital day #J_ DetaineeName: Felipe Almazan Ruiz Alien#: A028866428 Date of Birth: 06-26-1966 Country of Citizenship: Mexico Date of Arrival: 09-08-2017 Relevant Medical History: Cirrhosis of the Liver Date of Admission: 09-12-2017 (correct date of admission) Current Diagnosis: Upper GI Bleed Attending physician: kb)(6); (b)(7J\Cl )~;) ~\rr., Current Status; (NOTE:include Vitals, Meds, labs, etc.) report received fro t 1200 A+O x 4 BP 117 /58, P88, R19, T98.3, 100% on RA Afebrile, received 2 units of platelets hemoglobin is 11.2, platelets 27'"L Discharge Plan: NO DISCHARGEPLAN AT THISTIME. PLEASECONTACTA-1EDICAL FORANY FURTHER INQUllllES. I l(b)(6); (b)(7)(C) From: l(b)(6); (b)(7)(C ) Sent: Wednesday, September 13, 2017 7:44 AM (b)(6); (b)(7)(C) Subject: RE: HOSPITALDAILY REPORT I should also mention that you do need to have the detainee full name and A#. I always have to remove it when I am communicating out of the ICE network (to your emails) or encrypt the emails to protect PII per policy. You all however when you send me this information are sending it to an ICE email (in network). Very Respectfully, Kb)(6); (b)(7)(C ) L . r ~L ______ __,~N,BS::--1, CCNM Houston Field Medical Coordinator ICE Health Service Corps/ USPHS 16038 Vickery Dr, Suite jlCAL/SURGICAL ro ·r.\L NO . ()II !'.\011'.i, INCLUOINCl C0V~I\, !•l·IUl'oli UMllhl\: . ' (936)539~7595 (936) 788-8037 PA-XtE.NTINFORMATION ~ •PLE ASE KEEP CONFI DEN'TL\L,. mittd with it mrJ.yconbln PR. • · • · ,\A-"cs. c the 111.1 • atnny ·ctly :ill •~~~---~-.!..~.!'.'..~_,;..;_, u ll1 ~ro , •dnl:~r..d.e en~ and notify5~ndcc ~t the telephonenum 2020-ICLl-00006 4308 . ,.~ ··" l!li-----+--------------~-----------------:•J :-,•: : :•: iH' Spe iHen Inquiry Report ,o. CONFIDENTIAL ioo~ Conroe~eaiooal Medical Ce1ter, ConroeTX 5 Ned.oi rec tor :~ lC l; (bl(? J(Cl _ i\il ..fn ti CRPll21190.;..El 1 A[[Tti:~ r _x7_KE_l__ ~ILac: B.MEDU DO: ABBAL A6E/5X:51/H ROON: B.141 110 ANSNR STATUS: ROM IN BED:U PATIENT: RUIZ.FELIPE FO: -~--~ RESOR b)(6 ); (b)(? )(C) :➔ 0914:CR: 00128R COMP,Coll! 09/14/17-0450 Recd: 09/14/17-0503 (R#D7674936) **** Test Result Flag Reference :,: :,, SI te Ver If Jell COHPM TABOLIC i I 1 ) NA I 133-144 MMol/L 137.0 09/14/17-05◄ 1 i ' '!) !: I I( 4.2 3.5-5.1 NMOI/L 09/14/li'-0541 1> CL I 95-105 11HO 1/L ! 09)14/17-0541 I I :> :t CO2 ,l 'I :> AHIO 6AP 25 I 21-32 111101/L 09/14/17-0541 4.0-15,0 GRPcalc I 09/14/17-0541 7,0 2020 -ICLl -00006 4309 ' ,. I.', I, ~: ::v· :n:, ·.1. :w 111-----+------------------------------""S:1 Conroe1/eoinnal MedicalCenter,Conroe TX 5 7 e>< ), (b)( )(C) I CAPIZ11!30-01 Spe iNen InquiryReport ~* CONFIDENTIAL k-1,,- 11ed.(}i rec tor: 7 ACCT ~ b)( )(E) PATIEHT: RUIZ,FELIPE FD: OD:ABBAL RESDR l b)(5); (b)(7)(C) ANSNA ffl f ':w,:' I Lac: s.Hrnu AGE)S>{:51/N STATUS:ROMHt d ' UI: BH00861890: •',i:· REG:09/12/17 DIS: ROOM: B. 141 BEO:U ·)u. I-:-.-;• ;~: .·➔; Coll: : 0~14:CR: B0871R COMPJ Test 09/14/17-0◄50 flee~: 09/11/17-0503 CRff0767◄936) .Result Flag SHe Reference i-l_ !,J.. ·:.:.._,; Uerlfled 'I : ! l> i tee UBC J ,J,· I I ' !> ' L 4 . I - 12. I k/ 11t13 09/14/17-0542 L I 3.8-5.5 M/nnJ RBC I O'.:J/14/17-0542 i I !> I HGB L I 10.6-15.8 6/DL I : 09/ 14/ 17-0542 i> HCT 25.5 ) ttCU 93 .1 L I I. 36.0-47.4 "/. SIi. 1-101, I fl I 09/14/17-0542 I 09/ 14/17-0542 -··~···-·•-.......- 2020-ICLl-00006 :·;~:; ::;;: 4310 •: ' i :: '. '• ' ' ! : 1,:;~ i ::·' : : j : ' ',·; ' . ' Sp ciMen Inquiry Repart ~ ~ CONFfDENTIAL *~~ ConroeRe ional Mec:lical Center.. ConroeTX Med,Dfrector 5 ' !PATIENTRUIZ,FELIPE [ :FD: i RESllR: (b)(6); (b)(?)(C) Accrn: OD: ABBAL ANSNR 7 CAPlt21190-0l bJ( J; (bl( HCJ pc:B.NEDU 7 ._l (bl_( l_(E_J ___ RGE/SX: 51/N STATUS: Aon·IH ROON: 8,141 BED:u if 0 IS: :➔, ._.··, 0914:CRC600013R COHP1Coll: 09/14/17-0450 Heed: 09/14/17-0503 CRI07674936) ~~~~ Test Result i'f, Reference Flag :,~; Site ,- ... ....... Uerlflect > > PT PT ATJENT :.'...... · !l. I 1I .3 IttR H I 9.4-12.5 SECONDS 09/14/17-0538 H I 0.85-1 .11 INR Unit 09/14/17-0538 ----------------------------------------------------------Therapeutic range for IHRls dependent upon the situation. I 2.B-3.0 Proph~Iaxls/ venous throttbOeHbolisNJ TreatHent af OUT,Acute Myocardial infarction stroke preuention, SysteHic eMbolisNpreuentlon In fibrillation 3.0-4.5 AH[ recurrence preventlon1 SysteNlc enbulisM 'I 2020-ICLl-00006 4311 q ( · )f t±r1 drH: dC t 1 ! ••... ·, I •• ,,, '. I 11 ' L' ' Patient Information Form I Phone: !{936~ 539-111 1 HosptlalName: Jconroe Regional Medical Center HospitalAddress:lso4MEDICAL CE::'.'ITERBL VD co:KROE, TX 77304 ~----------------~--------------------------------- PatientDemO{lraphlcs ...,,Ad.,.,_m....,l"'"'t a=n....,d'--"Len=gt..,hc,...=,d_.S1ay=._,l"""nforma'-"'-'--:'~tl"';on;:.... ____ ____,: PatientName:!RUIZ,FELIPE l .....----Unit: CR MedloalRae #::=ju;::-2=92=4=53=1=6 ===;::::;]-;SSN;;;;;::;::-;;~=ss=-s=s=-j=ss:::::s===;I Admlt'fypa:!ELECTIVE -·-1Roorn=:-PB=_rc=u=4====4i Marttalstatus:!Single : Gander:jM I Adml&Blon Date:[09.12-2c17 jBed: n.1crns Dateof Birth:,..::lo6=-2==6-=19=6=6 ==::;1AQe:.... js....:1 Eel OlsohargeDate:!09-14-20171 AlC ';.;;Oa.:::-:te.:-:.,: ====::::I! Religion: bi_o'l'E J PL Functlonal status !Bed On!, Episode1Dl (b)(7)(E) ] PrtortoAdmission: '-'__ l _______ __,1 Haight:! : (b)(6); (b)(? )(C) ======~, I: - PhoneNumber: weight:[ Dlag0911s lgfao!11Uon: Rugs:L..__:_:_,]Pr1mary:,..ju-P-PE-,R-G-,I-B_L_EE-,D------.! Secondary:....._ ___________ · ModectTransportatlon:..._I ____________ WIii 1908lveradiation ordlalyslaoff-site? 0Yespatient O No .] _ Peyer Sou roe:_ ""·--:----=======··=-=·--·Schedulerl TreatmBl'lta: ,,_,,________ -'! Emergency eom1,,ct: Llvi1gArrangement. ________ FirstNama/M;..:.:;.:Jl:fipw=F.Fi=:1=,1::•:P:;;:-:J:'i.=-=:===:::=: ~Jl1 First Nam&IM,----1:/:JJJ; L=====-"''"=:J~ -~ ...... se'"""-le ..... ct ...... O'"'""ne-.LastNameqRl:1Z LastName: FacllllyName: stNet: r_:-:-:---7 S1reet.----1 , l}LOCTh! 350 SOUTH I . ____i ~--========! City:LIVINGSTON City: Natt rl Kin Patla1tAddrass 1 Straat:3400 FM 350 SOUTII ciw:LIVINGSTON statalZlp:TX 77 351 HomaPhona:19 36-967-xooo Work.Phone:999-999-9999 Work.Phone: Ralatlon: 01 0Emerg.Contact 35 i Stats/Zip:TX _1 HomePhone:[2.'.?.6-967-8000 ?};--_=====:Q Payer lnformatlgOi ~--,;;;;=======~ Siate/Zlp: ] HomePhon....._e-;::: WorkPhone: Ralatlon:.--~=======ll ======~ ,-=======:::::=::a □Emerg.Contact POA □POA Ins.GroupID#;.:.=-====:;:::============11 Prtma,yPayar:!oVERRIDE wrn-I PAYOR KAME Contactpel'90nat Ins.co.(Flrst/MI/Lut}:C ! MemberD#:l (b)(6); _(b)(?)(C) 1=[==;;;;---.:=:=====::::i ~ ! Phona:....._ ____ __. Patienth• met 3 ooneecuttve,acute kweld ca.red~ durtngthis admission& may ba ellglblefor the MedlOB19ExtendedCara Benell!:. []Yes 0No □NIA □Unknown SeoondaryPayar:loVERRIDE_JY1Tii!'.AITIB] Member1Dif bl(6 ); (b)(? )(C) .J Phone#:L====-·-J OtherPayer: MemberID#:i Phone#: [ L IncomeIf kncwm: □SSA VA D PrtvateFunds Pension PatientMedicaidEllglble'1 0 Yes l D No □ss1 Oother lf'Yes,submltted t7,-ourflnanclaloffice? Y• Phonei(936)5 Jb l(6); /bl/? l/Cl 2020-ICLl-00006 4312 No 1oate: 09-12-2017 1 I 9/:..2/.2C17 (I:;: :n PM HCA CoYporate Certific&tion Insurance CONF~r.~N'':'TAT. For Facility: ----------------------------------Acct Date.: -- Patier,t - 340C Age: '>lY Type: United Sex: s;~ot: ?1 S:.ngle TX I Sta:es of Arr.e 77351 Home l?hor.e : 93 E, 9E, (b)(6); Phor,e: 999- 99 (b)(?)(C) Work Emer - IN?A':'IEN':'{Inpati.ent) M'a.clo1l Cou::1ty: Country: Zip Cocie: 6/26/1%6 D2.te: FM 3~0 SCUTH LIVINGS':'ON DOS: MR'li: BH0086H9C F~c: Conroe Rcqio l?:-.Lys: Att Ci. sch Enc A::.:com.'l'toda ti on : Home Adcir: Center (b)(6); (b)(7)(C) Adm P'.1.ys: CR-3 IN':'ENSIVE C B. :CUl8-1, 1 Room: Medical RUIZ 1 FELIPE - Name: 8:20AM 9/12/2017 Location: :NFORMATION Regional Ccnroe. IQ - ENC~~TNTER/ IICM DATA---------------------------===-=--=•••• N'o. : -fb_)(_7 )_(E_ ) ___ Start PATTENT PAGE l Report SSK: Cor,~aL:t.s: Hone Tel: Mame: RUIZ,FELI?E Rela~~on~hip: Self Admit S':ay: current HCM DRG: ::oJr.plaint: UPFER Gl Work Tel: 93€-967 1 GLOS: l.LOS: outlier: BL£.ED HCM Di;..gnosis: HCM Procedure: Dx ca::eqc ry: Adrni t P.eview: ,.,'·',_."'""'"'==================== 'PAYF,R ( S) ================== =========================== OVF.R?.Ir>E WITH PAYOR NA'MF. Auth No: NR/: OVERi<.IDE WITH PAYOR NAME Aut:h No: State;:,;: Statt:.s: NP./-:- P Cert? Insur s Cert? I!lsur ~o: 028866428 No: 028866428 ====== LJ:\.ST COMPLrTED REVIEW Q}J::,y ~eview Date S/12/2017 Care Date 9/12/2Cl 7 Review ID S:ni th, Kath leer. I::ttensity Severity Reviewer Revi€wer Ca::egcry Ccrn.~e!lts: ---9/::..2/2017 1531 by !(b)(6); (b)(7)(C) Point cf Ent.ry: per cpoe ddm.:. L :::.:1pl paye"'-· over1·ide ::~anster from L.::.vingsto~ P~ese~ting symplcms: Gi bleed, Failec OP treatment: Vita.:. signs: Medications/route: ~abs/Cul::u1es: p 93, p94, h/h 77, bp 181/1C7, 184/95 1 1,,i th 203/95, ::.2/30.1 Irnag.::.ng: :Jiel/Acliv.::.ty: ox~rgen: ?'l/C':'/ST: 2020-ICLl-00006 4313 payxor 211/1J4 N;,.mc Referral From: Conroe Regional Medical Center From: (b)(6); (b)(?)(C) To: IAH Immigration Phone: (936) 539 (b)~~);__ Attention: Heather Fax: (936) 788-8076 Comment: 028866428 ins# our fax 936 788 8076 tax id 621 801 361 npi 196?455816 The following documents are included in this fax: Name Pages Patient Information Form (rev.7/2012) 09-12-17 03:37 pm 1 Insurance Certification Report - IQ 2 Patient Health Information Legal Disclosure: This facsimile transmission contains coniidential information, some or al: of which may be protected health information as defined by HIPAA (the federal Health Insurance Portability & Accountability ACT) or persona: information protected by state data privacy or security laws. This transmission Is intended for the exclusive use of the individual or entity to wncm It is addressed and may contain information that is proprietary, priviieged, contidentiai and/or exempt !rom disclosure under applicable law. If you are not the imended recipient (or an employee or agent responsible lor delivering this facsimile transmission to the intended recipien1), you are hereby notified that any disciosure, dissemination, distribution or copying of this informatio · . · o · 'led a d may be subiQf; )(6°') ;'°"]~ restrictio . a c ·o ou eceived this in error, please not (b)(6 ), (b)(?)(C) hone (936) 5~◄<"-"~- 1 e-mail at b)(B), (b)(?)(C) to arrange the return or estru -;tt> q((/fo 91 ion at the information a,..n_d_a_l_l c-o-p-ie_s......_..,____._....._. __ \fie IS1o b)(6); (b)(?)(C) (b)(6); (b)(?)(C) 2020-ICLl -00006 9/12/2017 03:33 PM Insuran<.:e HCA corporate C= 8ne: General, >= One: IV medicat.io:i administration, Medica~ion, >= One: Antihypcrtcn::,ive Both: Admi:-.istration, > Or.e: Titr~1tion q1-2h a:--.ci:m,.,:,:i::odng Int.erO.ual(t Corporation CPT only;;;: COKflBl:!N':' .:.1u,- ccnta.in.s CareEnhance•.ct• Review M,mager and/or one o::. it ..5 ~t:bs-.d~a.riec1. and 2016 Americar. proprietary 2 - JQ YlHiical ;c:, 20] 7 McKes.~on All Rights Reserved. A.~sociat:..cn. AL_ Rights Rese:::ved. i:--,f orrna tion. Not intended 2020-ICLl-00006 4315 to::: external di.stribu::..on. ::: ::; Referral From: Conroe Regional Medical Center l(b)(6); (b)(?)(C) From: Phone: (936) 5:.i~ (b)(6); _. (936} 788-8076 Fax: Comment: To: I Attention: IAH 0ENTENTION CENTER l(b)(6); (b)(?)(C) I NOTES AS REQUESTFD The following documents are included in this fax: Pages Name Insurance Certification Report - IQ 4 0913_ 12:23:13 1 0913_ 12:23:04 4 Patient Health Information Legal Disclosure: This facsimile transmission contains confidential informatio n , some or al: of which May be protected health information as defined by HIPAA (the federal Health Insurance Poriability & Accountablllty ACT) or personal intorrnation protected by state data privacy or security laws This transmission is intended for the exclusive use of the individua. or entity to whom it is addressed and may conta in information that is proprietary, privileged, conlidenfal and/or exempt from disclosure under applicable law, If you are not the intended rec pient (or an employee or agent responsible for delivering this facsimile transmission to the intended recipient), you are hereby notified hat any disclosure, dissemination, distribution or copying of this inforrnatlo · . · · · · ed and may be subjec . al restrictio1 ac sanction If you recejved this jn error, lease noti (b)(B), (b)(?)(C) I phone (936) 539- (b)(B), re-mail at b)(B), (b)(?)(C) to ' '---r-------__J< / h \/ 7 \f P arrange the return or destruction of the inlormation and all copies I 2020-ICLl-00006 4316 9/13/2017 11:4l AM In.suranc:?.X: M S7:at:: Single SnlJ'l'E LIVINGSTON, TX ccunty: Countrjr: Un1.t.,od '."tates o: An·.e :S:.p Cod<".'. 7735·1 Eo~c Work ~!Iler ~hone: ?hone: 936-S67999-999- SSN: Cont;,ct:s: Name: RTTJi,~~tT?E HCM DRG: Work ':'el: 936-967-8000 Home Te~: Sel: Relatio~5hip: Ver: 872 Admit Co~plaint: HCM D:..agnosi s: Stay: Curren-:: 34 1 ALOS; 4.5 GLOS: 3.8 o·-1.tlier: UPPER G- BLEEJ HCM Prccedi..;re: clx Category: Adrr.i t Review: ===:= ====-=========::: ===:===-- ==== ===:· ; OVERRI!:JEw:TH PAYm NAME .D,..uth No: Statu."l: From #Days Type 'Ihru P Cert? :nsur No: 028866428 s~atus Auth No Cert - P NP./ I Compa:-iy: SubmiL Submit Phone: to: Fax: OVERRIDE '\IH TH PAYCR NJ\ME Auth :-.R/ I No: S~rvice 'lime: Jate: by: Ref No Statt.:.s: ~ Cert? l~3ur No: 02EBE6428 ========="""""'"'=="'===================•"' CURRSNT REVIEW---------------------------------="'"'"'=--Review Date S /13/ 2 01 7 Care 7 Review Ca-::egory Reviewer ------- l(b)(6); (b)(7)(C) Int ens:::. ty Sever.:.ty Reviewer D~te 9/,.3/.?01 Cnr:lll'.ents: b~b}{6); (b}{7)(C) l ---9;1312011 1133 Vital s~qns: '------------' 36.E, 57, 109/66 TC 89/S,, 94 % 2020-ICLl-00006 4317 ID :JE6 9/l3/2'Jl"/ 11:41 I,1tiur<1ncr-- AM HCA Corpo:::ate Cc>r-::i ficatior. Report - CCNF:DENT:AL Fnr Accl Nu_: Facility: BH9C2107RlR1 con.roe REgi one.l Co~roe Facility: Regional NaJr.e: Pat.:..ent Meciical PA~IENT ?AGE 2 Selected Review INFORYIATION ~edical - JQ ~An~~r Age: '.l.UIZ,FELlPE SlY D03: 6/26/ : 966 Ce::i.ler .. ····-·--------=~=----~-~---------~--- ...---·------====:===ac=-- CURREN'lREV l f;'tl Mf'rlicdtions/Route: PO MF.:JS, PROTON:::X IV, :EVAl;UIN 1 V, l V TRANOA'fF, PRN, IV ZOFRAN PRU, IV :10'.l.PHH'E PRN, -:.... J'' s ~ :::VY @ 75 CC/ER, :::v CA.-l.DEN~ Labs/c·.i.:. tu res: H1.H 8.4/23.e, PLT 35, I~aging/Other test~: C'l'T TITRJ\TFD P'f/ :NR 16.f'..;s_,:_r, RBC 2.60, Diet/A.c::tivit.y: CL DIET Oxygen: AS NEEDrD PT/OT/ST: Other treatment.,; 3LOOD PRODUCT Leve: cf CJI.Jrn:o, TR1'.NSFUSHJK"- PLATELE':'S care eval/referral$: GI, CRI~ CARE Barriers to :V PLJUMttt;xh (cr Inter:Qual Ver~icn: Inte:::QualG' 2 Cl 7 .1 Review iate: 09 13-20:7 Review Status: In PriDary ?.:·oduc::: LOC:A<.:Utt, Adi.:.lt C.,iteria .subset: General Medical C.:iteria status: Cri~~cal Met (Symptom or ::in :Jr.e: IV mcdic.ation adm.ini~trat;._on, Bo-::>-i.: Medication, >= one: c~,lcium channe1 b1oc:,er Amr.inis-:rat1 on , >= one: Titra-:io~ ql-2~ a~d monito=ing 0 InterQual·~' and careEnhance0 Rev:..ew Manager ::orpc·raticn and/or one cf its s·-lbsidiarie:s. CPT only ·_o:2016 ll.m.,,r i c an Mec.ica.:. Association. :;, 2017 McKesso n All Rights Reserved. Al: Rights Rc~erv<"(5); {b){7)(C) Addendum1: 09/ 12/ 17 1524 109/12/17 at 1522 _____ ___. 5 b~ ._(bl( ); (b)(?)(C) 2035 363 b)(6); (b)(7)(C) h 09/ 12/17 at 1525 Electro nicall y Signed b, RPT # : 0 9 : 2 - 04 90 *• *END OF REPORT~** Page 1 of 1 2020-ICLl-00006 4320 nic /compu t er _, CONROEMEDICAL CENTER (COCCR) Pulmonology Progress Note REPORT#:0912-0575 REPORT STATUS: Draft DATE:09/:2/17 TIME: 1714 UNIT#: BH00861890 ~OOM/BED: - ?ATIENT: RUIZ,FELIPE ACCOUNT# : j(b)(7)(E) ATTEND: DOB: 06/26~/~6~6,.....:....__~A~G=E~:---,,,-5~1~ SEX: M ADM DT: 09/12/17 * ALL edits document* or amendments mu5t b)(6); (b)(7)(C) ACTHOR: be made on the electronic/computer Subiective ChiefComplaint: RFC:GI blP.~d/lCu management. Obiectlve PhysicalEx:am VS/1&0: Last DocumP-ntc.d: esu t Tern Pu se Ox 02 Date 1me YHJ 09112 1600. ow te 100 09112 1447 2 09 12· 144 7 11"7.58 BP 09121400 ·-88 09 12 1400 19 09112 1400 Pu se Medications: + DC'd Last 24 Hrs FolicAcid 1 MG DAILY PO Lactulose .l O ML Bl D PO (CKD) Pantoprazole 40 MG Q12HR IV Trazodone HCI SO MG BEDTIME PO i'1\etoprolol Succinate 12.5 MG DAILY PO Sertraline HCI 100 MG DAILY PO Sodium Chloride 250 ML ASDIR lV Labetalol HCI 10 MCi Q4H PRN PRN IV Levofloxacin 100 ML Q2411 IV Morphine Sulfate 1 MG Q4H PRN PRN IV Ondansetron HCI 4 MG Q4H PRN PRN IV Sodium Chloride 2.50 ML ASDIR PRN IV Sodium Chloride 1O ML ASDIR IV Sodium Chloride 1,000 ML .Q13H20M IV Lisinopril 20 MG DAILY PO (DC) Nicardipine/Sodium Chloride 250 ML ASDIR IV Actjve Meds Page 1 of 4 2020-ICLl-00006 4321 Patient: RUIZ,FELIPE Unit#:BH00851890 Acct.#: Date:09/12/17 !(b)(7)(E) ! Nica~dipine/SodiumChloride 250 ML .STK-MEDONE !V (DC) Generalappearance: al~rt, awake Head/eyes: normocephal ic1 PERRL,EOMI, dear cornea Neck: full range of motion, non-tender, normal thyroid, supple/no meningismus, no bruit/NL carotids, no JVD, no lymphadcnopathy Cardiovascular: regular rate & rhythm Respiratory/chest:decreased breath sounds Abdomen:soft, non-tr.nder, no distention, no guarding, no mass/organomcgaly, no rebound Extremities:moves all 1 normal capillary refill, no edema Musculoskeletal:full range of motion, normal i nspcction Results Findings/Data: Laboratory Tests 09/12/17 1.200: ---t----+----<< 09/12/17 1155: >----< 102 133.0 24 4.2 Laboralor Tests 09 '2 1530 ·09/12 1530 emist.ry .. 09 12 1530 90.0 *I I Amm6nia (11.b ~-32.0 mcM K-2 (l.0-3.6N l 4.9 JroponinJ (0.000 - 0.045 NG ML). 0.270 *H, B~Natriurctic Pc ti e (0.00 - ~_00.00PC_1_M------'U_.__ __ __._2_2_6.:..::..S_9_1_1,___ __ -, B( 09/12 1155 --~~~i Page 2 of 4 2020-ICLl-00006 4322 133.01 Patient: RUIZ,FELIPE Unit#:BH00861890 Date:09/12/17 I !(b)(?)(E) Potassium (3.5 - 5.T--mmol/L) · Chloride 4.2 102 24 95 - 105 mmol/L) e1)1-32mmo) 15 ,o GAP-c~a~----+-------7~.o,._..i !----,~-~~~~- -1 ·creatinfnc GiDL) 67 H 1 j6 (0.55 - 1.30 MG1DL; -----'.~~---------c---..---! omeru ar ate ( > 60.cst ucose(70-11 MGDU H 5.3 1 - Ca.,....k:...,.....i u-m-+(8,,-_..,,..5-~,;,,::0.-::-1--.M"""77' s,,,J~ Relationship: Adrr,i. t of r Comrnen ts: ---9/]3/~017 Vi'::a.l :siqns: 36. 6, s7 , 1133 1 o9 / 6 e ·~y l(b)(6 ); (b)(l )(C) M , ro s:i I 5 4 , 9 4 'i: 2020-ICLl-00006 4327 HCA. Corporate 9/13/2017 11:L Ins·;,rancc A..'111 fi cat: on COKFI!JENT:AL Crrh For Ac.:cl No.: Faci:ity: Fad I sJ(b)(?)(E) Conrn~ .1i ty: R~g,ona: F.eport PJ\.GE 2 PATIENT Kame: - IQ INFORMATION Medicc1l Co:::11:ce ~egional ?at.:.ent Revie;,; Selecteci - C•mte:,_· Age: RUIZ, FELE'E s·:y DOB: 6/26/1966 Ce~ter Menical ··-·,...- ========='-== = CU RP.ENT REVIEW --- =======~ 0 --··, Merli cations/Route: PO MF.0S, rv, PROTON IX :.EVAQUIN IV, IV ':':,.AND.An: P':>.l\, TV ioFRAN PF.N 1 :v MORPHINE PRN, :v· .;;: :V? @ 75 :v C:C/ER, Labs/ C'.il ture CARDENE GTT Tl TRATED s: 1-J'&H8.4/23.8, ?:.T 35, Inaging/Other te~ts: REC 2.60, PT/ INR 16.6/~-~6 Diet/Activity: CL DIET Oxygen: AS NEED~D ?T/OT/ST: Other ~realmenl:;: 3LOOD PRO:HJCT TRANSFUSION- Level of care CARD~O, Barr~crs IV ME:JS, ~l, CRIT to PT,A'l'F,T,F.'JS cval/re~errals: C18.~ Ciscr.arge: PLAN STRES.~ WHF,N'HGR 10 Corr.mer.ts /Ot'.'1er: --===========-----=============== IN':ERQUAL REVIEW HlS'l'ORY ------------------------.., .,_ I:,:~e::Qi.,;al·t 2017.1 09 13 2J17 Sta::us: I~ Pr~ma::y :.,oc:A.cu Le Adt;.l t sub.'3et: General Medic"'l Criteria status: Critical Me:: (Synp::om or ::i::-.ding within 24h) (Excludes ?O :uedication.':l lL'l.:..e.ss r.otec) Selec:: :iay, One: Episode Cdy :, One: CRIT:CA.I,, >= Or:e: -',I. Review Review Product: CritEria ca-:.e: Ge:-i.eral, >= One: :v medic.:i.ti c,n acin'J.ni s::raticn, Medication, >,· One: ca: ci·.lll\ char.nel Adrr.i,.istra-cior., Titrat~on Inte.r;Qual Corporation 1~: Bot:-.: bl,-,c: kier >= Cne: ql-2h and moni t o r ing ar.d Care&hanc.e0 Review Manager and/or or.e of i::s S\;.bsiciar.:.es. CP'I on:..y ;t,; 2016 Arr,e.!"i,,:.n Medi.sal Associ2..tion. :;, 201'/ All McKesson Rights Rcscrvec. Al l 2020-ICLl-00006 4328 Right!l REsc.:-vcd. =-------- ... 9/U/2017 11:C lns·,1r.,n~:"' AM For N0 . 11::A Corporate Ce1:tificatior. Report - Selected Review CDNFIDEKTIAL PA".'IENT INJORMATION Facility: :!(b )(7)(E) ~a~i'.ity: ConroE Conroe Patien-: Peq~ona: Medical - Co:-itains pr-opr:ieLe.r:y Nair.e: Meciical Center !l.UTZ, FE::_rp;,; :ONflD~NT:ALTTY .1nfonr,at:..on. Kot: Age: ~1Y DOB: 6/26/1956 STATRVENT --------------------------:int'.f>nrl<'Sd -:°or exte::::i.al 2020-ICLl-00006 4329 3 IQ CenLer =----------------------------------- CONF'TD"NTTAL Regional Pl\GE - distr::;.butior .. b)(6); (b)(7)(C) FAX: FAX: Patient Campus: 936-585936-585- Onit Name: RUIZ,FELIPE C St: ADM No: BH00861890 EXAMS: 020697794 RAD/XR CHEST 1 V To be perfonned PORTABLE? Travel Mode: Isolation Type: Reason for Exam: le~cocytosis comments: *? Location: T 18 Chest x-ray CLINICAL exam, AP frontal projection, HISTORY: Leukocytosis, Comparison exams: ~one 9/12/2017 ICU patient. of t~e chest Elevation the right bemidiaphragm difficult to assess in terms of age given lack of prior exams. Probable scarring veroua atelectatic changes mainly at the right. lung base. No active CHF. Overlying lines obscure detail. No findings of high concern for pneumonia ** ** Signed by l(b)(6); (b)(7)(C) on o9 / 12 /..,2""0..,.1~'7,........,,a"t=--1T""TT"/ 2.,.,6.,....------------.l Reported and signed by:~l (b-)(_6)_; (_b)_(7_)(C_)__________ Electronically J: ~ ___J (b)(6); (b)(7)(C) CC:_ l Dictated ~ate/Time: 09/12/2017 Technol ogi St : b)(6); (b)(7)(C) Transcribed Date Time: Orig Print D/T: S: (1726) j(b)(6); (b)(7)(C) 09 12 2017 09/12/2017 (1726) (1729) Signed _ NAME: ~UIZ,FELIPE CONROE MED CTR IN/OBS MEDICAL IMAGING 504 MEDICAL CENTER BLVD CONROE, TEXAS 77304 PHONE#: 936-539-7026 FAX#: 936-539-7681 PAGE 1 By: PHYS l(b)(6); (b)(7)(C) MD DOB: 06 /26 /l 966 AGE: 51 SEX: ACCT NO: ..... @_ )(7_l(_E)_____ _.lc: B. rcu1s Report M w EXAM DATE: 09/12/2017 STATUS: ADM IN RAD N8: DC Dt: Printed From PCI 2020-ICLl-00006 4330 Patient Name: Unit ~UIZ,FELIPE BH00861890 No: EXAMS: 020697791 US/US ABDOMENLTD Travel Mode: Isolation Type: ~eason for Ex.am: RUQ ahd pain.H/0 comr:ients: non alcoholic liver cirrhosis *? site:Rl6 Limited History: liver Abdominal Ultrasound upper Right cirrhosis. quadrant No prier Comparison: Technique: similar studies and color Gray scale pain, abdominal history e.vailable are imaging Doppler of nonalcoholic for were comparison. utilized. Findir.gs: 'l'his examination The liver markedly is markedly is measures 15.2 cm in limited. The main portal The gallbladder negative. is not The common bile duct The right kidney thickness measuring The pancreas The visualized unremarkable. is due well-visualized. is measures not is on this x 5.8 x 4.2 1.9 not beam penetration. Sonographic identified 10.9 to poor length. Evaluation vein is not well cm. It demonstrates or cortical thinning. nephrolithiasis There limited of the liver visualized. Murphy sign is is exam~natio~. cm, with a cortical ~o hydronephrosis , visualized. o= the abdominal portions no evidence aorta and IVC are of ascites. :Zrnpreesio:o: 1. Markedly limited examination due to poor beam penetration. The liver, gallbladder, common bile duct and pancreas are inadequately visualized on this exa.mina.tion. 2. Unremarkable right kidney and visualized portions of the abdominal NAME:,......_.u....i....z-_= ............ --=:..i:,______ PHYS: CONROEMED CTR IN/OBS MEDICAL IMAGING FAX#: Page l 936-539-7026 936-539-7681 Signed MD DOB: O~-r=2.,....,..,.....,...,...,_,.....,.,_....___,...,......----j., EX : M ACCT NO:~b_)(_7)_(E_) ____ _, EXAM DATE: 09/12/2017 504 MEDICAL CENTER BLVD CONROE, TEXAS 77304 PHONE#: ~ RAD NO: Report Printed From PCI 2020-ICLl-00006 4331 (CONTINUED} Patient Name: EXAMS: 020697791 Travel ~nic RUIZ,FE~IPE No: BHOO861890 US/US ABDOMENLTD Mode: Isolation Reason Type: for Exam: RUQ abd pain.H/O non alcoholic liver cirrhosis Comments: *? -< 102 133.0 4.2 Labora_toryTests_·-----------------=-=-=~-~ 09 12 24 097f2 1530 09/12 1530 1530 C:herni$try · Ammonfa--~1~1~.O~3~2~.=o-----.-.-~~-----+----+-----90.0 * H · 4.9 H i C T .(Ck-2)(1.0-3.6 --0.270 *H B- _ _____:__::---'-'---'----'-----'-L....O....__;'---'------'---'---'--......::..:..-L;:!...-l.... ____ 16.59 H 1 2_· 09 12 1155 ...____, __ ·stry m(i33 - 74:.:fmm 133.0 m (3.5 - 5.1 m 4.2 c (9 -Carbo -, 102 l Anion BUN"(~:----;c'-;----,--,,..,~~. ------'------+----~6=7 Page 4 of 8 2020-ICLl-00006 4339 24 7.0 H Patient: RUIZ,FELIPE Unit#:BH0O85l89O Date:09/12/17 Acctt: l(b)(7)( E) reat'1nine. (O:S5 - 1 .30 M JI 1.3n H 55 L L) omeru ar Fi tr Rate (5-60 estGFR) ucose (70 - 110 M DL) Talcium-tB.5-10.1 J, LJ ····r.s Tota Bi iru in (0,0b- 1.(Jtf·'-M~=D~L)-------+-----~6~.5~6~H~ Direct i iru in (0.00 - 0.30 MG7DL) 3.35 H Tn-direct8il1ru 1n. -1., 3.21 AST (15 -37 Unit/L) 81 H A T(12-78Uni L) !19 TotaTA asp atase (45 -117 707 5.41 Tota ProTeln (6.4-~ 8.2 DL) A umin (3.4 - 5.0 G/DL) . 2.9 L 1.2 Albumin/Globulin Ratio (1.2 - 2.2 RATIO) cfmen A- --earancc(1 NORMAL lndex/DL), 3 SMALL--5~1 OMG. Specimen Hemo ysis (1 NORMAClndex/DL) I) TRACE10-25 MG. Laboratoryl ests 1· 09/121 1200. · Coagulation PT (9 A --,~2~.s~s=E~c=o~N=D~S~) ------,,=7,-,,.J,-,H-,-- : INR(0.85 -1.11 INR Unit) I {52 H • PTT _(Dade)(24 - 37.7 SECONDS) - 29.4 j l Laboratory T_e_s_ts ____________ _ 09/12 1200 Hematology wsc·(~4--'-".1L___-, 2-.,-IJmmJ) 1s:TTT RBC (3 ,8 - 5~5 Mlmm3) 3,StlT Hct (3n.O - 47.4 %) 30.1 L ----,-:.-------------+---- Flgb (10.6- 15.8 G/D'""L,.....; ~--- 11.2 MCV (80.1 - lffL·-==-'1-r.L-c--)----------MLH {2'5.3 - 35.3 p-g) MCHC (12.7 - 35. 7 C/DL) ~RDW (12.2 - 16.4 %) _ ., Pit Count (155 - 337 K/mm3) MPV (7.6 - 10.4 f L) (}7,8 - 82.6 %) ·- I . .. re-ran¾ Lymph¾ (Auto, (14.1 - 4.5.4 °?;;) Mono % (Auto) (2.5 - 11 .7 %) -Eos% (Auto) (0.0 - 6.2 %; • ··-·--·Baso % (/\uto) 10.0 - 2.6 °l;,j Page ··-· ... -· ··-··· 0.5 5 of a 2020-ICLl-00006 4340 86,0 32.b-, ·~ --- 37.2 H 17.2 11 27 * L 7 0.3 fi.5.8 12.1 L 12.7 H 1.7 Patient: ROIZ,FELIPE Unit#:BH00861890 Date:09 12 Acct#: 17 (b)(?)(E) 1ran 2.0 - 13.7 9.95 Fl' 1.82 1. 9-1 H mm3 l" m h :ff(Auto) (0.6 - 3.8 K/mm3) Mono # /Auto 0.11 --~-..:..,....,...--------- 0.59 K/mm3) rrim3) uto aso .... 0.0 . 1 mm3 ··--'----------------~(fiS. 0.08 MAN DIFF iNDI ATED SCN) 100 -immature ran °o .0 - 2. o) . hils ¾ (40 - 75 %) --· ymp 7.2 H 73 12L s%(Manual)(12.6-43.5% Monocyt.es % (Manua) (4.2 - 12.7 %) 14 H ~Manua) (0.0 - 5.2 ¾) 1 0 olb.0-1.0 700V _°Jo 1.7Tl Nucleate .s # (0.00- 0.05 k/mm3) 0.25 H Toxic Granulation (NONE ON SCAN S Platelet ' :,;...:,-.=-.-......-.~;-r,"?.;.,....N".-------t-i=-.-...ii7--,,.._ CR L Eo,;in'o Nuce . . Pt1'0_orp L- RARE T _AN N) .. ~----'-~....,.,...,,_~~,.....;:....,....,...,.,.;;....,..-N~) -'---- scANf NE ON~SC~A~N~) ____ 1-----,---____....L..-'--=-~ S_CA_N_:_) _-- ____ T ·_ 1 T -----;..s~u~c~1=if-----RA~R=E____ j _.__RA_RE__ ... _,__,i LaboratoryTe,.c--sts'----------- 09 12 1530 Sero o Hepatitis A lgM A (Nonreact · ·nreactive He (Nonr~ac 1ve. He _____ __,y (Nonreactive Non Reactive G-NONREA _ NonReactive NR --l'lc Radiologydata: Recent Impressions: ULTRASOUND~ US ABDOMENLTD09/12 1637 *** Report Impression - Status: SIGNED Entered: 09/12/2017 1913 Impression: 1. Markedly limited examination due to poor br.am penetration. The liver, gallbladder, common bile duct and pancreas arc inadequately ?age 6 of a 2020-ICLl-00006 4341 Patient: RUIZ,FELIPE Unit#:8H00861890 Date:09/12/17 l(b)(7)(E) Acct~: I visualized on this examination. 2. Unremarkable right kidney and visualized portions of the abdominal aorta and IVC. 6 7 Impression By: t.SOR.RH 16 - ~l (b-)(_>;_(b-l(_>_ ~:tAL:**t·· . . . . . . . . -. . . ~A'l:iENT: >:~~1_ :~/: / \< .. .QSJ12./l7:f21Q:5 24.6 88.5 ::>:>.::::::::::::: :--::'1:---, .·,·.··· ::;:::::::::: .·....... ·-· · ..·.·.· ..·.·.· f·rr:: '.,, 32.4 . :•:•:=:::::•••::•••·•·•··=·=·••:•:•:• .. ·1·1 ' ·:·:·. •<<·>•: •..... 36.o-47.4 i 25.3-35.3 pg i •...•..... o,ff:i.:i/:i.t-~to:s.• 3.6 . 6 32 .7-35.1 I G/DL ••••••••••••••••••o:;i•Ji2/17:;;;;:,iQ .. '/{\ l:··•.•.•••·········· . ·•·•()~112/1?l~;J.;0:~• .·.•.•. .1I'(}~.-~·····~~~~~~....;.;.;.;.;.;....:..;. ..,,.1 =~~~~.,.,._;....::'--,-,-,-- %- .•.•·•.• •··•··•·•'·=-·· .•.•.,.·7 •-;;J.1.0S·:•:•:•••:•• .L...... ••=-•<•=-:•:• .Q.9-:f 12/1· .,::.:::=-=·=· Ji-'-•·~=~=c..:.:.;.;.;c.......:..~~-""'-"---'---'-""'CC;: JL--,........ _ ____;;.._ _ .~:~:;1~·/i7 ljj_6l····· .·.·. ______, ...JI ·.::·::-:-:. •••·••• •••>•••··•o•~:/?c2/ ;I7l;:J.:of ·..·..·. 69.9 ~F> :~·. .<<<•·•·•• . l ::• •···...... l[- --- ... MV:J~/:t7lJ\~s .. >~<7·•·: ..~.~82.:"~\' .... . . . . . . . -. i 0.0-2.0 I 14.1-45.~ t 1..... ······ -·----_-_./:\-:-:-:.:.:::.-::\:::: ...:: -·········· i:P:$.)ft~/J J::~iJJt-~)'.:'. ···· . . . . . . . <:-=:••=: •:•••/•-•~:os#f/17•1+):¢:s•< .:: ·•/;t:io:9;;.;:;i.,_:J2;; ••·.·•· tr:::.:__:· .. :::t/:a•9Jt.:i:iJtl2:1:6.s: ~1Jtlf7l:@qf I •:tt•··•·• •:::::::·••:tt o~Jijii&2:fi!=? 2.0-13.7 K/mm3 · ·············:: :nr<:/09.J1.:iiij>:f1.~s<·"· .....• <•::-:•:..... 0.0-1.0 %....••}()b /lOOWBCt =- ·· 0. 00-0. 03 K/rr.m3 :=:::::::::: :/{ .··?o~lfi/i:'7}2io)f · =- .•.· ..I: :a·~ /.i} qf'.11 · ·. 3 . · · :-•-::•:•••:• :: :•:::•••••••: :::9'9 f 12/J?/.21:G~\<• H.i_ 0.~1-0.59 i K/mm3 ··•••::?•• ••••••••••A•~1 :2/t%~2:9~/:•••· .. 1 2020-ICLl-00006 4344 .------~~.~ ..~ .. .............. .-.______ ,.,.,...,......,..__,....,_.....,..,-,---.,.,..,...,.,.,.,.,.,......_.......,_-4 (b)(7)(E) :•·~PEBA~q/iii +o_/o\¢:;:J/ t./~illf\ .. : :/Yd>..ft> ·•:u ==•:=··1== · o· o···o·====o ..·••o·•s<.•.·.•K·_· 3::: ... ·.n: <:::::: < .•:'-:•.. :cc .... :,:....:.. .. - ::.::_ ' 09/12/17-2105 ;,.• Nit1s¢"f: =. =1•,:mm·· .· .. •.•.:_•.•·•.,= •.:.=_:_=_:_=_:_=_=.·•.:_•.= .. 09/12/17-2 ... - :-:-:-:-:-.-.•. , <<·(b)(7)(E) .)\~if .·....·.·.·:-·:::::•:=:•:•: 1---------' 2020-ICLl-00006 4345 1 05 l '7: CR: BC00114.19S Source: > RES, Coll: 09/12/1 BLOOD IBLOOD CU--~TURE '7~1530 Recd: Deoc: 09/12/17-1619 (RJi0'?6'73570 b)(B); (b)(l )(C) PERIPHERA:., I Pf$~##r1~fy: o9 In/: NO GROWTH AFTER 12 HOURS 2020-ICLl-00006 4346 7 - 04 19 -:-·........... :.:-:-:-:-:-.:. 1 7: CR: BCD D1142 DS Source: RES, Coll: D9 /12 /17 -1530 BLOOD Recd: Desc: 09 /12 /17 -1619 5 (R# 0'16735 7 0) (b)( ); (b)(l )(C) PERIPHERAL o9 I 13 / 1 7 - 0419 CUL T!JRE-j 1':it~].:;i:ihi~~cy: NO GROWTH AFTER 12 HOURS 2020-ICLl-00006 4347 . ·. D913:CR:H00074R COMP, Coll: 09/13/17-0420 Recd: 09/13/17-0614 (Rll076"13571} .•.l I I •»>: )~J):i,)Ji)/o6'4f :: · · 35.1-43.9 I ON 09/13/17 1 2 5 . 3 - 35 -3 ..!-~-.,.,.,~~,....C.,..,,---'--"-~~ ;u\....... j •a~liib.i- :cfi(fi'( / ••>=f':o~/))}i1,@,~:i so .1-101.1 £L:::: : :::::: f :::: ·:.·.··:.•,•.········ ·.-:::::;;:::::::::::::::::::· .·..·.-.-.•.·.·· l:fJjibh ::::::::.1:::: : '""·.;.;._; fL ······•••··•• : . \ .::~~:::;\::: / CALLED TO ELAINA. HULL. :;;,:~i~di'ntifuiiid':6.Yreia 1.i~c:k: 1-1f;;,t}~~i~)f#V < : . iJ._·9 ·..•~<:. .·. . : I H I 7. 6-10. 4 fL ..:1.•• ::::::::=::. .. ; : :=::=:::: 67.6 4 13 ::=•·=·:> : »:>>> ·....·..·. T 3 1. a - s2 . 6 L · r ::::,:::: ,:::: '=d9/:ii/i .. %- : :: 71()6J9\ .. 1· ..... ·.·.·o 6 /·•1· ·-,:•/"1 ..'··1 □ · ~-•·;, ·:.:;.·". . .-: 0·5--4 : : ·;;J:····· ....·.·.·.· ..· .·..·..··.·. ·. 1······· ::=:::•:::::::::. ·.·····.·. : 0 f;f/;1:3':/:i::'i-9:6:ig .···.: .• f4·_·1.:.,i:r:t%- ····· · · : ::t=/:os;f:t:a=tL::i::; oe;if: : ::: . :1 : .. 0.0-2.0 H The :-:-: 't r.. · ,:: D:9/13/:t}':;:064:$ ••••.••• I ... ::::::~::1:: < :1::: . I /100WBC% ! ·············•o•fh-,s!:tt~oi4~ 3 ::::_)l~)):!}1'7.~0l.549:::•:•·•· m3 ·••9f/i3./i1.~:ci:~4-ti•···•· I •··:••: Q 2020-ICLl-00006 4348 9:Ji~/1-7•~ q$J$•·•··•··•·•··: b)(7)(E) ::::I:_::·.·.·.· ;.;::-tofJ>/ . ?. : )B,]:;S9)!:/ : =-=::-:c::::::_:_: __ :_:_:_:_11'. :_ .·.·.-.·.•.•.· .. ·.·. :::::::::::::::::::: .. = ::\[:.. .... .............. -:.::9/1.f . ::. 09/13/17-0649 ::•=-·-· ••:f H>o ;:i/~s •t ••Fri{'== ;;;R.E~... 0913: .AB··.·•.:•.••.s•·•.••.·•.:•.·•. CR: C00ll COMP, Coll: 7R · 09/13/17-0420 ......... ,. BUN {R#07673571) 0:9/;i.:1/i? - o6 sj cai:C:::: I :: . . a.o °L__G0•_ ... sIO/ .•·o .• • .... 11 'i: j o~s:i:::::::: .... .. . 57 :::::i:;:<· I I ): 09/13/17-0614 Recd: 23 ••:::( GLU .¢:Wsx:•si/ivi\ • •e.~fl??>:••······· ROOMi>BticcfastREG: : DI.~/ .·.·.· >>>:::::<.·.·. )?<< 1· .. "" •••:•::1· > · ·· 100 The estimated ::•os/J)jj_"jl~f($~/ >60 estGFR glome:nilar :rate filtration is ccmputed using :;:::;:~:~Ji¥.ti!;;:::#.~-1~:;:;;~~~9~)::t~:ijjfiii;:i~~:,~r~:~-~##.::~:9-.#:~ ···-·.-.·. needed data elements are missing the Laboratory can not :4i:>¥.iiu:fec•••~n::•.:.fb'.¼~:f:i'.9.ii\~t:•cii,,~f·•1~~~:hi1.:i:f::t.:tl.tiit:ic The GFR value units= ml/min/1,73 meter squar~d. Estimated •&iii:••••v~iiiJJ• ..:C.JJ~}efo••••1w:~1a••:fa~•·••tri.6~.7:piet:~c:i .:~s•••;=s=o, ••:n6ti ...... n exact number . .••·}" ~·PR.P:G: :PMAii.(}@E:kf )/:;;2 •) Drug dosage adju~tments •p~f$] effrs.\: / utiliz~ :•<:t?/·· ::::.: ::.············ 0.81 j •••I: • ••<<:•:e: ==< ,: ...::,:::::::: ............ ••• ·........ •:.......·.••:: •.·.·••.: I Results n,ay be depressed if patient is taking • ::::+ ••fe~/icil!:itfi•~#i+~tn:i!f::Jiilili:cr •a~4Heb~i.rili61~·••toii,fioii~J.< ······ ········· : . Ic-· .--- 4 . a Ii . i I 6 . 4 ~ s . 2 o/ni ·:':':':':': : : ·:>•] . . ....... ·•···T·• <••:::<<·•<•••••••••• ···.··.··, >.:..•.••.·•.:l•.s=-: . ....···.· ..· 2. 4 :/~)1)::1;3)1t~os$:ci/=::::' · LL 3. 4-5. 1.2-2.2 ...·>1r< ............·•·::·}? t•••••........... j .L ·.· ..·;.4 ....... ,.•<:•:•:•:•:•·\::::;::· }t•••>::·•·····•·>. BILT 1 BILD =:.:::.:.1 :: BLI f 1 > 1 ... :.:.·::.·.:.·.·• .... ·.· .·.·.·.·.·.• .... :.:.:•::.:··:• INDIRECT i ,: :: 0 G/DL RATICJ «ci~/):~jf'/)~t_s::f// ........... 1.. s.t{r1 MG/iJf' /:~~~p:l~~5,3 09 ·~==:-ir : • : :::: .......... :/:::o!l/:i;~:/:L}:'~:!;isf:: :: :])iIPMi;ih, ,\~Mh •······••??\9~/:ij:/47"':;,·~~\$3:. MG/DL I ··••>? eii/13/tt c (i.~•$~•··••· 2020-ICLl-00006 4350 sPEc >#! (b)(7)(E) ogffdi:co@~}1f :/~iii~~~···R9#\Fm4~~g ... ···-········-· :(¢ori.fi.fiµ~c11: ·.·.·. '.-'.·'.·'.<•:-:- :tr::rtJ:t •:I/•X• ALKF••:toT@.):)::).:•:•: .. \?\· ••4$.•~.}ii•:• tlnil/t!'•::.·..~:.•.9··•··1.· 09/13/1 ~oR:t-ti.hl, ~iP !4$:i >j:<< I ........·r.1 / >< . =troR~ .... . .. ..tndi;:,~)ti:i, . oi/13/l •.1.•··•··3······•1::•=·•.1.•··=······ I ...,. ••t]$1il(6tE11¢t/ttts· >:·>1, :•• ::: ./1 :,;:::):mii$():¢r~"iC:: 09/13/1 :1:n+:ti3:2'!'RP.CE •4?~-Mtf • J ... liOR~lAL:.fiid¢i./:ri1••• ,.............. 09 ' = ::f l>TC,RM1l.L: :C:nde!x/Di, 09 ............. b)(7)(E) :N~eH:~_wz:iFE~If¥:--:-:; i--:-:/--:-::: :--:-::::-'---'--'----'--'--'--'.;..;--:-:.""'"'"~-'---'--'------'"'""• 2020-ICLl-00006 4351 ·•••••••sp..;~i~n:::Jf4ut#:,J ... port:••••••·.•: bkn.io~•'fl~~M,i~it~,c:1i~h•• cehf~ii•• 8Q~r64! ::fki:::::::::::::::: .·.·.·. ••·•·•·•· ~•*~••::~PNn:;~IMI':r1'l'.i {~•.':.•.•••211!!~.Ilir~c::~ff:jt b>< 6>;(b)( ?> •• •·····•••••...k /,~sliiA/ 0913:CR:CG00DlSR •••> COMP, Coll: :~0=1: ;:~~:;~ ..•.!l@~;,~f~1. l~~~!~/~~1~;~ >>f~TAIB~.r i ... ••J:ix:.::::::::.• ......... · ApM•:P·T::::: C9/13/17-0420 Recd: 09/13/17·0614 (R#076?3576) .ft~LifTrENT .·.· ..·.·.·.·r§ =~~~=--,--,~~ INR t·•·· .( .~ eB.P.i~}i¢: =~@?Cfl'e .fb';tINR.1{=dfpe.t.id~1#/•~po~{\:1:ie()iitrti{ii)~ii\\: •·•· .·· 2. G-.3. rl Prophyl~xis / venous throm.boe~'llbo] isrr:, Treatment of ········••??)•·· ·••kvti )1eiiit;#•••foi6¢~hli.,;ii••••i1li .ifrs c:J§..i:i•· s\#f.4.%~:•pfei/ell t:i§n}•··.·•· Syst~~ic embolism prevention in fibrillation ..··.•J< •.3I: •J-•o:-s:;4 •• h.e.art 2020-ICLl-00006 4352 CONROE REGION.AL MEDICAL CENTER 504 Medic~l Center Blvd. Conroe, Texas 77304 0913-0004 PATIENT NAME: RUIZ,FELIPE ACCODNT NO: ~k h~\/~7= \/F~ \'------~ MEDICAL RECORD NO: BH0086l890 REPORT TYPE: ELECTROCARDIOGRAM ADMITTING PHYSICIAN: ATTENDING PHYSICIAN: 09/12/17 S.ICU18 ADMIT DATE: ROOMNO: AGE: 51 SEX:: M b)(6); (b)(?)(C) Ordei:.-; 2Cl70912-00B5 res:. Rea.son ; tropinemia Test Date/Time Stamp: Tue Sep 12 2017 17:17:29 ! Blood Pressure ***/*** Vent. Rate 070 BPM P-R Int 192 ms 416 ms QT Int QTc Int 449 ms ~oTl!lal sinus ~onspecific at eR outi,ide mmHG Atrial Rate 070 078 -14 QRS Dur P-R-T Axes •"-e erre d B y: ms 009 on 9/13/2017 (b)(6); (b)(?)(C) Conf inned Electronically Signed by; by l.__________ __.on Inquiry (PCI: l OE Database (b)(6); (b)(?)(C) Run: 09/13/17-11:21 7:14:36 by~-------""'"" AM 6 7 ~f b-)(_ > _; (-b-)( _>_ (c_>_____ at 09/J3/J7 ACCOUNT PATIENT NAME: RUIZ,FELIPE Care degrees _, I ~b)(6); (b)(?)(C) Patient 032 rhythm n ST and T wave abnormality Abnol.--mal ECG ~o previous ECGs available Can firmed by b)(6); (b)(?)(C) .,, f BPM #: 1 0714 r.... b_)(-? )-( E-) ____ _. COCCR) 20 0-ICLl-00006 4353 Page 1 of 1 CONROE REGIONAL MEDICAL CENTER 504 Medical Ccnxoe, Center Texaa Blvd. 77304 ADMIT DATE: ROOM NO: PATIENT NAME: RUIZ,FELIPB ~~~~~ =~f ~:E~o: bliVvoo1l9o REPORT ~PE: ADMITTING 09/12/17 B.ICU18 AGE: SEX: HISTORY AND PHYSICAL 51 M PHYSICIANJ (b)(6); (b)(?)(C) ATTENDING PKYSICIAN~l---~----___J ADMISSION DATE: 09/12/2017 ADDENDUMTO THE HISTORY AND PHYSICAL REPORT: Con:irmation Plea~e to #2035335 assessment. and pla~ after DVT prophylaxis. Sepsis. The patient has ~ignificant leukocytosis wi~h a WBC count of 15.1 , failure, and the patient wa~ tachycardic upon arrival with a hearL iate of 108. We will initiate antibiotics. We will not give fluid liberally as the BNP level was more than 4000 a.t the outside ER. We will obtain x-ray and BNP level to reassess the fluid status. The patient does have symptoms of vo::..ume overload at pres~t. renal It has been a pleasure participating have any questions, please do not Dict:.ated By: 6 ._r b-)(_ _); -(b-)(?- )-(C_) _______ NT: HP:B.HIM/FAKAL/NT.S DD: 09/12/20'...7 15:25:Cl 09/12/20'...7 19:14:36 7035363/DID#: 399106E DT: Conf#: PATIENT NAME: RITIZ 1 FELIPE Patient Care Run: in the medical hesitate to call. Inquiry 09/ll/17-11:21 (PCI: care of the patient. If yo~ _i " :l(b)(7)(E) ACCOUNT ff'. OE Database by._l(b_)(_5)_; (_b)_(7_)(_C_) __ COCCR) .....,.__ ..,..l 2020-ICLl-00006 4354 DRAFT COPY Page 1 of l 17:CR:BOOl_SBOSR So-.1rce: URINE RES, Coll: Recd: 09/12/17-1530 Desc: 09/12/17-1619 (Rij07673572) 5 (b)( ); (b)(?)(C) CLEAN CATCH .............. ·····-· .. . >>:< fuR_rnE: CUL'T~gj i:fo~H~Jna:rf ROUTINE WORKUP 09/13/17-0910 ~ 1 0,000 CFO/ML GRAM POSITIVE 2020-ICLl-00006 4355 FLORA CONROE MEDICAL CENTER (COCCR) Note REPORT~:0913-0215 REPORT STATUS: Draft DATE:09/13/17 TIME: 1024 Clinical PATIENT: ACCOUNT# RUIZ,FELIPE :! (b)(?)(E) UNIT#: BHOO861890 ROOM/BEG: B.ICU18-W !J DOB: 06/26/66 AGE: 51 ADM DT: 09/12/17 SEX: M or amendments l(b)(6); (b)(?)(C) AOTHOR: ~---~---------' MD * ALL edics ATTEND: must be made on the electronic/~omputer document* ClinicalNote Note: Seen9/13 See consult Admitted with GI bleed hypotension DEnies chest pain Tror mildly elevated EKG normal No H/O CAD stress test when H b close to 10 RPT #:0913-:)215 ***EN~ OF R~PORT*** Page 1 of 1 2020-ICLl-00006 4356 REGIONAi., YJ:rn:C.AL CEt:tl'ER 504 Medical Center B~v~. Conroe, Tex~s 77304 ~O\'ROE 0913-007:. PA'l'l E)J'l' NAf1~' · ?UIZ ACCOUNT NO t(b)(?)(E) PW IEE ADMIT I CATE: ROOM l\'C: AGE; MEDlC!\..:.., !foCORD NO: RH0086183 0 H.EPUR'.? TYH: ffi STORY AND :?IIYSICAL SEX: 09/12/17 1:i. IC:T1.8 5' M (b)(6); (b)(?)(C) PHYSTCTA AT~ENDlNG ~HY$1CIA, ~.__ __________ _, I\DMll'l'ING ADDEKDUJv:: 'J'O 'f'HF: HISTORY Ccnfi::-:n;,_t.Jnn i:'lease AND PEYSICJ\.L REPORT: 1/:l.035335 ~n assessment a:-.d plan a±ter CV'I' prophylaxis. 5ep~:s. The patient has s~gnitican~ leukocytosis with a WHC count of ,~.1, rcna: failure, 1~d thA pat'.ent was tachycardic ~~on ~r~lva~ with a hear~ ratR nf :08. We will in~~ia~e ant~tiotics. We will not give ~l~id liberally as the RNP :eve: was ~ore t~an 400C at the outside ER. We will obtain x-ray and l:iNP :evel Lo rcasse.ss the f1uid status. The ;,at:.ent does havte sy:.n?to;r1s- of vcl·.:mF>. rw l',_rload It h;i.,i heen a pleasure part:.cipating have any quest.:inn8, please c.o r.ot D:.ctaterl Ry: 6 l.._ (b-)(_ )_; (_b_)(?_)_ (c_J______ W'l': HP: 8. HIM/PAKA.T,/NTS DD: 05/12/2C17 D'I': 0C./12/2C17 CoY-.ft: 201S,6J/DTD#: ln tLe medica: hesitate to call. care o:::: ~he ___, 15:25:01 19:'..-1:35 3991~68 FJ>.Tl ENT }l/\M!,: RUI 2, FK, T P "R ACCOt,"1-J':' 2020-ICLl-00006 4357 pc1-:-.iAnt. :::f you :,l)lz;, ~•t:.:..,1p.cc /\C:C'.T: l~ lh_\_17_\I_F_\-----~, SEX: 3ED: 06/26/56 AGE: i,; NU'l' pare o[ DOB: :vJ This report D. :CU4 NU"'-S; NOTE: Truncated 51 the pen:12ment A'J'N D'< : !(b)(6); (b)(7)(C) ADMIT: 09/12/17 rr.e::l.ical rec::,rd arP. p;e<"!A:1?..rt by ~9sults MR: llH808611:!30 B.ICU18-i;; t--> process Plc,ase 1 per chart Consult Company for 'Polir.y. entire result. ,i\;_,LERGES Coded A1 · "'rqi.<"S Nr:, Known Rc,a.ct ~on 1111 e:-gies C:rRRRJ\7' M'P.D: C'A":'l ON S MED ------------···. C'ARDEKE-KACL 5·:J MG/250 20 GM/JC C:-fRONu"LAC DESYREL FOLV:TE LEVAQUI~ ML 5~0MG/108ML .'JAL:i:KE 250 ML 250 ML NORMAL ;;ALlNE PR:..J'l'ONlX SODTUM CHI I .DJ,( w~ :J~: r:.~9% lOJO SOD~UJ\1 CHLORLJE ':'OP"-OL XT. 7Rfu"\'JDA':13: 7CPRAN 8-9% Dic~ated IV ;:llO PO 50 M(s 1 MG BED':'IME PO PO 20ML !J/1.lLY 1.0D Y!L O.24:-J 1 MG -->Q4H 250 YIJ' 250 )11, 4C MG 1~ MG MW.iH./PRN ASDTR Q1 ;.HR . ;:):3H20M AS:JIR DA::..y --·>Q4E PRK 4 MG lJO MG -->Q4R DAILY Y.L lC ML 12. 5 KG R,>.DTO:,OGY 11".PHESS.:.GNS FRCYI: 09 /12 /1 7 T:-LTRASOUN:J - q:: ABDO.KEN LTD REPORT STATU8: - by i\SDIR 1COO ZOLOFT 09 /1 ?./17 7.5C M!i JO MT, Phys1cian: Ha~g,Robcrl RO"'JTE START MD: IV ?R:11 PRK rv lV IV IV IV TV 09/12 09/12 09/12 09/13 09/12 09/12 09 /12 09 /12 ()9 /12 a.nd REC HGB 8.9 C9 /,?. 1 0 /l 2 C9/:2 ~9/:.2 '..0/1?. ~0/12 PO J9 /'. ?. '. 0 /17. 281-2~1-9472 L 9.D H 1~/12 IV TV IVC. L 2.79 09/13 PO TO: J9/:3/17 0236 J9 /:2/1'/ 11:55 HEMA':'OLOGY WBC 09/U lC/12 lC/12 1 ~ /1 2 l·J/12 TO: 09 /1 ~ /1 7 Signe.d LABORATORY :NFORMATION FRCJM: 09/1?./17 OCOO 0'J/:2/"_7 09/12/:7 09/1~/17 20:20 1 S :] 8 12:00 10 /12 10/12 10/12 10/13 C9 /1?. r.9 /12 1mpreesion: 1. Markadl y l i ni !_c,d cx.a:uina Li ,::,:c du., to poor bearr. penetra ti::,:-_. The 1 i ver, :;ral lb ladder, corr,mon b~ 1 P. dur.:-. ~nd pancrcaG are inu.dec.i:c..<1tely visualized on this exarr.ination. 2. Unre:rnark:<.1ble right kidney and visualized portion.!½AN 0 CIFE' 9 100 SEC ~ 7, 0 ~•YMPH L 1?. MO~TOCYTE H 14 ' 1 N EO~ NREC SL.lC.E'l' SL.lCH'l' AN/SO SLIG::IT FEW RARC OV/\LOCYTES SCHI STO 8E.ANTJLAT ACAN':'.'IIOCYTR$ PLT EST PT.'T MORPH '.'.'.OAC~'l,A7TO'J PT PAI l~N'l' H~R F'l'T CJ:lP.MTS':'RY NA K CL CC?. N 0 H I POLYCHROM HYfC POlK TOXIC 0 ST,1Gcl'I' s::.,rGHT RARE L MRK DECR LARG!l RARE H 17. 3 1l 1 . 5 /. ;:9. 4 133 . 0 4. 2 :02 '4 k"!ION GLU GAF '. 0 H 132 H G, BON GFR CR.EAT L 55 II 1.36 L 5 .4 L 2.9 1 .2 L 7. f:. I-I 6. 5 6 II 3. 35 H 3.L T . .l'HO'l' ALB A/G li..ll.'110 CA BILT BILC BlLl AS'I' HJUiH.l::C'J' E ALKP 10, '":'CTA~, "E 9 C-. 0 A.>m H 226 .Y:9 RNC H 4.9 CKMB *H 0.2·10 'TROPI INVEX HEMOLYSIS INDEX IC'I'ERIC T.Lis 8::.. " i\.L'.L' repu.::-t NO'l'E: J.,; NO':' parl ·1rcmca•_cC. :::-c8ult.s or are lhc pcnr.anent. prece.:l,e.d :.ABORATCR.Y I:-JFO3.MA':'ION 09/12/17 2·J, 2 0 medi~al re.cord -process P:e.ase. by'-->'. FRCM: 09/12./17 09/12/:i 15:30 Cons·_;lt 'l'H/\.CI:: -->.O SY.ALL pe:::- Co:npany chart TU: OOJO -->2 tor 09/12/17 1 '.,: 00 11 : 55 0 Policy. enti;::e .::-esult. "' "' " 0 "' 0 0 09/13/17 O'J/l"J./'...'f 1 02.'lC 9 ~ 0 ' 0 INDEX -->1 LIPEMIA NORM'.AL -->NonReacti >NEG NOt:RE -->KonReacti Hl\VMJ\B HBSi\G /-il:l CCKI:: lGM: NR .'iCVAl:l V' L,.·, Signs OS/13/17 09/12/17 C9/13/17 02:00 C1: CO Temp F Temp C Pulse Fesp B/P, S?02!', N 0 N EEROLOCY F::l.OM: 59 OOCO TO, 09/13/17 0 C: OC 64 '" 12 13 86 /';,0 87 /SJ. '.14 0236 09 /12/1"1 23 , 00 09/13/17 96/5 " 75 38 " " 3 99 /5 5 97 09/'...2/'...7 09/12/17 09 /12 /11 O'.!/l"J./17 22: '...O :C:2: OU 21: 4.5 21,30 Te:tip 7emp Fulse Resp F :::' B/r: sron 6' 63 6S G4 1S 16 1G :6 98 97 G [) /5:l 09/12/17 21: 1':> ---------'Temp Temp Pulse Resp 9S 97 89/17./17 21: Cl 09/12/17 2::..: oc. F C 67 17 83 77 66 JO 29 13 95 9c 9 2 /66 E/P: 93 9, S.?02% 09/-:7./'.7 20 ;J 0 ---------'l'emp F Te.u1p C E-''J.lsc Re.up 09/12/17 20:15 09/12/17 09/12/1"1 20:00 1':! ,45 68 15 Ge H 68 69 , 44 _,, 1C6/56 R/P: FROK: 09/n/u 09/1Z/17 19:-, 0 Vital Signs C9/12/l'f ::..9 : 3 6 Temp 7 Ternp c Pulse Resp " 96 95 SPC?'a ---------- TU~008 09/17./17 19: 15 --------- 9~ 09/lJ/17 67 JO 58 ,, 27 17 96 n 98 07.36 09/:2/:7 '..9: C0 SP02% 09/12/17 18, 4.'i ---------- 09/12/17 18: J 8 18:30 ---------69 17 GB 76 Resi;: n 17 9 E. 6 ~ ·1 . [} n lGl/55 lC-0 JC. 8 B/.E: SI'02% 09/1:Z/17 1 8: 15 F 98 9 8. 2 'l ernp I:" Tc'-1:,p C Pu.:.i?e 09/12/17 18:00 72 26 '/1,. 18 :01/Y;, :oo 9' 09/:2/::..·1 17:JS ---------98 .:: 09/12/17 l '/: U~ " 0 "' 0 0 0 ' 0 C9/12/17 -~s: 16 09/12/17 -"'"' ~ 111/59 B/P: Terip OS/12/17 20:45 ' 0 N 0 N ~ '::'emp C Pulse Resp 76 73 20 2S 2ir: 10 99 09/12/17 16:00 Temp Temp I"ulse 09/'...2/'...7 15: 00 29 SP02% 09/12/17 14,30 09/12/:7 14:00 B/P: SP02% '.00 11.1/.59 96 09/12/17 1 J: J 0 :.::i: 4':J ---------- ---------- 88 84 19 14 87 15 96 i 1.1/58 97 117 /5 8 97 09/12/17 13; 15 96 C-9/12/17 ---------, 8 ReEp 118/55 % E5 .t'ulse " :a 116/56 09/12/17 14: 1':J '.'. 09/12i17 14: 47 18 117/~9 97 l:'/F: "j'C,,np 98 SC " ac"cp F 21 1:.1/:,':l 99 9 8. 3 F C Tc,up 74 73 18 '...11/:,~ :../:i:, 98 SFO2% G. 5 09/12/17 13, 00 114/55 C9/12/17 N "' "' " 0 "' 0 0 09/12/17 12: 3 G '...2; 45 9 ~ 0 Temp Temp ' F C 0 N ?ul,;e ReGp 87 " 16 lC-0/S5 97 96 108/57 B/1': SPO2% 'l'hic repc,n. NO'l'J:;: '1'rUJical is NO'~' p"lrl c,d rcsu~ Vltal 'Tenp 9o o:: Lhe '. s a::-c prc,ccdcd Siqns '-->' by C9/17./17 FROM: 1S 16 record lc''...cc..s-c Conc:ull ':'O: 'J9j'.;.2/'..7 1 2 : 1 '.c 1 7.: 01 11 : 115 per Corupany charl for enlirc 09/13/~7 87.36 09/12/17 1, : ~ 8 F 96 19 '7.3/58 96 '1 G 8 97 '9 , , 1e 1311/E:C 114/5~ 99 97 N 96 -proceos OJOO 0 '.:.18/SS 96 09/12/17 Re Rf: SP02% rnodical n 113/57 09/12/17 '1 er:ir: C 1-'u· 11e R/f-: peIT!la:-.enl. , 9, , 1 00 '1 , 7.?./C,e sro2•, 99 100 09 /n/11 C9/12/17 09/17./17 '_0: 00 09: 5::0 01 93 9C 2' 25 1B6/te 2?; 218/1~5 201/91 '...00 lOC 100 09/12/17 09 :H 09/12/1"1 09:45 09/'...2/'...7 09:47 E2 " 19 ---------- F C 80 1E 93 Fulse ::i.esp 3/P: 47 10'4/':' 21:/104 8P02~, 4 82 75 26 203/95 CS 1 00 1 CC 1 7 0 /9 0 100 05/12/17 89/12/17 09/1 ✓./17 05 - 3 0 89: 15 09: 13 100 n 16 FI/P: 100 Vi:.a1 Signs 09/:2/:7 09 : 01 'l'E.rnp F Temp C '...00 FF.OM: 09/12/17 93 4E '...81/10·1 1 oc 77 84 18 23 184/9::, 184/87 100 173/92 182/92 S.c-'U2% 76 18 0000 TO: 10 C 09/13/17 0236 0 0 ' ~ 0 ' C J-iF.Sp "' "' "' " 0"' 0 0 N 0 N 09/12/17 09: 02 F r,e R/P: SFC2% 1 00 10 0 10 09 : 51 Pulse Resp 31 '.._42/71 09/12/1! 09/12/17 Fill " 1C-:15 137/60 lC 0 '.:'P02% 'l'cmp 'l'crup 105 2:. 135/65 F 2 F111se Re!:'p r,/p: 7erop ':'erup 1 ~: 3 ~ 99 134/55 120/'iB 09 /12 /17 100 51 Re~p ll/1': Te:up Te;;op J'J /:2/:_·1 10:45 09/12/17 11, 00 09/1:/17 11:15 =/0 INTAKE IV i/:1: lV);'.:ls IV #2: #3: ::3ld ?::-odu:: TOTAL oUTrUT 0700 ~-RCYI; - 1500 0?/12/17 1500 - r.e. ·l'OTAL F::.,UID BAf.A'\JCE TO: 23 00 C:9/:3/:7 C-70C U700 - 1',00 1500 - 7.300 9 00 9 00 6" 0700 24 H:\ TOTAL 825 lUU '5 825 100 '5 75 520 1565 :v J_rj 0700 2300 75 5?.0 2300 - 0700 1565 24 llR TOTAL ,oo 900 ----------~ 65 ""'"' " 0 "' 0 0 9 ~ 0 ' 0 N 0 N 0912 0324 MEDICAL CENTER Center Elvd. ':'exa 1a1 '/"/3 0 4. C:ONRo:,: !i.l:JIONA:... ~n/4 Me~ica: Co:-.roc, PATIENT NAME: RUTZ, FFT HE ACCOIB-n' NO: l(b)(7)(E) l(.ED:CAL RECORD NO: RHCl~.ifi'...89C REPORT' TYPE: EISTORY ~9/~ 2/n ADMIT DATE: I li.00)! ~!O: 51 AGE: SEX: A::ID PHYSICAL D. ICUl 8 I( AI:Y.!ITT: ~G ?IIYSICIAN (b)(5 ); (b)(? )(C) ATTE~'D:NG ?HYSIC::-Al'1" ADMHlSICN DA':'5: 09/12/20'..7 PR:MA.;i.Y CA.RE ?IIYSICIA'.'J: C.:HEF C::JM?LAINT: NO"'.P.. 'The palicnl is frc:r1 immigration jail cent-.f>r. :1e..-nati:m.es'- 8. H:~TORY O!' PRESEl.'IT ILLNRSS: Tte palicn::. ~s a; :.1-year-old l!isi;:a::ic Jncarr.P.n.ted :nale,. who was t.akan t-.<1 Liv~ngslon Memori.,_: Erae:c~ency Rocm with co:T1:::,l11ints of .;.bdomina.:. pain, :eight "lank pil.~n, _, and hern<1terr,esis. IIe .r.as a past. merHcal history sig~i::can'fnr no~alcoho:ic l~ver c::.r~hos::.s, gene~aii£P-'USCUT.OSKBJ,ETAL: Speech appears to be c:ear. J.ARORATORY AKD :JIAGNOS':'IC !JATA: From =..ivingston ER, soc..iun 12·/, potcts~ium 4 .3, ,,ON 85, ;;nn c.,..ea>::in'ne 1.5. Albu:n'..n c.ecrea.sed :.o 3 .3. AS':: 1J2, AL':' 6e, A.LKP :23, and ~otal bilirub~n '...0.8. CPK e:evated at 322. L:pase mildly elevated at 367. BNP P.'.evated at 1B5~. PTT 2,.1. ':'i:opon'.n I 0.07E. WBC 14.28, :t-.emoglobi~ :2.s, hematocrit 33 .2, and. platelets decreased -:.o 18. ASSESSMR:-J'T' Al\,T- P~.AN: A 5'...-year cld i~.ca.rcerated Eis;;:,anic ;::iale iv~-:.h hls-:.ory of r.ona1coho1ic liver cirrhosis, now presents with: G~strojntestina: bleed.. Cifferentia.:. d.'..agncs.'..s could be variceal, eso~hageal, or gastric t:leed.'..ng versus pept~c ulcer dlseuse vers~s ~astritis. The p~~lent :1as been started on octreotite drip. ~e will also iLitinte IV PPI and monito" ~emoqlobin/hernatocr~:: levels, so :ar are stajle. GI con8ul~atio~ has heen req'.:Ast.ed for evalua-:.ion of possible EGD. , . R i qht uppe:c quadrant at:dorr.i:-.al pai::, We wi 11 check t,epat 1th i,;a:!e 1 anatier.-:. is on Cardene drip. Lhiinopril was init:.c1.t-en. ';le wi 11 t'.trate medications as needed. We wi:l discontinue 1 i si~.opri :1 in view cf :?:"ena: :::ailure and ir.it.iate be::.a. !::locker in Vi<='w <..0£histor·y of 1:.ver ~~rrr.osts. 'l . r:;T a ncl deep vein thrornbos is prcp'.::yl ax:. s to be achievec. wi tL Proto::ix/ SC:Js , Unab:e ~.r. r,i Vf'. any hl ocd ttinne:::-s due to active gas-c:::-ointest:.nal b:eea.. C.ase disc.nssF>:"l wit.'."-. t.·ne :iatient, the gua:?:"::.s, and ll hac1 bee:-i. a ,:--,1 ;,,a ~u,e part1 ci ;ia t'. ng in the :nedical have any q-_iest'.ons, please do ~ct hesitate ~o call. IJicta-.:.eu WT: ~r,: By: t:r,e RN i::-. deta:.1. ca.re of the Fe..tie:::.~. Kb)(6); (b)(7)(C) L ?~:R.HTM/FAKAT /h'TS S9/12/20:7 15:22:'...2 ACCOUJ',,""I#:Lj-e.:na..-J<-a h 1 e.. Jmpre.ss4 rm: 1. Marked:y limitefi e.x11m1nat.io:: tue. ~o poor bea:n pe::etraticn. 1 i ver, qa 1: h.1 adde,_, col'.lmor. bi le d"Gct and pancreas are inadequa vi~ual~zed en this exaninil~inn. 2. unrf'.rnarfrnr.le. ..-;qht. '.dc:ney 1o:-.d ·-risua~ized port:ons of the acrla and :vc. "* Eler::~.ro:·• ..ir..;lly Siqnea Reported cc: and siqnec: ~rnscrb-:nc,lcq~ si. (b)(5 ); (b)(?)(C) Orig bn89/12/2817 5 h~ (b)( ); (b)(?)(C) ~he te:.y D'1E: 77 'I Q4 ~fi/?li/"1966 AGF:: 9 3 6-539-7026 EX.IIY. :)J\TE: 93F-5~9-7~Bj RAD NO: Siqned 09/J :iJ SF.X: K B. I CU1 S W 7 S'T'A'f H S: AD"! TN ! LOC: ACC:1' '.'JC : !lh\/ 7 \/ F \ 2/nJ Report 2020-ICLl-00006 4368 \. COMP, Coll, 0.914:CR:H00071R 09/14/17-0450 09/14/17-05◊3 ge~~: (R#07674936) ~~~::::::~:~:;:~~::t:: ll ~i:;,-~~~:::::::::~:::.:::::: ;, HGB ~ . 8.7 L I 10.6~1S.B G/DL I MCV I ) 80.1-101.1 fL . j 93.1 i~~{ .·t[(;:;t.·:: f?{;}%t ~ ~ ~~~~ 3'fl 1~·~~t~~ !~~1~ ~ .·~~~ ~:: ;:_ ~ ;~-'.,,: ..~ii ~; :'~>~ ,,,,,,,::~l:t~::::;~i~t; -~ii·J!ii~t~ni;~itt~ ~ ?.~\t;f~}~/::tt:~{ii:~:W\.I!~ ~: r:·:1\:;::~-~l~~i11t~r:1~1:{1t:)~:::2i~::i~ti!Jt [hf:r±~j~-~jf !Z:[·~~!f; Qi~~:g[:i\{ f-~ 1 H~if ~j{;;:0:0. 11ti~iiil 11n iitti~HgJ]ItirntliiigJJli mm:mtJmMr:tl1ti:~;:\\Fttt:i1ttzrrrn }t~ll'itJ~1:fM!t:t•i:i'~:wl:q:; :*{~[~:i~},1J!1iim111:§:~;, \1IiHI 1 1 :,, MCIIC . . . 1 34 . 1 32 . 7 - 3 5 . l . G /DL C~i~ic~J v~lues after the first occurrence are excluded from ·'.fIT\~::£:~~ :~f/f:i~~~~~~-~~7I~~rf l~,1~ ~"itt}¼!· Jf~~:;~:~f~~~i?fi~ii@!:~Ji1fl,t-jg,I~~~~H.~ii[!ittft~t ~i'.'A~#.~::tefl~~:~f~~t~il~~~:~ !!}Jrrmti !I pati~nt diagnosis thera or rotocb1s. , I o.9/i4/1?-os42 . 0,114/17-os,2 I os;14/17-os12 ::::::::::::::::±::::::[;::: ! - . · ~:::::,:::~::::~;:;:::~:::~:: 09/l4/17-0542 t~J; rl\fi~~:#@fti\~::[ffI1rn ii:l~mtim::mt: Ji:::,·: mni;ii~;1n:01~;y;~irii?$_:a~1r12nn11tsm~m; l0t/iittt!}tlt~@f@f¥~~i:7\~!~wm~i!l1 m%t!~{1{:;~1'1ill: 8ltrti~ {\g@ 1 . · - [ · 09/lt/17-0542 i~EitH~~~'{#)g{ffrntPm1tm}rn:)rn:J,:rstiEtUUM%MtE%J\);~j~;,jJfi~~Mt?itl:fm\t'i-Jil~Iit~ i1i1)!j@\\i{Z®;{_$.J;:;t~~~ 1 I 09/14/11-0542 202Q-ICLl-00006 4369 :;;:;,::;~;;~:;;;;J::~;;~;;~;;;;~:~ }if~ti~ti~~dij_@tl·!ff:LII@};¼Uiif0hi1t,~'.;f~f/1;@m;rn:;gJnil]/plt~:~\)i\:mt~i::;~:@?rng \H'. Hi)i,~:~:~:~\f~N';'.p¥lI~{Mfuiil~''J: 1 I · 1 09/14/11-os,2 ,r 2020-ICLl-00006 4370 CONROE REGIONAL MEDICAL CENTER 504 Medic~l Center Blvd. Conroe, Texas 77304 0913-0070 PATIENT NAME: RUIZ,FELIPB ACCOUNT NO~l -< 102 133.0 4.2 Laborato Tests 24 -b-9/l'.2°--09/12 09 12 15301 1530 1530 Chemist 90Jf*H Ammonia (11.0 - 32.0 m --LR= --=rra -2 ( 1 .0 - 3 .6 4. 9 0.2 70 * H (o.ooo B- a riuretic Pepti ML) 226.59 H 09 12 11551 1em1slry :--SoaiumlT33- 144 133 .0 mmol/U Page 2 of 4 2020-ICLl-00006 4375 1@~~132H.,. ~ CONROE MEDICAL CENTER (COCCR) Pulmonology Progress REPORT#:0912-0575 DATE:09/12/17 Note REPORT STATUS: Draft TIME: l7l4 PATIENT: 'RUIZ FE"",IPE ACCOUNT#~l (b_}(?~)(_E)_____ DOB: 06/26/66 AGE: 51 ADM DT: 09/12/17 * ALL edits document* or UNIT#: BH00861890 ROOM/BED: B.ICU18-W ATTEND: l(b)(6); (b)(7)(C) __J SEX: M AOTHOR: amendments must be made on the ._ electronic/computer Subjective ChiefComplaint: RFC: GI blced/lCu management. Objeclive Physical Exam VS/1&0: Last Documented: Rr.sut: Date Tern Pulse I me 98.3 09 12 1600 100 0912 1447 x owR~a~te-+-- 2 . 09 /r 2 144 0 2 Fl 11 7 58 09 12 1400 ·s P 88 09112 1400 ··19 09/72 1400 Pu se Resp Medications: Active Meds + DCd Last 24 Hrs Folic Acid 1 MG DAILY PO Lar.tulose 30 ML BID PO (CKD) Pantoprazole 40 MG Q12HR IV TraLodone HCI 50 MG BEDTIME PO Metoprolol Succinate 12.5 MG DAILY PO SertralineHCI lOOMG DAILY PO Sodium Chloride 250 ML ASDIR IV Labctalol HCI 10 MG Q4H PRN PRN IV Levofloxacin 100 ML Q24H IV Morphine Sulfate 1 MG Q41 l PRN PRN lV Ondansetron HCI 4 MG Q4H PRN PRN IV Sodium Chloride 250 ML ASDIR PRN IV Sodium Chloride 1o ML ASDIR IV Sodium Chloride 1,000 ML .QHH20M \V Lisinopril 20MG DAILY PO (DC) Nicardipine/Sodium Chloride 250 ML ASDIR IV Page 1 of 4 2020-ICLl-00006 _______ 4376 _J :::::mi;_;~J@:{}r4irui# R~1~~t':\ .. :,· ::/:}*ir.i:¢0:Niir>~iAL•• -:--:... •.·,•,········· :·:·:·> ::;::::::-..... ·,·,·. \}}::.: :ift:rt~J••••1fr/fa•)•~tftRt :. . Coll: 09/12/17-1530 < . . . . . . . . . . . . o..01··· · •·-·•· -:-•·•-•-=->•·•<·•·•-•·•-:-•-:-:-•--·• - ·•· :•:•::::.: ..:•:->· ::::•:·:·-. .-·. · · •-•••••: · · · ._-_ :.• )(7)(E) i,~c:;:~ttobs~ie~ci•: llqoii:" ,:13· .J¢ti:i, a.• hcN\o~/12417 >) M-:...-.•·•-·•·•--•·•·-• •--'•-•· >#fftl'.s;.Aorit:: IN> COMP, -. ¢APtfii 19 _... _-x-1-:s_x ___ -i -i s-1-:;-: :l;~~~~~fb)(~);:(~;·;~)(~ )-:_:-:,:.•>·•··•·•ox>;••: :;aaf¼:::4TE#k['.: / 0912:CR:S00025R . . . . •ti.•:~-:t: •c:;~p~}l'Jt : .,Ji.u:iL::i.>:i.:iU.:::.Jitiaduc:i...Ju!.i.i• Recd: 09/12_/17-1619 (Rl!07673575) I SCREEN -••·-·· - :=i:i:::i/i2/:('i:~1'i!i:<:i:>>_ •• •:~j:::112.J~;.;111 8 ·.·.·.·.·.·-----------·.· ...•-•·•=:•••••• =:: .SCREEN •·•······ •·•·······••#W12 l;'l@)::•·· .. SCREEN #J::, •·=:•:::A@12/t7/:r.7M)\: ... ·.··.·.·· .· .... -.... · ... ·.·.... ·· ........ . .. :.·.·.·. . :j.#~>:%H;~:E_--'-'-'-.;..;..a..;_----,-ea~-__..,..;_~~ 2020-ICLl-00006 4377 ·.. : .. ·.·...... . ...... . =•uriii#!3Hti6 iiia :~◊••=•:••=-·. CONROE MEDICAL CENTER (COCCR) Clinical Note REPORT#:0912-0490 DATE:09/12/17 REPORT STATUS: Signed TIME: 1522 PATIENT: RUIZ,FELIFE OOB: AGE: 06/26/66 UNIT#: BH0C861890 ROOM/BED: B.ICO18-W 6J:~)rXC) ATTEND, ~ ACCOUNT# : l(b)(?)(E) 51 SEX: r)( M AUTHOR: AD~ DT: 09/12/17 * ALL edits or amendments be made must on the electronic/computer document* **See Addendum** ClinicalNote Note: 2ms:-us I (b)(6); (b)(?)(C) l Electronically Signed by,______ Addendum 1; 09/12/17 1524 _.on 09/12/17 at 1 522 b JCbl(B); (b)(?)(C) 203 5363 5 7 Electronically Signed b1,_b_lc _l; _Cb)_c _Hc _)___ RPT _.lo9/12/17 at 1.17S #:0912-0490 ***EN~ OF REPORT*** Page 1 of 1 2020-ICLl-00006 4378 Nane: Pa-::.ient RUT7,~RTTP8 U!:it No: EXAMS: eE•"l' C.OlJ'::: 710:0 XR ~HEST 1 V C2069779~ T 18 ,cJc:.ad on: Chest x-ray CLIN:CAL Corrpar1 exarr., HISTORY: son oHC0861890 exar:is: AP frontal pro-je:::t:io:., T.euimcytosi !l, tJone of 9/J 2/2rl:7 TC.U piltiA:,t_. che!lt. the Eleva-::.10:1 t'.~.e riq".t r.P.m'.niaphra(Jlr, ii.ffic;,:lt. to assess in terms cf qive~ li'!r.k of prior ex~ns. Probable ccarring versus a-::.e:ectatic changes rr.ai~ly at: the r'qht J·.:nq hi'!!le_ No i'lctive ~•:-rl-'. Overlying 1 i nP.;; nh;;c;11re tetail. Ne findingo c,[ high concern for p::eun,onia ff• F.Jectr,:rically on Re:iort_P.rl I. u 5 ~(b)( ); (b)(?)(C) ~'.qnerl 09 /1 ...2~/~2~0~1~7-a_:__1~7~2~6-------- anrl •• byf ._b_)_(6-);_(_b)_(7_)_(C_)_________ !"'.gned agc _ l (b)(6); (b)(7)(C) CC: . tic-:::ated Date/'T''me: 'Jechnol :-i<;"ist: 'Tnnscri:ied cr:q Pri:::. 09/1;;./n17 jr h \/ A \· th\t 7 \tr\ (172fi; I Cl9/12/2H7 nau'-/T'lT,P.: D/T: ~: os/12/20:7 b)(6); (b)(7)(C) (1726) :1729) CO~OF. MED CTR I~/U3S 336-53S-7026 #: 9'.lfi-5~S-76A1 F'AX PAG: 1 ------ Nf\MV ·~(b'T: : )(7 ;~ ~~PE ~(6t~ KC ) MED::.CAL D1/\GDJC -~ ClI'., J'cKlI CJG '.~EN'l'ER 3::..VlJ COJ\ROF:, 'fF.XAS 77."l Cl4 PH~NE #: by: PHY~ DOB: 0 / / - AGE: AC<."~' NO: (b)(7)(E) EXA.'l DATE: 09 12/201'/ RAD KO: "igncd 5: SEX: M 3. I en 8 W STATUS: ADM :N DC Dt: Repor-::. 2020-ICLl-00006 4379 Page 1 of 1 EARM Detention History Detention History ;:· ,'··~.f b)(7)(E) C0r :,O11o n9 A-Nun,oc, 028 866 428 Na rr+ Almazan Ruiz, Fellpe Dionisio Book In Detention DCO Location Book Out Date Rele ase / Days In Sook Out Type Custody Days In Facility 358970139 b)(7)(E) HOU POLK COUNTYJAIL 09117/2017 0833 Released - Died 67 9 028 866 428 358970139 KRO 09108120 17 FOLKSTON PROCESSING CTRID t 759 Transferred • HOU 67 028 866 428 358970139 KRO GlAOES COUNTY DETENTIONC Transferred • KRO 67 27 Transferred • KRO 61 30 Subject A-Number ID 028 866 428 028 866 428 358970139 Book Case ID Date In 711212017 700 KRO 09/0712017 14 56 KROME NORTH SPC 0811112017 1930 Deta inee arr ived to Krome on July 12, 2017. While at Krome SPC detainee Alma zan Ruiz, Felipe Alien # 028-866-428 was assigned to Pod 4, Pod 5 and Pod #6. From July 12,2017 till July 14, 2017 detainee was assigned to Pod# 5 From July 15, 2017 till August 04, 2017 deta inee was assigned to Pod # 4 From August 05, 2017 till August 11, 2017 detainee was assigned to Pod # 6. tb){7)(E) 2020-ICLl-00006 4380 10/3/20 17 Pagel of 1 [ii Pictur 81 IAH Secure Adult Detention Facility Inmate Bed History For Inmate a028866428 09-25-2017 A028866428 9:28:43AM Almazan-Ruiz, Felipe Arrival Date Departure Date 09-08-2017 09-17-2017 2020-ICLl-00006 HC Bed 04-09 C 20-04 Dorm 4381 Start Date 09-08-2017 09-09-2017 End Date 09-09-2017 09-17-2017 9/25/2017 ll.S. Department orHomeland Security 126Northpoint Drive Houston, TX. 77060 U.S. Immigration and Customs Enforcement September 25, 2017 MEMORANDUMFOR: I f b)(B); (b)(?)(C) Assistant Field Office Director (b)(6); (b)(?)(C) THROUGH: FROM: eportat1on SUBJECT: 1cer ALMAZAN Ruiz, Felipe A028 866 428 l(b)(6); (b)(?)(C) I On September 13, 2017, Deportation Officer ..,_ _ _,..__ _.and myself spoke with detainee ALMAZAN Ruiz, Felipe while he was in the intensive care unit at Conroe Regional Medical Center. Upon our arrival, detainee ALMAZAN was found to be asleep but during our conversation with Management & Training Corporation (MTC) security assigned with guarding ALMAZAN, he woke up. During the course of speaking with detainee ALMAZAN, he indicated that he had intentions of filing an appeal regarding his immigration case and that he had a petition pending with Citizenship & Immigration Services (CIS). When ALMAZAN was asked if he had family in the United States, he indicated that his family was in Florida and possibly New York. At that point, we ceased interviewing ALMAZAN. www.ice.gov 2020-ICLl-00006 4382 ORDER TO P-.ELE!\SE AUEN TO:(N,\ME and TJTIX of parson inchorgcof facility) OIC I \Va rden (Name offocility) IAH Secure Adult Detention Facility Dat~ ')/l 7/2017 Time 4:00 File Number Nameof Ali.:11 Al mazan Ru iz, Felipe Dionisio ,\gc I Date or l.lirth(!'--lo.!0:1ylYr.) 6/26/ 1966 51 Sex Nnlionnlily No ne given Mexico M A028 866 428 Fordgn Addrc.-;s Signature ofOl!iccr Rccdving :\lien Nnturcof Procccding,s Deceased Rcmlrks Release Pick-up Information Name: Phone# US Forwarding Address: Phone: (b)(6); (b)(7)(C) xxx-xxx-xxxx .._ Si! itk Oflicc SDDO ICE/ERO LiYingston, TX Fonn 1-203 United Stat.-s Ocpanmcnt of l lomdand Security !mmigr:,tion & Customs Enforcement/ Enforcement & ·RemovalOperations U.S. I1nmigration and Customs Enforcement Any problems I issues with alien listed should be reported to ICE immedialely. 2020-ICLl-00006 4383 II Management & Trainin~ Corporation Unit: IAH Secure Adult Detention Facility Classificiltion Chrono/oqicill LOQ Personal Information Number: Inmate Name: Date: A028866428 Almazan-Ruiz, Felipe 09-08-2017 Month/ dav /vear b)(6); (b)(7)(C) Arrived From: - ICE -·-~· Housing Assigned: ( /X) . : Staff will .ensure that entries w111 QI:. mace wnenever tnere 1sa .cnange.in inmate's program; · · services houslnq;discii:>llnarv or anv other occurrences.·. · - Date: Note any changes in the space below: 09-08-2017 ARRIVED AT I.A.H. 09-08-2017 PHYSICAL FITNESS FORM 09-08-2017 Mental & Suicide Screening Form OTHER DOCUMENTS EX: Seg., 1•6o's, clearance forms, PREA Form, etc. .......... 09-08-2017 MEDICAL TREATMENT P b)(6); (b)(7)(C) qf111n DP P~ 11.vd - - IPage Number: 2020-ICLl-00006 4384 1 Page 1 of 1 1: .r Fu 2020-ICLI-00006 4385 )1 A Man-o - Management & Training Corporation FACILITY: /AH Secure Adult Detention Facility Reconocimiento de la Actividad Fisica Nombre del preso (lmprimir): __ Preso Numero: Almazan-Ruiz. Felipe A028866428 "Asumo el riesgo en favor de las MTC, Inc. y sus filiales para participar voluntariamente en la actividad fisica, incluyendo pero no limitado a, baloncesto. levantamiento de pesas, softbol, futbol y balonmano." ACEPTAR □ DECLIVE □ Yo he revisado la declaraci6n anterior y se ha brindado la oportunidad de hacer preguntas y / a aclarar inquietudes a traves de personal de la instituci6n. Si me niego a asumir el riesgo de mi grupo de actividades fisicas se estructurara en consecuencia. Presa Firma: Fecha: X ~~ 02-os-2011 (b)(6); (b)(7)(C ) Personal Nombre del Testigo (lmprimir): __ Personal Titulo: --1 Correctional Officer --:::=============-~E _;.. -""' ---=--------. (b)(6); (b)(7)(C ) _"T_;.:.; _::..: _::..: _-_-_-_-_-_- Firma del personal:_ Fecha:____ 09-0a-201 z Original placed in inmate file Copy provided to the inmate 2020-ICLl-00006 4386 PolkCounty Screening Form for Suicide and Medical and Mental lmpainnents Per Jail Standard §273.S(b}: ALL Questions SHALL be Completed in Full Immediately upon Admission I Name: !Almazan-Ruiz Felioe I State I.D. Number (if known) Date/Time: .._I I .J (b)(6); (b)(7)(C) __.! Completed By:IL.j_ 0_9-0_8_-2_0_1_1 ___ __ Date of Birth:lo.,;;..;;6...;-2;...6;...-.;;;1.;;..96.;;..6.;;...... _______ _JI I A028866428 1 of Inmate __________ 1--l ---1 ___________ Does arresting officer or any other person believe that the inmate is at risk due to medical condition, mental Illness, mental retardation, or suicide concern? Comments: (Circle one or more if applicable) I I SELF-REPORT QUESTIONS (please elaborate as needed): ny current me~'.~~s, YesO recent hospitalizations or serious injuries or concerns about withdrawal? ~ L Medications? YesO D O D y.__ ______________________ If female, are you pregnant? Yes No Not Sure --J YesO Have you ever received services for mental health or mental retardation? YesO Do you receive a social security check? Have you ever been in special education? No~._ Yes Have you ever been very depressed? fil_· D Ye~D No~ Are you thinking about killing yourself today? Have you experienced a recent loss? STAFF OBSERVATIONS _.. _.. ---------'---------.I YesO YesO~ No~· ,--------------------------------, YesO Have you had thoughts of killing yourself in the last year? Have you ever attempted suicide? ______ _________________ Do you hear any noises or voices that other people don't seem to hear? YesO ._! Yes~ Do you have any previous military service? Do you feel this way now? ~ YesO N~ ._ _____________ ____J N~ ft When?._I ,~.___ !_____ ...JIWhy? ... ---1 How?Lj____ No YesO lease elaborate as needed: Does the individual seem (circle all that apply): confused, pre~ccupied, hopeless, sad, Comments: paranoid, in an unusually good mood, or believes he/she is someone else? Is this person's speech (circle all that apply): rapid, hard to understand, hesitant. or childlike? Observed to be under the influence of: Alcohol? □ Drugs? Observed to have visible signs of self-hann (i.e., ruts on arms, etc.): Does the screener suspect mental illness/mental retardation? If yes, when was a magistrate notified? Datetnme Additional Comments □ Withdrawals? YesO Yes □ □ No~ No~----------- How? Written!Electronic 2020-ICLl-000064387 (circle) -----1 II IAH S'?c u; e f'.du it Getent ::,1: r:c.cd 1~y II INITIAL Almazan-Ruiz. Felipe Detainee Name SCREENING FOR RISK OF VICTIMIZATION AND ABUSIVENESS 0 □ SPECIAL SUBSEQUENT A028866428 09-08-2017 Detainee Num ber Arriva l Date CFR 115.41: Requires staff to screen all detainees upon arrival for sexual abuse history and for the risk of victimization and/or abusiveness. To completethis form, 1. For items 1-4,ask the detaineethe questionsandcheckthe appropriate responsein the yes/no columns. 2. For items 5-17,baseyour responseon the detainee'sfile and all other official documentsavailable. 3. For items 1, 11, or 17,a "Yes" responserequiresa referral to Mental Health. 4. Totalthe scoreto determinea "risk of victimization"or "risk of abusiveness." If "Yes", referto MentalHealth. (b)(7)(E) If "1,11, or 17" were answered "YES" Referred to Mental Health on: b)(6); (b)(7)(C) ate: nit: J//1- PSACM 20170105 2020-ICLl-00006 Qtet o County Processing Center Detainee Classification System- Prlm•ry Assessment Form ) A# A028866428 · NAME: Felipe Almazan-Ruiz Unknown D.O.B:. 06/26/1 (b)(6); (b)(7)(C) ip: --------- CTASSIFlEDBY: L.......,........,....-------J--(ID DISllSPC,-""PS L.- LANOW\G£, ()!NGUS-0/N? q,-2✓ ~entl,. #,_ __ DA'IE: tf (b)(7)(E) 71 (D "'O (1) e3 ru N Q.) ::l I ;o C ) N ) Page 1 of2 2020-ICLl-00006 4389 .... ,,,C> C b)(6); (b)(?)(C) ; (b)(?)(E) 77 CD '"CJ CD ::t:- 3 ru N n,) :J I ::0 C N Sl!CTJll'.\"111 Sl l'f'.RVISOR\" Arl'R0\'.\1.0..-ov.:~RJl)E I DIS,\l'l'J{()'. A. ltl:CO~!~l E~Dl'D Ct;STODY LE\"El..~l'fW\TD il. n:-.·,,1. C"LS'IUDYLl:VEL tlf •·•n::-:-1,:.: \!i,:iri':"\~·ll, ........ . I )USl:L 3 : ]!.l:VEL I : ]1.E\'E!. l TU j Ll:Yl:L 2 ~\'Fl _; ; 11.. D',f!:'\ SECiRH,:\TiO~ (M.,111c , rcq.i (b)(6); (b)(?)(C) Page2of2 2020-ICLl-00006 4390 Page 1 of2 Inmate Record Site JAH Secu r e Ad ult Detention Fac ili ty Inmate Number A028866428 Name • First Name !Felipe Middle Name • Last Name IAlmazan-Ruiz Alias Arr ival Information Arrival Dale 09-08-2017 16:00 Arrival Code Tra nsfer Arrival From Oth er Location :is Noted Arrival Comment JPAT FLORIDA V • Proj Dep Date Demograph ics I12-07-2017 Classificat ion lli gh Affiliation U-n-kn_o_w_n ______ ___ ,-I Departure Code • Ethnic ity Iimmigration Customs Enforcement IMale vf IHispanic vi Departure To • DOB 106-26-1966 • Nationality IMexico Departure Information Departure Date • Inmate Type • Gender Not Ocpa rlcd I _______ Departure Comment ... Bunk Assignment Dorm C Bunk 20-04 :I _ Height js-os Weight 1220 Hair Color lsR Eye Color lsL • Custody I v v~! I vi vi IRED Education Related Information • Highest Grade • Primary Lang Acad Status IUnknown IOther vi v I l\ot Enrolled - Waiting Res idence/ Birth Locations Res County Res State ITexas Birth State vi I Birth County f Texas vj Other IDs SID SSN User Defined Data Medical Clearance For Work Date Refuse to Work 2020-ICLl-00006 4391 I D ~-- --' 9/12/2017 Page 2 of2 Inmate Record Update !I DeleteArrival !I Un Depart 11 Help I Notes A b)(6); (b)(?)(C) 9--8-; 7 V (_ 2020-ICLl-00006 4392 9/12/2017 II Management &Training Corporation Unidad: IAH aseguran la facilidad de I la detenci6n Listado de Visitacion • • .• • del adulto Los internos sobre la recepci6n proporcionaran las nombres para su lista de la visitacl6n, · · · · Los individuos 16 y el excedente se consideran los adultos y se deben enumerar en la lista de la visitaci6n. Los edades 16y 17 de los individuos se deben acompafiar por 18 individuales Omb viejo en la lista de la visitacion. •- Los nillos debajo. de16 deben ser' acompanados por un adulto en la lista de visitaci6n. .• · · Elnumero de visitante y la longitud de los limites de las visitas se pueden limilar solamente por el horario de la faci!idad, el · esoacio;v ros· apremios del personal, o cuando hav razorisubstancial de iustificar tales limitaciones. · · ·· Diez(10)"adultos "pueden ser enumerados en la forma., lntemo Nombre: la Felipe Nombre: Edad: A028866428 locallzacion: I Relacion: ITelefono: I I Ciudad: Direccion: Nombre: Edad: I Relacion: Nombre: Edad: Nombre: Edad: I Direccion: I Edad: j Relaclon: Nombre: Edad: I Ciudad: Direcclon: Nombre: Edad: Nombre: Edad: Nombre: Edad: I I Telefono: Relacion: Nombre: Edad: Telefono: I Estado: I Relacion: I Estado: I Firm~ del intemo I Cierre relampago: Telefono: I I Cierre relampago: I Telefono: Relacion: I j Cierre relampago: Estado: I J Relacion: Telefono: I I Cierre relampago: Estado: I Relacion: I Telefono: I Estado: I Clerre relampago: I Telefono: / Relacion: I Estado: Ciudad: r01!1~ Cierre retampago: I 1 Relacion: I Dlreccion: I I Estado: I Cludad: Dlrecclon: Clerre reJampago: Estado: I Ciudad: Direccion: I I I Cludad: Direccion: Cierre relampago: I Telefono: I Ciudad: Direccion: I Estado: Ciudad: Nombre: I Telefono: I Ciudad: Direcclon: (df) I Cierre relampago: Estado: I Ciudad: Direccion: ~oiLDf I Cubietra Numero: Almazan-Ruiz, I Cierre relampago: (b)(6); (b)(7)(C) 09-08-2017 Dia/ Mes/ Ano ~ ' 2020-ICLl-00006 4393 Detainee Personal Property Record IA H Secure Adult Detention Facility Report run on 09-18-2017 7:33:49AM 2. A#: A028866428 1. Name: Almazan-Ruiz , Felipe 3: Nationalitly: MX , ) bate and Time of Actio .... n·_0_9_-_8_-_2_0_1_7 ______ 1-77#: Bin#: ___ __ Seal#: _____ _ _ _ 4: Date September 8 , 2017 6. Disposition: D - Disposed M - Mailed S - Storage K - Kee in ossession C - Contraband 7. Type of Property b. Hygiene, Etc. a. Personally Owned Items # Article # Article Disp # Article Disp Toothbrush Photo Album Belt Photos ---+-Toothpaste Billfold Books -'-- - --+-Playing Cards ---+-Dental Floss - Hard ----+-Purse ----+-Dentures - Soft ~s medal ----+-Deodorant Boots ----+--''+-~louse .,-1"--":..C..U.-+Powder Disp ---- Brassiere Cap, Hat Coat Combs Dress Eyeqlass case Eyeglasses Gloves · ----+----+--'- ----+----+-- Shorts Skirts Slip Socks _ Stockinqs Razor Razor Blades Shampoo Shaving cream Lotion ----+-Soap l,v J-'--'--'-'-'--+-Soap Dish n - ----~w _ Sunqlasses . h ~~,r'j r· c. Hobby crafts ----+-- Personal. Pa ers ---1 Ciqarettes T Sweat Pants --~:..c,...... e. Tobacco/ etc. Canned Tobacco Chewing Tobacco ----1 Sweater ......... --,--+- Pencils / Pens l,viit/ l .... hoes Shower ( :. oes, Tennis Hairbrush/Pick H_ andkerchief Jeans Jacket Joqqinq suit Leqal Materials Letters .... · :,.. Shoes Sweat Shirt Tie T-snirts ( ,) Underwear ----+-- ~J./ . Ciqars, snuff Pfpe cleaners Pipes r """tv.--,1,-=1·,,...-i baqqaqe location information ~- Wt, Radios Television tc.h ; '!,..;,~U~ :,...ci '1'1 f. List any damaged property and where it was received t~, Shipped Out: Property Via Mail: Item: Property Officer. Received By: Date Sent: 8. RECEIVING: The receiving officer(s) by signing below certifies receipt, review and disposition of the property listed above . The detainee , by signing below certifies the accu racy of the inventory and turns the property over for safekeeping. Any missinQ or damaoed ite l (b)(6) ; (b)(?)(C) . =• or or (b)(6);(b)(7)(C) r. /,l . / I>, Receivinq Officer/Star# ~ . I _ _Date/Time: __ '"' _1_!2~.--- - -Receivinq Supervisor/S am< Date/Time: ________ _ _____ _ _______ _ __ Date/Time: ________ _ Detainee Siqnature: _______ 'r I] 9. RELEASING: The detainee, by siqninq below certifies that all of the above listed property was returned to him/her. Releasing Officer/St ar#: _ _ ______ Detainee Siqnature : ___ ___ _ _ ___ 2020-ICLl-00006 439 4 ___ Date/Time: _______ Date/Time: ______ _ _ _ _ _ Detainee Per sona l P _ ✓ perty Record IA H Secu re Adu lt Detention Facility Report run on 09- 11-20 l 7 I 0: l 4:48AM 1. Name : Almazan-Ruiz, Felipe Bate and Time of 2. A#: A028866428 Actiou□·-0_9_ -_-_2_0_1_7 __ 1-77#: 7. Type of Property a. Personally Owned Items # Article Disp Belt Billfold Books - Hard - Soft Boots Brassiere Cap , Hat Coat Combs Dress Eyeqlass case Eyeqlasses Gloves # ll. 1_0_: _14 _ a_m_ Bin#:- - - Seal#:____ Art icle Dis p Photo Album Photos Playinq Cards Purse Reliqious medal Shirt/ Blouse Leqal Materials ----+-~ Letters Shoes Shoes , Shower Shoes , Tennis Shorts Skirts Slip Socks Stockinqs Sunqlasses Sweater Sweat Pants Sweat Shirt Tie T-shirts Underwear Maqazines Pants / Slacks Radios Television Hairbrush/Pick ----,..Handkerchief Jeans Jacket Joqqinq suit 3: Nationalitly: z5 4: Date September }1' , 2017 6 . Disposition: -_ _ b. Hyqiene, Etc. # Artic le Toothbrush Toothpaste Dental Floss Dentures Deodorant Powder D - Disposed M - Mailed S - Storage K - Kee in ossession C - Contraband Dis p Razor Razor Blades Shampoo Shavinq cream Lotion Soap Soap Dish e. Tobacco/ etc. Canned Tobacco Chewinq Tobacco Ciqarettes Ciqars, snuff Pipe cleaners Pipes c. Hobby crafts d. List valuable or extra qqaqe location information Pencils / Pens Personal Pa ers f. List any damage d property and where it was received Shipped Out: Property Via Mail: Item: Property Officer: Received By: Date Sent: 8. RECEIVING: The receiving officer(s) by signing below certifies receipt, review and disposition of the property listed above. The detainee, by signing below certifies the accuracy of the inventory and turns the property over for safekeeping. Any ,:z~ ,~ I C missino or damaoed ite'.::[ 6)/6\ (oxij (i'f · Receivinq Officer/Star#· ~ate/Time: Receivinq Supervisor/Star#· ate/Time· Detainee Siqnature: ·?'"'Date/Time: 1:11 ?.-:-£ -<:< 2 rf--3-t.2 9. RELEASING: The detainee , by siqn (b)(6); (b)(7)(C) Releasinq Officer/Star# : J Detainee Siqnature: ,r;<__ above listed property was returned to him/her. Date/Time: Date/Time: -· 2020-ICLl-00006 4395 C Facility Iss ued Prope. i Report IAH Secure Adult Detention Facility Report run on 09-11-2017 10:31:l0/\M Name : Almazan-Ruiz, Felipe COG : A#: A028866428 Level: DOB: Condition (Circle) Quantity Property Issued: Uniform Shirt: Uniform Pants: - '>. .,_ 1 " C'h=~ ♦r• ? Pillow Case: Towel: ,,,--..._ Jacke.Y.\ Sbnes: '-----"" Shower Shoes: 1 1 ,,,,,,---.1.,,,,-... ----- Socks: Underwear Laundrv Baa: Pillow: Mattress: 1 1 ".d 1 1 1 ~ E E E E . 1 u u Initials L L (b)(6); (b)(7)(C) u u u u L L ~ IJ J~ ~ u L L u u L L L L L E E 1 C: E t: E E E E E C ~ ' ! ~ ~ ~ u u u u Sil'.lnature of lssuinQ Officer: Date: \ "' SiQnature of Detainee: Property Received: Date: Uniform Shirt: Uniform Pants: Blankets: Sheets: 3 .,_ 1 2 1 1 1 '\. ........__ Condition (Circle) Quantity 1 _ ...... 1 Socks: Underwear Laundrv Baa: E E E E E E E E E ( E E 1 E L L L L u L L L L u L u u u L L L u u ' I L.---- .d .d u u I> u u u Quantity Razor: Comb: Toothoaste: Shampoo: Skin lotion: Bath Soap: Toilet Paper: Toothbrush: L L I 09/08/2017 1 06/26/1966 Hygiene Items: b)(6); (b}(?)(C) Pillow Case: Towel: Jacket:~ Shoes'.' Sh'owerShoes: 2Z Arriva l Date: Initials 1 1 1 n n 1 n 1 fl CC!r&l ~-/0 /J Comments: Initials (b)(6) ; (b)(7)(C) b)(6) ; (b)(?)(C) Signatureof Releasino Offi~ Date: SiQnature of Detainee: Date: Disposition: E - Excellent, S - Satisfactory, U - Unsatisfactory, L - Lost 2020-ICLl-00006 4396 ORDER TO DETAIN ALIEN TO:(NAMEand TITLE ofpeoon inchargeoflilcility) OIC /Warden (Name of facility) Pollc-IAH Dale 9~/2017 Name of Alien File Number Alaman Ruiz, Felipe Age Date ofBirth (Mo/Day/Yr.) SI I Time ,1=00 6/6/1966 Sc:ii: M Narurc of Procttdings 028 866 428 ForeignAddress Nationality Mexico Signature ofOflicer ReceivingAlien Remarlcs US Forwarding Address: Phone: Title Sign.alllre of Officer )(6); (b)(7)(C) I Office Deportation Officer ICE/ERO Livingston, TX Form 1-203 United States Departmcnl of Hameland Security lmmigra1ion& Customs Enforcement/ Enforcement& Removal Opcra1ions U.S. Immigration and Customs Enforcement Any problems I issues with alien listed should be reported to ICE immediately. 2020-ICLl -00006 4397 Subject U.S. Departmen t of Homeland Secur ity Name(CAPS) ALMAZANRUIZ, ID 358970139 Reco rd of Deportab le/l nadmi ssibl e Alien Sex F.,..ly FELIPE DIONISIO Pu:spon Number 1nd CoW'III')'of Issue Counlryof C1tit.eru.hip MEXI CO BLK Weight 220 Eyes BRO Cmphcn MED Oa:upalton UNEMPLOYED Scars and Marks U.S Address 18201 Hair M Hc,gh1 65 SW 12TH ST MIAMI, FLORIDA, 33194 See Narrative D.11e,Platt:, Time. and Mu.ner of Last En1ry SYS, wt 05/04/19B5, Passenger Bo.ardcdat - Without 1!lSingle D Oh.-orc.cd.□ Married D Widower □ Sc ara.ted (b)(7)(E) Inspection Number. Street, City, Province{Sta.te) 1111d Country of Pcnnanent Residence Methodof Loc:irion/Apprchcnsion PAP NA DttcofBtnh Age: 06/26/1966 At/Near 07/12/2017 MIA/M IA R IB) Fonn: (Type andNo.) Lifted □ NotLifted 0 C,ry. Pn;,vmcc (Stare) and Country of Birth MEXICO CITY, l.oc.ationCode Dateof Acrion 51 See 07/12/2017 See Narrative Soc.,al Security Account Name Status 211Entry SOaal Security Nwnbcr LengU'Iof Time lllegaJly in U.S. lmmigraDonRecord Criminal Record NEGATIVE See Narrativ 14 ,so By MEXICO NIV Issuing PoS'Iand NTV Numbtr Da.tc/Hour I-B31 Stai-usWhen Found e Name. Address. and Nanonal1tyofSpouse (Maiden Name. if Appropriate) Number.andNationalityof Minor Children None Fathu"s.Na.me.N&tionality,and Address, ,f Known ALMAZAN, PELIPE NATIONALITY: Mother·s Prescmand Ma1denNames. Naiionaliry,and Address.ifKno'I.A.Tl MEXICO ADDRESS: , MEXICO CITY, Monjes Due/Property in U.S. Not in Immcdiale Ponession MEXICO RUIZ, EPIPANIA NATIONALITY: Fingerprinted? ChugcCodeWo1ds(s) See Narrative Employedfrom/to None Claimed NL'llemd Add,ess of(wt)(Curren1) U.S. Employc1 MEXICO ADDRESS: , MEXICO Typc of Employmen t Hr Narrat ive (Outline partu;u lars under which aJien was located/apprehended . Include de1a1ls no1 shown above regarding t ime . place and mann er clemen ts which es tab lish administrative a nd/ o r crimi na l violation . Indicate means and rou 1e of 1rav cl 10 inlerior.) FIN: 1230226197 Left Index fingerprint orlas t enu y, anempted Right Index entry, or any 01hcr cn1ry, and fingerprint -~~-~ I OTHER ALIASES KNOWNBY: PEREZ, ANDRES ALEMAN, FELIPE SCARS MARKS AND TATTOOS None Indicated - NONE VISIBLE .. . (CONTINUED ON I-831) b)(6); (b)(?)(C) ICER Alien has been advised or commu nicat ion privileges (Da tc/ln i 1ials) (Signature Distrib uti on : ts) b)(6); (b)(7)(C) on : _J_u __ ly_ _1_2_,_2_0_1_1 _ ___ Disoosi,;on: Warrant Exam,nin•Offiw of and Title of Immigr a tion Officer) {Rcpon of Interview) ___ Arrest/Notice __ _ ___ Crimel to Appear l(b}(6 }; (b}(?}(C} Form 1-2I3 (Rev. 08/01/07) 2020-ICLl -00006 4398 . . p age ~1or Form I-213 C ontmuation U.S. Department of Homeland Security Alien's Name ALMAZAN RUIZ, Subject The Hea1th subject Current good Administrative Previous Crimina1 health. Charges - 212a6Ai - 212a7AiI - 212a2AiI - ALIEN PRESENT WITHOUT ADMISSION OR PAROLE - (PWAs) - IMMIGRANTWITHOUT AN IMMIGRANT VISA - CONVICTION OR COMMISSION OF A CRIME INVOLVING MORAL TURPITUDE History On 04/27/2007, the subject was arrested resulted in a conviction on 07/10/2017. for The the crime of acruelty subject was sentenced On 05/03/2001, which resulted the subject was in a conviction arrested for on 05/31/2001. On 07/09/1998, in a conviction the subject was on 07/09/1998. arrested for the crime of The subject was sentenced On 07/09/1998, conviction on the subject 07/09/1998. On 12/08/1993, the subject conviction on 08/11/1994. Records Date 07/12/2017 Status claims 07/12/2017 07/12/2017 07/12/2017 File Number 028 866 42Kb)(6); (b)(7)(C) Event No: I FELIPE DIONISIO the crime of The subject Toward Childn to N/A. aoriving Under was sentenced nrndecent to N/A. which Influence to N/A. Exposuren Liquora which resulted arrested subject for the crime of "Larcenyn was sentenced to N/A. which resulted in a was arrested The subject for the crime of qLarcenyn was sentenced to N/A. which resulted in a was The Checked (b)(7)(E) ARRESTING AGENTS ----------------------- b)(6); (b)(7)(C) I At/Near MIAMI, FLORIDA Record of Deportable/Excludable ENCOUNTER: On July 12, 2017 Alien: ALMAZAN RUIZ, FELIPE A#028866428 Signature l was referred to Miami Title l(b)(6); (b)(7)(C) I DBPORTATIOH OFFICKJt ___2 Form 1-831ContinuationPage (Rev. 08/01/07) 2020-ICLl-00006 4399 of ___ 4 _ Pages . . p age &:1or Form _______ 1-213 C ontmuation U.S. Department of Homeland Security Alien's Name ALMAZANRUIZ, FELIPE _ I File Number Date 028 866 42..,::B;,..,,,.~------...._-w"7 /12/2017 Event No: ~b)(?)(E) I DIONISIO Fugitive Operations Team by Miami Dade Probation Office at 7900 NW 27 Ave , Miami Florida 33147. ALMAZAN is an Illegal criminal alien who was originally arrested for ENGAGE IN SEXUAL ACT WITB FAMILIAL CHILD and later the charge was dropped and convicted on 07/10/2017 for two charges of CHILD ABUSB/AGGRAV/GREAT BOD HARM/TORTURE. ALMAZAN was taken into custody and transported to Krome SPC office for processing. IMMl:GRATION STATUS: ALMAZAN is a citizen and national of Mexico who entered the Unit e d States illegally without been inspected at San Ysidro, California on 05/04/1985. ALMAZAN clai~ed that be tried to get papers thru an attorney, but after checks were performed on ALMAZAN claim, nothing was found in the system. Therefore ALMAZANwill be issued an NTA and the following charging documents will be served to him; I-862, I-200, I-286, and a list of free legal services. ALMAZAN does not have any documents to live in the United States, neither derivation issues. ENTRY BASIS FOR RBMOVAL ALMAZAN is amenable that, you are an alien who is present paroled, or who arrived into the US. Attorney General. to Section 212 (a)(6)(A) (i) of the INA, as amended, in in the United States without having been admitted or At any time or place other than as designated by the 212(a) (7)(A) (i)(I) of the ImmJ.gration and Nationality Act (Act), as who, at the time of application for admission, is not in possession im1nigrant visa, reentry permit, border crossing card, or other valid by the Act, and a valid unexpired passport, or other suitable travel of identity and nationality as required under the regulations issued under section 21l(a) of the Act. amended, as an immigrant of a valid unexpired entry document required document, or document by the Attorney General Section 212(a)(2) (A) (1) (I) of the Immigration and Nationality Act, as amended, in that you are an alien who has been convicted of, or who admits having COIIIJllitted, or who admits committing acts which constitute the essential elements of a crime involving moral turpitude (other than a purely political offense) or an attempt or conspiracy to commit such a crime. CRIMINAL HISTORY: ALMAZAN was convicted for the following; CHILD ABUSB/AGGRAV/GREAT BOD HARM/TORTURE on 07/10/2017, DUI on 05/31/2001, Larceny on 07/09/1998, larceny on 08/11/1994, Indecent Exposure on 06/14/1998 and several arrests for traffic issues. CUSTODY DETERMINATION: ALMAZANwill States. MEDICAL PROBLEMS: ALMAZAN claims MINORS: ALMAZANclaims to have remain good Not PHONE CALLS: ALMAZAN was allowed SPC processing area. to Signature f b)(6); (b)(?)(C) I ICE custody pending removal from the United health. a child CONSENT TO ENTER THE RESIDENCE: Miami Dade County. in living needed, call with his mother ALMAZANwas the following at an unknown apprehended 786-223j at l(b)(6); address. a Probation I (b)(7)(C (Paz Ofice from Almazan) in Krome ! Title DBPORTATIOK OPPICKR ___3 Form 1-831Continuati on Page (Rev. 08/01/07) 2020-ICLl-00006 4400 of ___ 4 _ Pages . . p age 1,,or Form _______ I-213 C ont muation U.S. Department of Homeland Security Alien's Name ALMAZANRUIZ, Other Identifying FELIPE DIONISIO _ I Date File Number a 2 a 86 6 ~4=-=2::..::s;__ ____ Event N¥b )(7)(E) _.___, 01 / 12 /2 o 1 7 1 Numbers ALIEN-028866428 Signature b)(6); (b)(7)(C) Title DBPORTATIOH OPFICBR ___4 Form I•831 Continuation Page (Rev. 08101/07) 2020-ICLl-00006 4401 of ___ 4 Pages DATE OFARREST (DOA) DPS NO , (SID) FBI NO. CONTRl6l/TOR ORI OUT OF COUNTY? NAME (1.AST.ARST. MIDDLE) (NAM) DATE OF BIRTH (008) SKIN TONE SOCIAL SECURITY NO. (SOC) PLACE OF BIRTH (POB) SEX RAl,, ETH. HGT. WGT. □ Ol/T OF COUNTY ORI YES OUT OF COUNTYWARRANTNO SCARS, MARKS. TATTOOS, AMPUTATIONS(SM1) LEAVEBIANK .cMNuJ Almazan-Ruiz,Feli e STATE CITY AGENCY ARREST NO. (AGN) STATE ZJP AGENCY CASE NO. (OCA) FIREARM □ CODE DOMESTIC VIOLENCE □ OFFENSE? OFFENSE CODE (AON) OFFENSE LITERAL (AOL) Yot N STATUTE CITATION (Cll) iEVEL FEL0~~ - .{rl.Z.3or DEGREE lJ S) MISDEMEANOR (A. 8 or '-,.---,-----------.----• □ 1. R. THUMB 2. R. INDEX 3 . R. MIDDLE 4. R. RING 6. L THUMB 7. L. INDEX 8. L. MIDDLE 9. L. RING OLOEA ORI 5. R. LITTLE Vi ~~ SiMULTANE .. , LEFT FOUR FINGERS T~Y ~ L. THUMB RIGHT FOUR FINGERS TAKEN SIMULTANEOUSLY'= R. THUMB ~ 2020-ICLl-00006 4402 Management & Training Corporation • Intake Procedures Checklist Task File Section Chronologic Log Reviewing Supervisor Initials Sectionl Attach inmate photo Mental & Suicide Screening Form Section I Signedby officer PhysicalActivity Form Section I Simed bv inmll1c/officer Section 1 PREAFORM Signed by officer Classification Section 2 Sismedby officer/ supervisor Jail Report Section 3 Signedby officer Section 3 Visitation List Simed by inmate/ (2)officer Inmate Personal Property (Computer) Section 3 Siened by inmate/(2) officers/supervisor Clothing/Hygiene Issue (Computer) Section 3 Siened by inmate/Officer Section 3 Fingerprints Sil!lledby inmate/officer Inmate Handbook Ack. Form Section 4 Signed by inmate/officer Money Contraband @ Intake Section 4 Sil!Iledby inmate ICE Video,s- P.R.E.A Video Section 4 Sim acknowledJ?.ement form inmate/officer Money/Phone Card Fonn Forward to Business Office NIA NIA ICES1pec1 'fi1c Forms Form 1-203 Form l-213 Form 1-385 Criminal Histo Almu.an-Ruiz,Felipe b)(6); (b)(?)(C) Section 3 Section 3 NIA Coun S ecific Information Section 3 A028866428 Inmate/Detainee nwnber 09-08-2017 Date 2020-ICLl-00006 4403 .ManagPment & Training Corporation 11 ACKNOWLEDGEMENT FORM BY MY SIGNATURE BELOW, I CERTIFY THAT I HAVE RECEIVED A COPY OF THE IAH SECURE ADULT DETENTION FACILITY INMATE HANDBOOK, VISITOR INFORMATION FORM, PRISON RAPE ELIMINATION ACT INFORMATION FORM AND HN/A1DS INFORMATION SHEET. INMATE SIGNATURE 09-08-2017 DATE OFFICER SIGNATURE 09-08-2017 DATE FORMA de RECONCIMIENTO POR MI FIRMA ABAJO, YO CERTIFICO QUE HE RECIBIDO UNA COPIA DEL GUIA DE PRESO DE IAH SECURE ADULT DETENTION FACILITY, FORMA DE INFORMACION DE VISITANTE, FORMA DE INFORMACION DEL ACTO DE ELIMINACIONDE VIOLACIONDE PRISION Y HOJA DE INFORMACION DE HIV/SIDA. (b)(6); (b)(7)(C) x~~ PRESO FIRMA DE 09-08-2017 09-08-2017 FECHA FECHA ( 2020-ICLl-00006 4404 Management & Training · mm Corpc:;ation IAH SECURE ADULT DETENTION FACILITY NOTICE TO ALL INCOMING DETAINEES ALL MONEY MUST BE TURNED IN DURING THE CLASSIFICATION PROCESS AT INTAKE. IF CAUGHT WITH MONEY BEYOND THE INTAKE AREA, MONEY WILL BE CONFISCATED, CONSIDERED AS DANGEROUS CONTRABAND, AND NOT BE RETURNED TO DETAINEE. AVISO A TODOS LOS DETENIDOS ENTRANTES TODO DINERO DEBE SER ENTREGADO DURANTE EL PROCESO DE CLASIFICACION EN EL AREA DE ENTRADA DE ESTA FACILIDAD. SI ES AGARRADO CON DINERO MAS ALLA DE ESTAAREA, EL DINERO SE CONFISCARA, Y SERA CONSIDERADO COMO CONTRABANDO PELIGROSO, Y NO SE REGRESARAAL DETENIDO. Signature:.~X-"--~~&~L---=--1-1---~ I~ 2020-ICLl-00006 Date:_ 4405 __,,Oz::.9-""08c,-2.,,0-'-'17'- II , Management &Training Corporation Acknowledgement Form I have viewed the ICE orientation, Florence Immigrant, PREA Video and Refugee Rights Project Know Your Rights/ All about Bonds video. Detainee signature 09-08-2017 Date 09-08-2017 Date Officer signature Forma de Reconecimieno Yo Almazan-Ruiz, Felipe he vista la orientaci6n de ICE. Florence derechos Del irunigrante, PREA Video y refijuiado que proyecta saber sus derechos /Toda Acerca del video De fianz.as(Bonds). 09-08-2017 »--,-~------------' 2020-ICLl-00006 4406 Fecha FORMA DE AUTORISASION D!i: MANEJAR DINERO Y TARJETAS TELEFONICAS Tengo entendido que IAH no sabe cuando sea dia de mi salida de esta localizacion. Se hara cada intento para que yo me Ueve el balance que tengo en mi cuenta y tarjetas telefonicas que yo aiga ordenado. En caso que yo salga de IAH y mi dinero se quede en mi cuenta por cualquir motivo, o yo aiga ordenado tarjetas telefonicas y no se me entregaron antes de mi salida, doy mi autorsasion para que el Business Office de IAH me envie por correo mis fonos y/o tarjetas telefonicas a la direccion siguiente. NOMBRE DE DETENIDO:_~Ac,l,em,,,a,.,-,,,n.:-,:R.,u,.iz,,...,;F.,oel,.,,ip,,e'-----NUMERO DE I.D. A028866428 PORFA VOR ENVIE MI DINERO Y/0 TARJETAS TELEFONICAS A: ENCARGADO: ________________ _ (Nombre de Ia persona que vive en esta direccion) CALLE/P.O BOX-_ _____________ _ CIUDAD, EST ADO, CODIGO. _______ _, ___ _, ___ _ TEN GO ENTENDIDO que el Business Office intentara enviar el dinero y/o mis tarjetas telefonicas a la direccion escrita. Si esta persona se a cambiado o no acepta Ia carta, el dinero se regresara a mi cuenta hasta que yo contacte a alguien de IAH y pida que me envien mi dinero a mi 09-08-2017 Almazan-Ruiz, Felipe NOMBRE ESCRITO DE DETENIDO FECHA x~~¥ FIRMA~NIDO *******FOR BUSINESS OFFICE USE******* All checks will be payable to the Detainee and not to another person. Ck# ____ for$._____ _ __ Phone Cards mailed Mailed on ------Mailed on ______ _ 2020-ICLl-00006 4407 :::ep 18 17, 09:24a ~ Texan EMS 936-327-9116 p 1 (b}(6); (b)(7)(C) EfV6 2~20-ICLl-00006 4408 p2 -rexan EMS Sep1817,09:24a ARCePCR - Alrr-.a.zon Ruiz- 842335-\vebJ .ARconcepts.com https://tel253.qcr.com.'newbase/repons/legacyprintitypc/hoq,1tal/: Subje,:t: =Ms P3ttnt Core Report Fax/Pmt Date: 0~/16/2017 ra: conmc R.egtinal(Fa><,) From: TEXAN EMS -LC (Phone: o; Fa)( Conrldenti.ility Notice: The ,rr'ormati:Jn ::or.ter-,e-:l1nthis fa> from s~ne: 06;45:58 08:13:43 Return to service·, D5·,4S:~2 ArrNi'II at d.KDA Patient contact: Cltr- LM'JGSTDN 1-1-.,ight(ft): county: PCIL< Sl::;ate: TX Zip: /73Sl Phone.: 9369(,'/8000 Nnme:c nore Next of Kin Phone: Name: Origin Faciatv: C!i! St. Lukes o' Eas'. Tex a~ City: U\ll'IJ:.STON Z-ip, 77351 Street Add~: county Patient 1717 H111)' so:;By~~, 936•327-8500 Assessment Su!lLK Phone#; Normal Br-e,;,t:1,.,9,CIEarL-tR Site of Pain: EKG Revealed: Patient I,;:,; In Place: N octreomkle drp 2Smcg_,'hr,02 4lpm vi. NSR (07:04:55; Pain Salle1 NC, EKG Neurological LevdA--rOXm b)(6); (b)(7)(C) Dr;.,.,,, Nan,., Report Ends. 2of2 2020-ICLl-00006 4410 9/18/2017, 9:21 I l(b)(6), (b)(7)(C) From: Sent: To: Subject: 21 Sep 2017 19:07:42 +0000 (b)(6); (b)(7)(C) RE: Funera Home data Buenas tardes oficial, Disculpe, tendra un expediente medico del Sr. Almazan? Queremos contestar a nuestras oficinas en Mexico sobre en que condici6n medica lleg6 a Houston. Saludos, r b)(6). (b)(7)(C) SRE 1 Departamento de Proteccion y Asuntos Legales Protection & Leg11lAffairs Departme11t Casos Migratorios I l111111i gratio11Ct1ses CO~HllADOt i l~IAAL lJL \\I XKO HOII\ I ON TIM' 4507 S . (713) 2 (b)(6); (b)(7)(C) F~(b)(6); (b)(7)(C) TX 77004 lce.dhs.gov] Sent : Tuesday, September 19, 2017 5:43 PM re.gob.mx> Tl b)(6); (b)(7)(C) Subject: RE: Funeral Home data . (b)(6); Grac1as (b)(7)(C) Sent with BlackBerry Work (www.blackberry.com ) b)(6); (b)(7)(C) Fro sre. ob.mx> O..,...:~.I'~EJ~;x-:z~If:f~;:}C~Irl:'r:=~.['CZJ(;J:::.=,-----1' ~~~To (b)(6); (b)(7)(C) ce.dhs. ov> Subject: Funeral Home data Buenas tardes Oficial, Estos son los datos de la funeraria: Bernardo Garcia Funeral Home Telefono: (305) 23 (b)(6); /bl/7)/Cl La Sra. Paz inform6 que hasta manana firman el contrato con la funeraria debido a que el cementerio continua cerrado por el paso del Huracan Irma. Manana temprano nos confirma la firma del contrato para continuar el proceso de traslado. Saludos y que tenga buena ta rd e. 2020-ICLl-00006 4411 SRE co, ,ULAIX) til, I RAL lll \\I lil<.O Ho11,1nN , TLM\ N(b)(6): (b)(7)(C) Departamcnto de Protecci6n y Asuntos Legates Protection & Legal Affairs Department Casos Migratorios / l111111igratio11 Cases 4507 San Jacinto St, Houston, TX 77004 (713) 271-1(b)(6) ; (b)(7)(C) I 2020-ICLl-00006 4412 Fax Server 9/18/2017 8:35:47 AM To: 1st F'ax: 9193696'18846 E'rom: CHKR PAGE A-nobody Phone Pages: IMNET/EPRS 45 (including fax banner) n=,quest. 2020-ICLl-00006 4413 1/045 Fax Server Fax Server 8/18/2017 8:35:47 AM PAGE . ,_ ··,~·. .·.--. 2/045 ' .1-. Fax Server ,-.....--:--1, , •.• 0 ""'fCHI St. Luke's Lufkin ,.J: Health. Livingston □ MEMORANDUM OF TRANSFER San Augustine SECTIONA (To Be Filled Out At Transferring Hospital) ----------'--------------------I. Nam(:of Hospital: ,---------'~-~-------------~ 8. I furtherhave determinedthal lhe patientwouldbenefitfrom transferto ~,ia- Address: '--· Ph~ne Numuc,.. 2. Cw\.\¼!. Of\ ,t Phone rzber: (~ s~x: M . F Age: Na~o_nalorigin: /9]¥1!,'.'G Race: Rehg!on: 0 .. ''PliysicalHllJldicaps: can: facilitydue lo the followingreasoning: SpecialtyCare for patient'sconditionnot availableat lhis institution ____ Hospitalbed accommodations al lllisfacilitynot available k::::,, Patientand/or familyrequest __✓ __ Patientwouldbenefitfromhigherlevelof clinicalcm 1 furthc:rhave dclcnninedthe risks and bcncfiliof Lransfcranchave explained these to the patic t. These~ as follows: Risks: 1'-A;. - . 5/ , f\ ,spau , \( _;e, _____________ ' 3. anolh~lh ____ HI St.Lukc's~ealthMemoria)L\vingst . 1717High.Qy59LOOpN Pat~cntInformauon(!f,kn~wp) , iv~:riosto Paucnl's Full ~ame: ~~-G'? ~~___:_2\] Address: ~~\Q(~ :E ~ ___ . _ ·\/'--------------------Nclitof Kin infonna~ {if known) 9, Ne~WfKin:---;;;,JI--------------Address: ::-4! 4. 5. ¢ con~ U7 _o~/~3~:1~--- ofQo ffG~ 6. IO. PhoneNumber:(jffj~~~----------Dateof Arri_val:Cj/U { f 7 Time: --&~\O_J.~---lni1ia! withreceivinghospital: Date: ':1,.J tcJ 'lime: Name receivinghospital: Accepti11g ph siciansecuredby transferringplt~iciiyi:((j Date:-::--:--........ .......,-VOIICA gl □ Ads EYES problems ~¢Ith visio1, Circle UAhk S'#CJliAg -R- ~ strikethrough + AB!'JBB•,•es unmarked= not applicable [ NAME: ALMAZON RUIZ, FELIPE- MRN: 00102823282()?iretqd()(J00(5da,1.ffitember 12, 2017 5:18:14 AM - Page 2/20] Fax Server 9/18/2017 8:35:47 AM PAGE 5/045 Fax Server ·~ FINAL (SIGNt:O) ~f CHI St. Luke's Health MMC LIVINGSTON Abdorrnm:I Pain Flank Pain lCD10, Transfer of Care Nole add on Patient: ALMAZON RUIZ, FELIPE ENT sore throat NEURO heaelt!iehe Male diuiness PSYCH I MR#: DOS: I Sex: 09/11/2017 23:20 0010282353 light I 1eadeel1 ,ess depfessien ~ except as marked positive, all systems above reviewed and found negative ~ HISTORY Reviewed ■ Updated No ohFenie diseases Cardiac disease: Diabetes: At1b Type 1 CAD Type2 CHF Ml diet oral insulin Hypertension Peptic ulcer Gall stones Kidney stones Rladder infection Kidney infection lschemic bowel risk factors: valvular disease elderly low BP recent Ml Pancreatltis GERO Diverticulitis Abdomlnal aneurysm CVA TIA: deficit: R L Ectopic pregnancy Fecal impaction ~c Hyperllpidemia Intestinal obstruction Circle~ strikethrough !'lOgaWos unmarked= not applicable [ NAME: ALMAZON RUIZ, FELIPE- MRN: 00102823idzoE,rel~Q()(J~eda144~eptember 12, 2017 5:18:14 AM- Page 3/20] Fax Server 0/18/2017 AM PAGE 8:35:47 Fax Server 6/045 FINAL (SIGNl::.D) 11,~ ~r CHI St. Luke's Health MMC LIVINGSTON Abdominal Pain Flank Pain ICD10, Transfer of Care Note add on I Sex; Patient: ALMAZON RUIZ, FELIPE Ovarian: cyst(s) Male MR#: 09/11/2017 23:20 0010282353 fibroids STD Pelvic infection: x DOS: Old records reviewed I summary Surgeries / Procedures: hernia repair R cardiac bypass none appendectomy cholecysteclomy endoscopy upper lower L cardiac stent hysterectomy BTL C-section tonsillectomy ·················· ..··············-···-···············--··--······················--··· ···············---······-······················· ·····-···-·--·········· ........ __ ._··-·..·····-1 Full Problem List ~ Reviewed D Updated IUpper GI bleed (2017) I Allergies ~ Reviewed Q Updated :&l Reviewed 0 Updated ~_. I Re~~w_e_d __ □_... _. _u_pd_a_te_d ________ f3 ■ Updated No Known Allergies . Home Medications [ t~.~~nizatio_n_s _____ SOCIAL HISTORY Reviewed --·-···----------------, _ Tobacco Use Never smoker None Reported: (b)(6); (b)(7)(C) TOBACCO HISTORY Last Documented 8 n 09/12/2017 01:58 [Aicohol Use I Recreational D~~g Use FAMJLY HISTORY gall stones ~ Reviewed ovarian cysts Circle~ CAD ■ Updated ulcer strikethrough [ NAME: ALMAZON RUIZ, FELIPE - MRN: 0010282~.fi'C!fl!f.SO kidney stones Regatf,•ee aortic aneurysm unmarked== not applicable QCJOOd~ 4~ t!J)lember 12, 20 17 5:18:14 AM-· Page 4/20 I Fax Server 9/18/2017 8:35:47 AM PAGE Fax Server 7/045 ·~ FINAL (SIGNED) ~r CHI St. Luke's Health MMC LIVINGSTON Abdominal Pain Fiank Pain ICD10, Transfer of Care Note add on Patient: ALMAZON RUIZ, FELl?E 09/11/2017 23:20 Male VITAL SIGNS ~ Reviewed Last Set of Vitals: Interpretation: ! DOS: I Sex: MR#: 0010282353 ■ Updated nonnal hypoxic BP: 160/103 09/12/2017 02:31 Pulse: 94 09/12/2017 01:10 Temp:98.1 F 09t11/201721:36 Resp: 18 09/11/2017 21:36 02 Sat 99.0% 09/11/2017 21 :36 Additional Vitals: PHYSICAL EXAM ~ Nursing assessment revtewed CONST ~ distress: mild ~ anxious lethargic Comments: moderate severe Patient is alert and in no acute distress on exam. EYES ~nnorimiD scleral icterus EOM palsy pale conjunctivac R L anisocoria R L hearing deficit R Comments: Normal on exam. ENT ~ ~ pharyngeal erythema abnormal TM R L L Comments: Normal on exam. NECK ~ Comments: thyromegaly lymphadenopathy Norma1 on exam. RESP ~respiratory Circ!e I NAME: distre~ ~ ALMAZON RUIZ, FELIPE wheezes strikelhrough R L RB!ilatives rales R L rhonchi R L unmarked= not applicable MRN: 0010282~flc!n!t-'OOOffiJd~4l:f!J)tember 12, 2017 5:18:14 AM~ Page 5/20] Fax Server 9/18/2017 f-lNAL (SiGNED} 8:35:47 AM PAGE Fax Server 8/045 "'~- ~r CHI St. Luke's Health MMC LIVINGSTON AbdominalPain Flank Pain ICD10,-rans fer of Care Note add on Patient: ALMAZON RUIZ, FELIPE I MR#; I Sex: DOS: Male 09/11/2017 23:20 0010282353 ~ Comments: Normal breath sounds on exam. CVS ~ ~ ~ irregularly irregular rhythm JVD present tachycardia gallop: murmur: grade S3 decreased pulse(s): 84 systolic /6 radial bradycardia R diastolic femoral L dorsalis pedis R R L L Comments: Normal heart sounds on exam. L!::GENO T G = Tenderness "'Guarding R m = Rebound =Mild l·. mod = Moderate sv : Severe • I ABO rigid distended tenderness guarding rebound ~ hepatomegaly ~ abnormal bowel sounds: ~ prominent aortic pulsation ~ McBumey's point tenderness generalized RUQ LUQ RLQ splenomegaly increased psoas decreased absent Rovsing's sign tyrnpanic obturator sign mass: Comments: No abdominaltendernesson exam. GU external inspection normal catheter present PELVIC EXAM normal external exam vaginal bleeding normal speculum exam cervical motion tenderness Circle ~ strikethrough RB!21ati¥es LLQ vaginal discharge unmarked= not applicable [ NAME: ALMAZON RUIZ, FELIPE- MRN: 0010282~O.oot!M)00@:6;da:t,4:ii!~ternber 12, 2017 5:18:14 AM- Page 6/20] Fax Server 9/18/2017 8:35:47 AM PAGE Fax Server 9/045 _._:., FINAL (SIGNl::.U) ~r CHI St. Luke's Health MMC UVINGSTON Abdominal Pain Flank Pain ICD10, Transfer of Care Note add on Patient: Male ALMAZON RUIZ. l=ELIPE normal bimanual exam I MR#: DOS: I Sex: 09/11/2017 23:20 0010282353 adnexal tenderness adnexal mass enlarged ute,us tender uterus L R MALE GENITAL normal inspection testicular tenderness R L testicular swelling R L inguinal tenderness R L inguinal swelling R L RECTAL non-tender tenderness heme negative stool stool: fecal impaction heme positive trace black bloody BACK ~ CVA tenderness R L Comments: Normal on exam_ SKIN ~ cyanosis diaphoresis <@ir~ skin rash zoster-like embolic lesions signs of IVDA (§_iiii) ® ~ pressure ulcer location: depth/ stage: 1 2 3 pallor 4 Comments: Normal or, exam. EXTREMITIES ~ ca!ftendemess R L ~ Haman's sign R L ~ pedal edema R L C'.,ommenls:Normal on exam. NEURO ~ ~~ormal .@:!.__21:> disoriented to: person place weakness R L facial droop R ~ speech abnormalities ~ sensory loss R time situation L cognition abnormalities L Comments: Patient is alert and orientedx 4 on exam. Circle ~ slrlkelhrougt, Aogati1•oc unmarked= not applicable [ NAME: ALMAZON RUIZ, FELIPE - MRN: 0010282~20fi€!.E!~OO@§da4~tember 12, 2017 5:18:14 AM - Page 7120] Fax Server 9/18/2017 I-INAL (SIGNl:::D) 8:35:47 AM PAGE 10/045 Fax Server J -~ - ~r CHI St. Luke's Health MMC LIVINGSTON Abdominal Pain Flank Pain ICD10, Transfer of Care Nole add on I Sex: Patient: ALMAZON RU(Z, FELIPE MR#: DOS: Male 09/11/2017 23:20 0010282353 PSYCH ~ depressed mood .•ee Status Collection Final Result Final Result Final Result Final Result Final Result Final Result Final Result Final Result Final Result Final Result Final Result Final Result Final Result Final Result Final Result Final Result Final Result 09/11/2017 23:29:00 09/11//017 23:29:00 09/11/2017 23:29:00 ------09/11/2017 23:29:00 09/11/2017 23:29:00 09/11/2017 23:29:00 ------------09/11/2017 23:29:CO 09/11/2017 23:29:CO 09/11/2017 23:29:00 09/11/2017 23:29:00 09/11/2017 23:29:00 -□ 9/11/2017 23:29:00 09/11/2017 23:29:00 09/11/2017 23:29:00 ---- 09/11/2017 23:29:00 09/11/2017 23:29:00 09/11/2017 23:29:00 unmarked= not applicable MRN: 0010282M0.fffil1!M)~dat4~iptember --- - 12, 2017 5:18:14 AM - Page 6/20] ' --- .. Fax Server 0/18/2017 8:35:47 AM PAGE 11/045 Fax Server FINAL (SIGNED) .J~Jl ~r CHI St. Luke's Health MMC LIVINGSTON Abdominal Pain Flank Pain ICD10, Transfer of Care Note add on Patient: DOS: I Sex: ALMAZON RUIZ, FELIPE Male I MR#: 09/11/2017 23:20 CBC PLATELET AUTO DIFF ·CBC PLATELET AUTO DIFF Nucleated RBC 0 (0-2 /100WBC) Neutrophils 1O L (42-75) -CKIVIB CKMB 7.49 HH (0.00-2-36 ng/ml) 0010282353 Decreased platelets, NO Platelet dumping , few large platelets seen on peripheral blood smear. RESULT CALLED TO CHELSEA BULLORD RN (ER) AT 0003 THEN READ BACK //HH/ Final Result Final Result 09/11/2017 23·29·00 09/11/2017 23:29:00 Final Result 09/11/2017 23:29:00 :CMP COMPREHENSIVE ,METABOLIC PANEL .CMP COMPREHENSIVE METABOLIC PANEL ,CMP COMPREHENSIVE METABOLIC PANEL Glucose 127 H (75-110 mg/di) Final Result 09111/2017 23:29:00 BUN 85.0 H (6.0-17.0 mg/di) Final Result 09/11/2017 23:29:00 1.5 H (0.4-1.2 mg/di) Final Result 09111/2017 23:29:00 CMP Sodium 127 L (137-145 mmol/I) Final Result CMP Potassium 4.3 (3.5-5.0 mmol/I) COMPREHENSIVE METABOLJC PANEL ·CMP COMPREHENSIVE METABOLIC PANEL Final Result 09/11/2017 23:29:00 Chloride 95 L (98-107 mmol/1) Final Result 09/11/2017 23:29:00 Creatinine " :coMPREHENSIVE 'METABOLIC PANEL " CMP co, 22 (22-30 mmol/I) ,COMPREHENSIVE 'METABOLIC PANEL 'CMP COMPREHENSIVE METABOLIC PANEL Final Result 09/11/2017 23:29:00 Calcium 8.6 (8.4-10.2 mg/di) Final Result 09/11/2017 23:29:00 CMP T Protein 6.5 (5.1-8.7 gm/di) Final Result 09111/2017 23:29:00 3.3 L (3.5-4.6 gm/di) Final Result 09/11/2017 23:29:00 1_Q L (1.122) Final Result 09/11/2017 23:29:00 ,COMPREHENSIVE METABOLJC PANEL ;CMP :coMPREHENS!VE :METABOLIC PANEL CMP ·-Albumin NG Ratio .. .COMPREHENSIVE METABOLIC PANEL Circle ~ strikethrough --·" 09/11/2017 23:29:00 Rege~Pi•ee unmarked= not applicable [ NAME: AUv\AZON RUIZ, FELIPE- MRN: 0010282~O.ff'Ot!Ml0{)00d~4~Bptember 12, 2017 5:18:14 AM- Page 9/20] - - - Fax Server 9/18/2017 8:35:47 AM PAGE Fax Server 12/045 ,_ FINAL (SIGNED) ~r CHI St. Luke's Health MMC LIVINGSTON Abdominal Pain Flank Pain ICD~0 . ..,.ransfer of Care Note add I Sex: Patient: ALMAZON RUIZ, FELIPE CMP - I MR#: DOS; Male CMP COMPREHENSIVE 'METABOLIC PANEL !CMP COMPREHENSIVE METABOLIC PANEL 011 09/11/2017 23:20 102 H (11-36 U/L) Fina( Result 09/11/2017 23:29:00 ALT (SGPT) 68 H (11-40 UIL) Final Result 09/11/2017 23:29:00 Alkaline Phos 123 It (47"114 U/L) ICOMPREHENSIVE METABOLIC PANEL -----.CMP ,COMPRFHFNSIVF: 'METABOLIC PANEL Tota] -EIIlirubin 10.8 H - - . 09/11/2017 23:29:00 (0.2-1.2 mg/di) Final Result 09/11/2017 23·.29:00 (2.3~'.fS gm/di) Final Result 09/11/2017 23:29:00 Final Result 09111/2017 23:29:00 Final Result 09/11/2017 23:29:00 Final Resull ... Result Final Result 09/11/2017 23:29:00 09/11/2017 23:29:00 09/11/2017 23:29:00 Final Resull 09/11/2017 23:29:00 CMP Globulin 3.2 Anion Gap 11 CMP Calcium, Corrected 92 (8.4-10.2 in!ildl) CPK 322 H (30-135 U/L) LIPASE SERUM Lipase 367 H (8-223 U/l) PRO BNP 8 NATRIURETIC PEPTIDE Pro BNP(B-Pepticie) 4850 HH (0-125 pg/ml) .PROTIME PT INR Protime 15.1 H (9.0-11.8 sec~_r:i~sf_ COMPREHENSIVE , METABOLIC PANEL ·---- Circle~ strikethrough ---- ' Result 'COMPREHENSIVE METABOLIC PANEL ·CMP ;COMPREHENSIVE METABOLIC PANEL :cPK 0C10282353 Rega&,,es Various formulas exist for corrected serum calcium results, each yielding different values. This ; corrected result was based on the formula: Corrected Calcium= SerumCalcium +[0.8·(4SerumAlbumin)] '' Final Final RESULT CALLED TO CHELSEA BULLORD RN (ER) AT 0003 THEN READ BACK /IHH/ - - unmarked= not applicable [ NAME; ALMAZON RUIZ, FELIPE - MRN: 00102823~~2!J'-'lif:!1:~fl0{)@661a',1:j..ffl~lember12, 2017 5:18:14 AM - Page 10/20] -~-, ···-- - Fax Server 9/18/2017 8:35:47 AM PAGE 13/045 Fax Server ,~!# ~J FINAL (SIGNED) CHI St. Luke's Health MMC LIVINGSTON Abdominal Pain Flank Pain ICD10, Transfer of Care Nole add on I Sex: Patient: ALMAZON RUIZ, FELIPE Male ;PROTIME PT INR INR PTTPARTIAL THRO_~.BOPLASTIN Th1 j aPTT I MR#: DOS; 09/11/2017 23:20 1.4 H 1221 L I 0010282353 INR results are Final intended ONLY Result to monitor Oral Anticoagulant therapy in slablized patients. The JNR Therapeutic . Range is 2.0 3.0 Patients with a mechanical heart, !he INR Range 1s 2}:i - 09/11/2017 23:29:00 3.5 (25.3-35.7 seconds) Final Result 09/11/2017 23:29:00 Documentation Cont. Next Page Circle~ slrikethrougl'i Aegaw. 37wk <37wk chronic R testicular chlamydia ovarian chronic R L with hematurla LIVER/ GB I PANCREAS Biliary colic: with gallstones Cholecystitis: acute chronic with: gallslones Hepatitis: acute chronic viral: A Pancreatitis: acute chronic alcoholic B biliary obstruction C alcoholic drug induced: idiopathic OTHER Dehydration Peritonitis, acute Pneumonia: aspiration viral: Sepsis, severe: atypical RSV bronchopneumonia influenza: A B interstitial lobar bacterial: with shock SIRS Circle ~ strikethrough Aogativos unmarked= not applicable [ NAME: ALMAZON RUIZ, FELIPE - MRN: 001'J28232€12cf-~'1:P-OCl8m:flal!l-ffltember 12, 2017 5:18:14 AM - Page 17/20] Fax Server 9/18/2017 8:35:47 AM PAGE 20/045 Fax Server FINAL (SIGNED) ,J~ ~r CHI St. Luke's Health MMC LIVINGSTON Abdominal Pain Flank Pain ICD10, Transfer of Care Nole add on I Sex: Patient: ALMAZON RUIZ. FELIPE I MR#; DOS: 09/11/2017 23:20 Male 0010282353 SIGN / SYMPTOMS Abdominal pain: RUQ LUQ RLQ acute abdomen LLQ generalized with: rebound tenderness Fever Flank pain Nausea Vomiting Diarrhea Comments: [ Cu_r_rentProblems Upper GI bleed 18] Reviewed I&] Updated Upper GI bleed (2017) DISPOSITION Decision made at 02:35 AM To: Left department at ~ Horne Present on arrival: patient condition: Nursing Horne Police pressure ulcer UTI unchanged improved ambulatory active Admit Morgue Funeral Home Medical Examiner senous drinking fluid Care transferred to Dr Abas critical eating deceased pain controlled time: 05:15 AM Basis For Discharge Decision: patient exam: test results: stable improved unchanged tenderness migratory no rebound no abnormal no serious abnormal social support: adequate good follow up: available arranged Circle ~ no rigidity min abnormal mod abnormal excellent discussed with physician strikethrough Ao§ati,•96 unmarked= not applicable I NAME: ALMAZON RUIZ, FELIPE - MRN: 001028232()2CJlt®etl-O@Oel61a}4-4.i):l:tember 12, 2017 5:18:14 AM - Page 18/20 J Fax Server 9/18/2017 8:35:47 AM PAGE Fax Server 21/045 ,~ ~r FINAL (SIGNED) CHI St. Luke's Health MMC LIVINGSTON Abdominal Pain Flank Pain ICD10, Transfer of Care Nole add on I Sex; Patient: ALMAZON RUIZ, FELIPE Male I MR#: DOS: 09/11/2017 23:20 0010282353 Basis For Admit Decision: need for. further evaluation additional testing monitoring telemetry pain control IV hydration IV medication IV antibiotics culture results surgery I intensive care (b)(6); (b)(7)(C) Relinquishing Scribe: Report given to Assuming Sc Relinquishing Mid-Level: Report given to Assuming Mid-Level: Relinquishing Mid-Level: R~port rive~ to Assuming Physician: Relinquishing Physician: Report give~ to Assuming Physician: Brief history: Items pending that need to be checked and documented: Labs: X-Ray results: Pain conlrnl: CT results: MRI results: US results: Procedure(s): other Physician I consult arrival: Tentative impression of patient admit discharge transfer Pending results: Circle ~ strikethrough AB!Jaw.e1.1me11to1Uon h'l$ b••"- pr.pued llnd•r ttle direction ll'ld i" tha P"'""""Q of __J_Electronically sign{ b)(6); (b)(?)(C) D,\a 09/1212017 Time: 02:35 AM 09/12/2017 05:17 Mid-level Signature OR Scribe Signalure Date!Time Emergency Physician Attestation rx··. , This scribe's documentation has been prepared under my direction and personally reviewed by me in its entirety. I confirm that the note accurately reflects all wor-1<,treatment, procedures , and medical decision making performed by me. f b)(6); (b)(?)(C) rpages have been reviewed and completed Authorized Signature 09/1212017 05: 18 Dalerrime Circle ~ strikethrough Aogati>.•o,s unmarked:= not applicable [ NAME: ALMAZON RUIZ, FELIPE- MRN: 0010282~ijCitt!+(QCJOOOda4~tember 12 , 2017 5:18:14 AM - Page 20/20 J · -· Fax Server 9/18/2017 8:35:47 PAGE AM MMC LIVINGSTON LIV ED Triage R&port Printed: 09/1112017 21 :35: 16 Page 1 of 1 Fax Server 23/045 11111111111111111 11111 llllllllll1111111111111111111111 Visil ID: Patient ALMAZON RUIZ, FELIPE Age: 51Y Chief DOB:06/26I1968 Acuity; Sex: M Heai:1 Clrcum_: 1-iemoptys Is Co1np1alnt: T~eg• err 09/11/2017 21:25 lnfecllOl'I Control: EMS: Room/Bed: Radio Cell: EMS Llnlt Afrlva I □11: A!Tlwdfrom: 09/11/2017 21:02 Forensic Faclllly Mode of Amwt: Law Enforcement 0300267948 Med Rec: 0010282353 3 N Pre Hcspitl!IICa.re: Screening·. 'OomealioVlolenc:e, 'TB, Out us Lllot {None entere~ 300ay• NC Accompanied by: Olher Suldde Risk: Self Informant: Consent loTrest?: Sc'l!en~d - No S!Jclde Risk LMP: Pmgnant?: Stroke Asa11111ment lsat KnownWell: I\IPOslnoe: BP 149/97 mmHg Site: Ami,Upper LI P°"'. Pain Assessment Seore:7/10 Cheracier: ""tlnt,iko D/T Lest Intake Solid: Height 15 61 in Qly: M-6 V-5 Weight Type: E-4 77.13 kg 98.1 F SIie: Radiation RelIIIV8dBy: Durman: Goal: NONI:, NONI: 0,Dal: FSBS I'CP: ,a Qlv: Scale: 7,'-umerlo S00le $g0,, Ra5,plrations 99bpm stabblrig Dr. DfT LlqLJ\d: acs Pulae Tampareture Slle: Forehead I. Electronlcelly (b)(6); (b)(7)(C) SignedBy: DI Signed:091111201721:36:10 Fax 9/18/2017 Server -------------------------PATIENT: ALMAZON 8:35:47 AM PAGE 24/045 Fax Server CHI ST LUKE'S HEALTH - LIVINGSTON ABORATORY - CUA# 45D0697930 1717 HIGHWAY 59 BYPASS LIVINGSTON, TEXAS 77351 PH: (936) 329-8589 RUIZ, FELIPE DOB: 06/26!1966 SEX: M MR#: V0010282353 LDC: ER LIVINGSTON ENCOUNTER"---- b)J(?~ )(E~ ) ==~ ~------, A TIO.PHYSICIAN (b)(5); (b)(?)(C) ADMITTED:09/11 /2O'17 HEMATOLOGY R-afenmca 09/11/2D17 Collected Units Ord Physician WBC RBC Hemoglobin Hematocrit 3.94 12.5 33.2 L L L MCV MCH MCHC 84.3 31.7 37.7 ROW 16.0 Platelet 18 LP No1 Measured 2 MPV NE% LY% 72.4 MO% EO% 11.9 7.8 BA% IG% NRBC, Auto Nucleated RBC H H H L ,um ·10.so 10'-.1/ul -1.70-6.l0 ·IQh6t.lJ 1/4.0-18.0 gm/di 4?.0 fiO.O '% 00.0-94.0 ,~ 27. 0-3·) .0 pg 33.0-37.0 gm/di •;·1.5-M.5 % '130-,!DD 10h3/ul 1.4-1 OA .42.0-75.0 'J.0-!\2.0 4.J-14.0 f~ % % % 0.9 L ,.J-3,D % 0.6 L 6.4 1 H '. .J-3.D O.:l-0 60 mltrnifl/1. 73m'· 52" mUl'I"in/1. 73m'· 2 2 CARDIAC SE.CTfON "Estimated Glomemlar Filtration Rate (eGFR) Rderence hi.tervals Decision Points for l 8 years and older and average body ma;,~: >= 60 30 - 59 < 30 Do~ not exclude kidney disease. Suggests model'ale chronic kidney disease and indicates the oe~d fur fiirther investigation including assessment ofproteiunria and cardiova5Cularfllctors. u~u11llyi11dicates?. need for referral for assessment and manaiemenf o: chronic kidney faiJure. - - - ---- -=== PRINTED: 09:12(2017 18:43 ALMAZON RUIZ. FELIPE rb)(6i ;(b7 c9xcT "TO REPORT: Final Chart Livingston PAGE: 5 OF 8 2020-ICLl-00006 4440 Fax Server 9/18/2017 8:35:47 AM PAGE 29/045 Fax Server CHI ST. 1.IJKF'S HFAI.TH - LIVINGSTON ABORATORY • CUA# 45D0697930 1717 HIGHWAY 59 BYPASS LIVINGSTON, TEXAS 77351 PH: (936) 329·8589 ==============~-------------=== --------------------------------------------------------~------------------------------------------MR#: V00,0282353 FA.TIENT: ALMAZON RUIZ, FELIPE DOB: 06/26/1966 SEX:M ENCOUNTER ATTD.PHYSICI LOC: ER LIVINGSTON ~b~)(~7 ..,.,,,.,..------, (b)(6); (b)(7)(C) ADMITTED:09111/2017 -------------------------------------------------------- ------------------------------Collected 09/11/2017 23:29 Ord Physician Cte Rh Antioody Screen x 2 Cross match Ord l'l1ys1aan (b)(6); (b)(?)(C) 0 Positive Negative C::impleted: Compatible ALMAZON RUIZ, FELIPE PRINTED: 09/ 12/2017 18:43 ..,..,.=E'='"R-Ll'=V""'"I N""G=-=ST_,_0-=-----------,REPORT:Final Chart Livingston ._l (b_)(6_);_(b_)(_7)_ (C_) ______ _.I PAGE: 8 OF 8 2020-ICLl-00006 4443 Fax Server 9/18/20 17 8 : 35 :47 AM PAGE Fax Serv er 32/045 .J-. ~r CHI St. Luke's Health BLOOD BANK TRANSFUSION RECORD . Lufkin• Livingston• San Augustine Mem o rial Spe cial ty Blood Band#: • Product Antibody Screen:~ Segment # : Donor Unit Expiry Dat e: Unit # ; fr tJ- t,-,), Crossmatch Inter retation: b)(6); (b)(7)(C) Tech t l!EV. j011'lQl15) KWII< KO/>YPlll NT ,. t 2020-ICLl-00006 4444 Fa x Se rv er 9 /1 8 /2 0 17 8: 3 5 :4 7 AM PAGE Fax Ser ver 3 3/ 0 4 5 ·~ ~r CHI St. Luke's Health BLOOD BANK TRANSFUSION RECORD I,.ufkin • Livingston • San Augustine Memorial Sp ecialty Blood Band #: Antibo d y Scree n: Segm ent# : Exp iry Date : Unit#: Donor Unit A~V. (Olr.l!l.'15) ..... 2020-ICLl-00006 4445 l(WIK KOPY PftlHTI G · Fax Server 9/18/2017 8:35:47 AM PAGE Fax Server 34/045 __,_, ""'fCHI St.. luke·s Health BLOOD BANK TRANSFUSION RECORD lll!WJ!~ll)Wlllllml11m ~tt-~i I 1mm111n '" SPAI ALMAZ.ON AUIZ, FELIPE ii '~ ·. Lufkin • Livingston • San Augustine Memorial Specialty _! ~- 'j ·::-~ ED k.~ ~B: 09/1112017 06/26/1966 0010282353 51V M fJO![fWI?' -- PatientABO/Rh:-0 O fa'ittflAE Donor ABO/Rh: \i RELEASED t,tl~~ l/1..-f'Pf>c- Product Blood Band #: NOqto IJ.2.() Crossmatch Interpretation: Tech I (b)(6); (b)(?)(C) 1 ''..'·: .______, __ - 0 fo-~tf0 f_6~r,Af~ Blood Band #: Antibody Screen: °'J\\o\~ Segment#: EKpiryDate: Unit#: ~~ q{tff::r-0/~ Datemme: 1 ~':f'~; ,-:.·~'~:~:?' ~•;,, -,~· "".'.~?(!fiiAif~u~J'iff!:fiYsJtftiiilf~:··,r/I r:.::,_.\?~JJ~?·,~T8???t _,1:1 C?f!rti/y !hatpriono transfusion we havt1 verified the identity pfthis unitand its ·intsht;ledrecipient ,and h~VB che<;lctKJ ~ch item in the piesen<;e_ofthe;s/;ipienf . . ' x.___________ x.____ _,_________ 6ate.· _ ____ · Time. __ _ --;..,..-........,_2 ..... 0,..,2""'0.....,-IC'""[r'-,1...,--0 .... 0...,00 .... 6___,4...,.4..,.,46~------,,---Date._·~.....,--TimB,__ _ Fax Server 9/18/2017 8:35:47 AM PAGE 35/045 Fax Server MMC LIVINGSTON Ambulatory Asa11ument/Hlatory Report 09/11/:ZD17 21:02 Patient Name: ALMAZON RUIZ, FELIPE Visit ID: 0300.267948 Admitted: 09/11/2017 21:02 MR Number: Throogh 09/14/2017 04:01 00102B2353 ,-l (b-)(6-);-(b_)(_7)-(C-) Attending: --,I DOB: 06/:Z6/1966 Assessment Date Vit.Js Entry Data Entered By: ~b)(6); (b)(7)(C) Pl. Location: 09/11/2017 21 :36 I UNKNOWN_LOCATION Pulse Resp BP 02 % Ht Wt 98.1 F 99 18 149/97 99.0% 61.00 lr, 77.13 kgs '1--------------------------, I rb )(6); (b)(7)(C) Entar■dej Pl Location: Temp LIV EMERGENCY DEPARTMENTRM-04-A Pulse Resp 02% BF' Ht Wt 09/1212017 00:46 09/12/2017 00:50 Entry Date Assessment Date IV Medications. _________ Entan1d By: Pl. Location: 09/12/2017 00:49 09/11/2017 2 ';;36 Arm,UpperLt Forehead __________ UNKNOWN_BED Temp ~ l (b)(6); (b)(7)(C) _ LIV EMERGENCY DEPARTMENT RM 04-A Site: Jugu~le_r,_L_e_fl ______ ~ 09/12/2017 00:49 Started fb )(6); (b)(7)(C) 09/1212017 03:04 Fluid: octreotide 25mcg Started ~(b)(5); (b)(l )(C) 120 Fluid: NSS 1000 25 09/12/2017 03:04 I 150 09112/2017 03:04 started by:l(b)(6); (b)(7)(C) 09/1412017 04:01 NOTE: All striileoutf. were executed by person making original entry. 2020-ICLl-00006 4447 Page 1 of 1 Fax Server 9/18/2017 8:35:47 AM PAGE 36/045 Fax Server MMC LIVINGSTON Dally Focus A&&esi;.ment Report 09/1112017 21:02 Patient Name: ALM.AZON RUlZ, FELIPE Visit ID: 03002679411 MR Number; Through 09/14/2111704:01 0010282353 ..._ DOB: 08/26/1966 I _______ Attending: ---II l(b)(6); (b)(?)(C) Admitted: 09/11(2017 21 :02 .,_ ___________________ I _, Assessmmt Date Entry Dele Actions Ent&Nd By: l(b)(6); (b)(?)(C) Pl Location: 09/12/2017 00:47 LIV EMERGENCY DEPARTMENT RM-M-A Critical Value - Name: Plstlets Critical Value - Result 1B000 09/1212017 00:47 09/1212017 00:-47 Critical Value - Date/Time Received: 09/12/2017 00:48 09/12/2017 00:47 CriticalValue - Name of MD Nolllled: Critical Value - Date/Time MD Notified: Critic.al Vall.It! - Commel"lts/Orders l(b)(6); (b)(?)(C) 09/12/2017 00:47 0!l/12/2017 00:48 09/1212017 00:47 No new orders 09/12/2017 00:4 7 Pl Visually Checked 09/1212017 00147 Received: Rounding Action No change from previous assessment by this cllnlclan A&tiessmentDalo Entry Date ED Med Tlm~e~(~s)~--------~ l!ntered 8yl (b)(6); (b)(?)(C) Pt. Location: 09/12/2017 02:15 Pain As6&sGment LIV EMERGENCY DEPARTMENT RM-04-A Pain Location abd 09/1212017 03:02 Pain Scale 09/12/2[)17 02:15 Pain Score 5/10 Pain Goal acceptable pain reduction Name Of IV Push Med Givan octreotide 09/1212017 03:02 Dose 25mog 09/1212017 03:02 Time IV Push Med Given 09/12/2017 02:15 Re9ponse NoADR 09/12/2017 03:02 09/12/2017 03:02 Asseissml!flt Dale Entry Date Rounding EnteN!d ek~b-)(6-),- (b-)(-7-)(C - )----~ Pt. uic.atlon: 09/12/2017 02:33 Rounding Action LIV EMERGENCY DE.PAR.TMENT RM-04-A Will continue to monitor patient for complaints orohange& In status. Personal needs met 09/12120'7 02:33 Other 09/14/2017 04:01 NOTE: All strikeouts wore executed by p11rsonmaking ortglnal eiitry. 2020-ICLl-00006 4448 Page 1 of 3 Fax Server 9/18/2017 8:35:47 AM PAGE 37/045 Fax Server MMC LIVINGSTO~ Dally Foc:u&Aasessm.nt 09/11/2017 21:02 Through Patient Name: ALMAZON RUIZ, FELIPE Visit ID: 0300267!148 MR Number: Admitted; 09111/2017 21 :02 At1endin": l(b)(6); (b)(7)(C) '---------------------11 Report 09/14/2017 04:01 0010282353 '-----------~ I DOB: 06/26(1988 I Erttry Date Rounding E.ntaredBy: l(b)(6); (b)(7)(C) Pt. Location: 09112/2017 02;33 LIV EMERGENCY DEPARTMENT RM--04-A Group Note: As&i&ted to BR by guards with wheeh:hair. Dizzy when 11tanding.NSRon monitor Rounding Status No change from previous assassmentby this cWnician 09/1212D17 02:35 09/12/2017 02:33 ~t resting, no complaints voloed el this lime Pt. denies any complaints et lhrs time. Assesi;mant Date !:ntry Dal• Rounding Entered By: l(b)(6); (b)(7)(C) Pt. Location: 09/12/2017 02;35 LIV EMERGENCY DEPARTMENT RM-04·A Round:ng Action 09/12/2017 02:35 Group Note: IVattempted x3. EJ .__----:"." ___ _, Pt resting, no complaints voic1:1dat ttiis time Rouneling Slatus 09/12/2017 02:36 091121201702:35 Pl. denies any com plaints 111this time. A911es11mentDate Entry Date Rounding ~~-~-=------, Entered sj b)(6); (b)(7)(C) Pt. Location: 09/1212017 03;30 LIV EMERGENCY DEPARTMENT RM-04-A Rounding Action Rounding Status WIii continue to monitor patient for complaint& or changes in status. No change from previous assessment by this clinician 09/12/2017 06:18 09/12/2017 06:18 Pl resting, no complal nts voiced et this time Pl. danl&s any complaints at this lime. 09/14/2(117 04:01 NOTE: All &trllceouts were eKecut&d by person making orlglnal entry. 2020-ICLl-00006 4449 Paga 2 of3 Fax Server 9/18/2017 8:35:47 AM PAGE 38/045 Fax Server MMC LIVINGSTON Dally Focu& A&&assment Report 09/1112017 21:02 Patient Name: Al.MAZON RUIZ, FELIPE Visil ID: 030D267948 Admitte(j: 09/11/2017 21 :02 MR Number: Attending: Through 09/14/2017 04:01 D0102B2353 !f b)(6); (b)(?)(C) I DOB: As$e55m,nt Date Entry Date Rounding (b)(6); (b)(?)(C) Entered Sy: '-· 1 ________ Pt. Location; 09/1212017 06:57 08126/1918 _. LIV EMERGENCY DEPARTMENT RM-04-A Rounding Action Will continue to monitor patientfor complaints orchenges In status. 09112/20 17 05:5 7 Parsonalneeds met Rounding Status No change from previousasse&smentbythh; cllnlc!an Pt resting, no complaints voiced et this lime 09/1212017 05:57 Pt. denies. any complaints at this time. 09/141201704:01 NOTE: All strikeout& were el(ecuted by person making orlglnal entry. 2020-ICLl-00006 4450 Paga! of 3 Fax Server 9/18/2017 8:35:47 AM PAGE 39/045 Fax Server MMC LIVINGSTON Discharge AsSMsmant/Summary through 09/11/2017 21 :02 Patient Name: Report 09/14/2017 04:01 Al.MAZON RUIZ, FELIPE Visit ID: 0300267948 Discharged: 09/12/2017 07:00 DOB: 001 0282353 MR Number: Attending: l(b)(6 ); (b)(? )(C) I I Allergy ll111!11 Allergies No Known Allarglu 09/11/2017 b)(6); (b)(7)(C) Last Documenied by: Vlr.ls 06/28/1966 n 09/11/2017 21 :35 Entered By: Entry D11le Pt. Location: Temp 09111/2017 21:36 98.1 F Forehead v;tafs Entered By: N UNKNOWN_BED Pulse Rup 18 (b)(6); (b)(7)(C) Pt. Location: Temp 09112/2017 00:49 BP l 02% Ht Wt 99.0% 61.00 In 77.13 kgs I 09/11/2017 21:36 Entry Data LIV EMERGENCY DEPARTMENT RM-04-A Pulse Rasp BP 02 % 0911212017 04: 1D Ht WI 09/12/2017 02'.37 91 142/109 09/1212□ 17 05;5B Ami,UpperU As11eaamentO.te Transfer EntryD111te EntentG s)f b)(6); (b)(7)(C) Pt. Location: 09/1212017 06:45 LIV EMERGENCY DEPARTMENT RM-04-A Admit ta: ICU 09/1~.2017 06:55 Other 09112/2017 06:45 09/1212017 06:45 Group Nola: 17 Transported With: 09/12/2017 08:58 Oxygen 09/12/.2017 06:55 Cardiac I Apnea Monitor TR/DC with IV line iMact other 09/12/2017 06:45 09/ 1.2/201 7 06: 45 Group Note: Octreotlde infuain 09/1212017 Oti:56 Report Givan To Loretta Report Given On Current 09/1212017 06;55 IV Tllerapy Vital Signs Fall ? rer:autio ns 09/12/2017 06:45 09/12/2017 06:45 Tran:ifer tc Another Facility Yes Nolilied of Discharge/Transfer other Group Note: MTC guards MOT Ccmplelecj Receiving ?hysician Receiving Facility 09/14.12017 04:02 09/12/2017 Ofi:57 Yes l(b)(6); (b)(7)(C) 09/12/2017 06:55 Conroe Regional Page 1 of 1 Fax Server 9/18/2017 AM PAGE 8:35:47 40/045 Fax server MMC LIVINGSTON IV Site and Fluld Report 09/11/2017 21 :02 Through Patient Name: ALMAZON RUIZ, FELIPE Visit ID: 0300267948 MR Number: Admitted: 0!1/11/2017 21:02 Attend Ing: IV Site: 09/1412017 04:01 ""'""" l(b)(6); (b)(7)(C ) DOB: 16126/1966 I I Jugular, Left Started 09/12/2017 00:49 By gelb Pt Location: LIV EMERGENCY DEPARTMENT RM-04-A Type: Venous Entered Date: Catheter Sz: HI ga Position Modifier: Catheter Length: 09/1212017 00:49 Unsuecesstul Atten,pts: Lum11nsNo.: Note: (b)(6); (b)(?)(C ) l Added By: .....'.:IIl"lE'liIEl~:fil~. T~~-,..if..nMENT IV Sile Started By: IVS!te: l(b)(6); (b)(?)(C) Catheter RM-04-A n 09/1212017 oo:49 Juguls,r, Left IV Type: Fluid: 09/12/2017 00:49 Pt Location: Venous 18 ga Sz: NSS Entry For Date 09/1212017 03:04 By gelb Pt Loceflon: Fluld Startad By: LIV EMERGENCY DEPARTMENT RM--04-A f b)(6); (b)(?)(C) I Lumen Used: Rate: Starting Volume: Bag No.: 150 mVhr 1000 ml 5 L(b_)(_ _ ); _ (b_)(?_)(_C_) --.---JJ Added By: 09/12/2017 03:04 1\1Pump: Volume Infused: Bag Complet. Date: 'I Fluid: NSS Pt Location: LIV EMERGENCY DEPARTMENT RM-04-A IVSitl'l; Jugular, Lett 1...l (b.... )~0.,,. 6~.... ;~_b)_(?_)(C _l__ Rate: 150 mVhr IV Pump: y 03:04 n 09/12/2017 03:04 :)9/12/2017 03 :04 __,P" 09/1212017 03: 04 octreotlde 25mcg Entry For Date 09/12/2017 03:04 By gelb Pt Location: LIV EMERGENCY DEPARTMENT RM-04-A Flu Id S1at1edBy: l(b)(6); (b)(7)(C ) I Fluld Started Lllml!ln Us~d: Rate: Starting \lolurne: Bag No.: 09/14/2017 04:02 09/12/2017 E.ntryForDate: Fluid Started By: Starting Volume: Fluid: Fluid Started Date: Entered Date: 25 mc:g/hr 120ml NOTE: All strikeouts were axacu1ed by p■rson Oat■: 09/12/2017 03:04 Ent11rad D•te: 09/12/2017 03:04 IV Pump: Volume Infused: Beg Complete Date: y making original 2020-ICLl-00006 4452 entry. Pagl'l 1 of 2 Fax Server 9/18/2017 8:35:47 AM PAGE Fax Server 41/045 MMC LIVINGSTON JV Site and Fluld Report 09111/2D17 21:02 Patient Name: ALMAZON RUIZ, FELIPE Visit ID: 0300287948 Admitted: 09/11/2017 21 :02 Fluid: Through MR Number: ~_,Ao.ruA•~~l.5.3.----~ l(b}(6); (b)(7)(C) Attending: I I DOB: 06/2611966 octreotlde 25mcg Entry For Date 09/1212017 03:IM By gelb Pt Location: Fluid Started By: I IY EMERGENCY DEPABJMENT RM-04-A l(b)(6); (b)(7)(C) Lumen Used: Fluid Started Dote: 09/12/2017 03:04 Entered Date: 09/12/2017 03°04 ':I Rate: 25 mcg/hr IV Pump: Starting Voluma: 120 ml Voluma lnfuaed: Bag Complete Date: Bag No.: '--------------r rb )(6); (b)(7)(C) I I.....,o=-=9""11,....21""2=-=0"'1""7""'0"'"3:""'o.,..4-~ In0911212017 03:04 Added By: Entry For Date: Fluid: Pt Location: IV Sita: Fluid SlElrted By: Starting Valum&: 0911.4/2017 04~02 D9114/2017 04:01 oc::treotlde 25m cg LIV EMERGENCY DEPARTMENT RM--04-A n 09/12/2017 03:04 Rate: 25 mcgJhr IV Pump: y NOTE: All strikeouts ware axaculad by person making orlglnal entry. 2020-ICLl-00006 4453 Paga 2 of 2 Fax Server 9/18/2017 8:35:47 AM PAGE 42/045 Fax Server MMC LIVINGSTON IV Asaeument Report 09/11/2017 21 :02 Through 09{14/2017 04:01 Patient Name: ALMAZON RUIZ, FELIPE Visit ID: 0300267948 MR Number' Admitted: 09/11/2017 21 ;02 Attending: AliiHnm•nl IV Site: Jugular, Left Entered By. l(b)(6); (b)(?)(C) Date 0010282353 l)..;, Date Note: Dateslisted above must within one year of this transfer be Date in Cust ody : II. CURRENT MEDICAL PROBLEMS 300.02 GENERALIZEDAN XIETY DIS O RDER . 311 DEPRESSION, 571 .5 CIRRHOSIS OF LIVE R WITHOUT ALCOHOL Da tt Medicati o n Dosage Dir ect ion sN umb cr l0l 7-08-22 SERTRALINE R0,.100 MG TAB 100 Tak e t Tablet by mou th 1 time per day for 60 days 60 2017-08-22 T RAZODONE 50 MG TABLET SO 1 po q US 60 2017-08 -ll TRAZODO~E IICLSO MG 1/2 t11 b PO at bed,imc 1[ 60 day1 60 :2017-09-06 FOLI C ACrD 1 MG l 'ABLET l Take I Tablet by mouth l time per day Cot 90 days 9 0 2017.09-()(i OMEPRAZ-OLE 40 MG 1'akt I Capsule by mouth 1 time ptr da y for 90 dtly s 90 :2017-09-06 PREDN lSONE SOMG Take l Tablets by mouth 1 ti me pe r day for 3 d11ys 6 2017-0.?.06 SPIR ON'OLACTONE l!i MG TABLET 25 Take l Tablet by mouth :2times per day for 96 days 180 Addltlooai Comments: NKDA Ill. SPECIAL NEEDS AFFECTING TRANSPORATION Is prisoner able ta travel by airplane? y y Is prisoner medically able to stay o\ternight at another facilityen route to destination? y If not, W hy not? Is there any medical reason for restricting the length of time prisoner can be In travel status? N If yes, state reason: 0aes prisooer require any medical equipment while in Iransport stal us? N If yes, What equipment? Is prisoner medically able to travel by BUS; VAN or CAR? (b)(6); (b)(7)(C) If no, Why not? If no, Why not? Phone Number: 863-946-1600 Original - Upon Transfer Date Signe d : X2144 Form USM-553 (Est. 6/98) 2020-ICLl-00006 4458 II I. Master Problem List Medical Date of Occ:urrence 0 ~ ~ ,ir I Date Resoved lnit:~lr b)(6); b)(7)(C) / 00\l IA~\.Lo 1017 I Problem (Medical, Dental, Mental Health) Initials (b)(6); (b)(7)(C) C\ villl:'Ibf\- ) .....I ·- /h~f\ ........ _/ f'\o rrt'.,<., W r, a giIUJ q ~ 107 r, <"~hs1s I", f \\\ft t111 JJ\AlrN\i\ J ;.. ~I.,.,, I I ., f • ( I ....... - -~··-·-- -·--·-· ... --- ...... , .. Allergies: 028 866 428 ALMAZAN-RUIZ, FELIPE ADM 09/08/17 . . .. . ' . .......... ---·- .. - \.J¥,D\f, Medications: DOB 06/26/66 Revi=ed Sept 2016 / mb 2020-ICLl-00006 4459 II TREATMENT PLAN SPECIALNEEDS& RESTRICITONS Medical BUNK ASSIGNMENT: 0 No Restriction n Other housing needs _________________________________ _ Duration: ____________________ Expiration: _______________ Z RKl ROGRAM ASSIGNMENT: [! _ NO RESTRICTIONS OR □ Unassigned p-~~chiatry C No food service No reaching~:~~Y C No repetitive use of hands 0 Sedentary Work Only u □ Four hour work restriction :J No work in direct sunlight U Excuse from school thru _______ D Limited standing >______ _ No walking on wet or uneven surfaces :J No temperature extremes '.J No humidity extremes hrs D No walking> yds □ No exposure to environmental pollutants D No lifting > lbs □ No work with chemicals or irritants D No bending at the waist □ No work requiring safety boots D No squatting D No work around machines or moving parts D No climbing D No work exposure to loud noises D Limited sitting □ OR DISCIPLINARYPROCESS: n Consult repr No work requiring complex instructions entative of medical department before taking disciplinary action NEEDS: C On Dialysis C Adolescent in Adult facility , • Infected with serious communicable disease - Precautions required: _____________ _ :J Physically Disabled :J Frail or elderly ::::J Pregnant '.J Terminally ill □ Mentally ill or suicidal □ Developmentally disabled D Suspected victim of physical or sexual abuse -------< (b)(6); (b)(7)(C) ::11s -- ~:7 Date:_..___ -_---------. . ___ _ 'DOa\1l1 d2J3o l[V~ nme 028 866 428 ALMAZAN-RUIZ, FELIPE ADM 09/08/17 DOB 06/26/66 2020-ICLl-00006 4460 Reviewed May 201 7 / rnb 1111 Medical INTAKE SCREEN Translator available □ Yes Date/Time of Arrival at the facility:_. In the last 21 days what countries Have you been in contact have ou isited outside of the U.S,? -"--~~'-"--'-✓- / with anyone who traveled from these countries in the last 21-days and who is sick? Yes__ In the last 21-days have you been in close contact with anyone who has been diagnosed with an ir.fectious disease? Ye>_ NZ NoZ If yes please e,rplain: Do yo ave any current medical, mental health or dental problems that need attention now? NONE __ YES- explain: include any special health or dietary needs: *** Note Detainee should be Instructed on sick call processfor any non-urgent healthcare eeds. Do you have a family history of any Medical conditions? Yes o 6 a 10 Location .--'\-6.JJ..!...-'i.~~~6..l..i..~~~"---..1---~ uration ___ Do you ave any physical injuries, open wounds, cuts bruises or signs of trauma/violence? NONE NOTED/DENIES -~ YES (de5cribe) ____________________ . Do you have a past history cf seriousinfectiousor communicable illness (to includeTB)? (include ar.ytreatment __ YES or previous symptoms) Do yo, h,ve •nv meat oomm,a;cable maess symptoms, k lfye;, iadicate, :1 Chronic Fatigue □ Weight Loss/ Loss of Appetite :::i Night Sweats □ Bloody Sputum - •"'*If yes, cont.ct _ tile medTcaI pro11iderto determine lf the plltient requiresP. □ Frequent Productive *** □ Fever If Diabetic - Blood Sugar____ (\ YES !1.:tfil.,Note Diagnosis below NO HTN r: Weakness eme.nt in Respiratory isolation (Neg;,tiveAir Flow Fioom) until testing is completed ,rnd the patient ls cleared to be pla :ed in t~e general Do you have any Chronic Diagnosis? __ Cough DM SZR RESP H fer to Chronic Clinic\..:_.).\,-~" e · MENTALHEALTHDX:~~'H-l'--l-.."'-"':_: __ GS = ... =.·=YES~----~-~A ... C>--.·_-""_ .. Do you have a history of PhysicalIllness,Surgeriesor Dental Problems? , ~--·---..-~"""'--'.1-tMr-- (include past hospitalizations, surgeries and treatments) · / Do you identify yourself as a Transgender?-~_Nno ____ .,.YES (lf so, document history of trans ition- elated care and notify security supervisor) Are you currently taking a and/or herbal? Yes medications, Induding over the counter No /fyey V_ Current Medication listed on transfer paperwork - See Orders DON Time 028 866 428 ALMAZAN~RUIZ,FELIPE ADM 09/08/17 DOB06/26/66 2020-ICLl-00006 4461 Revised May 20:7 / mb i . .INTAKE SCREEN- Mental Health {Page 2 of 3) .Do you have a current or past history of Mental Illness or disabilities? Treatment: INPT Diagnosi ~:::t::A~<\--1~~~~~~-~..---,-:J.l~~~!C!~..::___--\------- Do you have current, recent or past history of Physical, Emotio ff yes • Perpetrator When _______ Have you been sexually assaulted prior to arrival at this facility? ~NO ~----------------------1 __ ~.,.L__~ _____ notified lmmediately ______ uSeCl.lrity Supervisor Victim or YES tfyes: Name _________ Date/nme ~-~Y~-n~e:i:~1#rify~~,~~rii~~k'.~~6~:s·~:·?~-~i61~-n~~-i _-7 ·~b-· · -··_·'f~s--· - -··-··· . •. , . h1Jui{ot'~oner if ap~ropr1ate ~i_ii.n Do you use Tobacco? __ YES If yes: Type: Cigarettes =::::::::: Haw Oft~e~? ....-----=..-------i ~ If yes: ~ llfeg ~ How Much? Do you have a history of Alcohol or Substance Abuse? \ . I -..P.~ Method: \\ IV Smoke \\ How Often?_______ _ S11orting Other Ingest When? Lastdrug(s) used? (if a female patient reports curre:,t Opiate use, make sure she was offered the pregnancy test. If positive she must be referred to the provider to avoid opiate withdrawal risk to the fetus) '. '(~~~'l)J'-"cs~~ ~ '. :"\ Cocaine Meth Heroin Inhalants LSD Opiate Other ty\\)~ How Much? ~ \ 0~~ \.\, 1[,~ ...... ~ -~~(L;'( NO Ty~ijuana o5Z:Y \O....~~ Oral Pipe Current or past illnesses & health problems r/t substance abuse: □ Hepatitis 't"' □ Seizures 1:; Trauma □ Liver Disease Do you get sick wher> you qu'rt usirlgthose drugs? ____ NO __ □ Infections YES (Le.: convul~Tons) If yes, what happens?______________________ Any history of substance abuse hospitalization ___ _ NO ___ YES If yes, when and for? _______________________ Any history of _ detoxification and outpatient treatment? __ NO __ YES If yes, when and for? _____________________ Do you have any withdrawal symptoms? __ NO ~s Symptoms:_'o~~~~~'~~~~.,,__ ·Have you ever thought about killingyourself? _ /_N NOO __ If yes, when and why? _____ iHave you ever tried to harm yourself? ~o Do you want to harm yourself now? Do you want to harm someone else? YES _________ _ --J --,,.~---------------------..~~~-------i ···- __YES If yes, when, how and why?--l'e..:Q.&J==•...,,\-=\l...,,,_""'-'~~----- 0o __ __/_ ~ NNIO __ YES If yes, do you have a plan? YES If yes to what degree - explain?______________ _ Time 028 866 428 ALMAZAN-RUIZ, FELIPE ADM 09/08/17 DOB 06/26/66 2020-ICLl-00006 4462 Rt!vised May 2017 / mo ■ INTAKESCREEN Medical (Page 3 of 3) OBSERVATIONS Is this person unconscious, semiconscious, bleeding, mentally unstable, severely intoxicated, in alcohol or~ withdrawal or disoriented to person/place/time or otherwise urgently in need of medical attention? G-N6" u YES If yes, immediately refer to medical persormel for further evaluation & care. IS T~ATIENT DISPLAYING ANY SYMPTOMS or UNUSUAL BEHAVIOR? c YES ~ rt"¢pearance - appropriate o Weakness o Seeing visions 121""' ~ropriate behavior □ o tTN/4al ~lert gait responsive :.i Yellowing of skin or eyes/jaundice o Hyperventilation o Disheveled o Rashes o Infestations (lice/crabs) o Persistent cough o Hearing voices o Evidence of self mutilatio n o Body deformities o Bizarre/ insensible o Alcohol or drug withdrawal □ o Loud / obnoxious c, Communication difficulties Slurred Speech Abnormal gait o Tremors u Lethargy n NeedlF. Marks Unusual su5pidou,ness u Disorderly u Other physical abnormalities n Sweating n Assaultive or violent behavior o other: __________________ _ ls his~? o Crying/Tearful o Incoherent c.YWNL/ Cooperative □ □ o 1~ted Any body piercings _/__ ;; N~O--__ Recent Tattoo(s) o Embarrassed Confused □ Uncooperative o Passive o Scared Depressed o Anxious YES DISPOSITION Population with NO Immediate Health ServicesReferral r:::i ~ral ~;.n;;al Population with Immediate Health Servkes Referral to ¼).t::':\'°"'!1Lf=~zf~~~~~u~~~~~\-~:::'.:.l..L..:L!~~.2..Jh::, :J Transfer to Hospital for Emergency Treatment LJ Constant Suicide Watch - provider contacted for order □ D Single Cell Housing Medical Observation / Isolation If a female patient and pregnancy test is positive, refer to provider to avoid opiate withdrawal risks to fetus ,., ..- . · .. --··. -~- ··-· - .. -· .... -. :O .tf viol~nce, M~ta! Health referra!madewithin 72 hours: □ ars0°~r~~:y~tc1JJqrr1esti~al;l~_se or P/PA . □ macy / Order Meds Request Records/ Call MD D Dental Clinic ~~a;1~~-f$:p_~~k;i~s pan ish / other:_·.-,-,-~-----,-,.......,.· -:_T~:_1~"-'::~...:r.:...~~_r_:S_p.....;·~_aks_· .... : ...___o:::.....;_..;../-_S-parii~h-/~ther::_·· .._··_.·. _·_··_·_·_·__ ••:__.-_~:_:.,.._~c ·-,·.Lan_~~-~ ~e~_:_-· _.... __ ------- -=--=··'""'· -=--""'· _,.,..._'"'""=,,,.,,,.,.,..,,.,.,..,,.,,,....,,,...,,,.......,..,,-,--.....,.........,....,..,.,,....,,..,.,,..,.-,--.... b)(6); (b)(?)(C) C\\~:) Date P~tip,-.-4- t,.1- •.. ....,-,..,..·-_· ,.._.--,---_·. .......... ----'--'----.....;.;.;..-__ Time - 028 866428 i: ALMAZAN-RUIZ, FELIPE ADM 09/08/17 DOB 06/26/66 2020 -ICLl -00006 4463 Revised M2y 2.01.7/ mb I Medical FORMA DE CONSENTIMIENTOMEDICO · PRO(iRAMADE CUI DADODE SALUD FORMADECDNSENTIMIENTO MEDICO El pro;i6sito de la clfnica es provcer a listed ,3tnecl6n me::!ica. Los inforrnes medicos que te obtengan seran niatenidos er. us expedientP. medico, confidem:ial. Se espen; usted que se someta a un examen medico para determinar su estado de salud al presente. Yo, par la presente c□nsient□ o aut□riio a una evaluaci6n o examen medico pa,a determinar mi estacio salud presente. ':"ambien corislento a cualquier otra evaluaci6n o procedimiento medico, cuidado rutiniariio, y tratamiento medico o dental o salud mental que el pl"rsonal medico de la clinica considere necesario, aconsejable o apropiacio. Yo .utorlz.o la divulgaci6n de mi historial medico a cualquier hospi~al er, case de que hospitalization sea necesari2 or recomendada. autoriza la divulgaci6n de mi informacl6n medica para el reporte a entidades federale~ y/o e5tales para la vigilancia y coritrol de enfermedades. Yo Esta forma se me has ex:i 1icado completa:nente y yo entiendo su contenido. Tambien entiendo que nose me han hecho garantia con respect□"' resuhado de tratamiemtos o examenes administrados en la clinica. He recibido instn,cciones sobre c6mo acceder a: • cuidado medico en esta unldad, dental y mental • el pmgrama de ,arifa-por-servicio :::i NA • el proceso de queja para las quejas relacionadas con la salud Pacientes se se.xofemenino: • Servicios di!' embarazo incluyendo pnuebas, nitina o atenci6n prenatal espedalizada, atencion en el posp,nto, Posparto seguimiento, servicios de l"ctancia y los servicio, de aborto como se indica • Asesor.miento y asii>tencia para las mujeres embarazadas de ac:uerdo con su expreso deseos en la planificacic\n de su embarazo, si desean aborto, servicios adoptivos o para mantener al nifio • Rutina, apropiados para la edad, ginecol6gica servicios de ateru.:i6n medica, incluyendo otretlendo cuidados preventives es;:ieclficos de las mujeres Solamente medicamentos basicos seran proveloos de a:::uerdo a los protocolos medicos. El Paciente podra obtener medi::amento y sern responsable para tomarse las pastllla.i cie acuerdc a las instrucciones para tomarse como en la vida libre. Este privileglo siars d.ido solamente a los Paciente que sean capaces y responsables. ElDetenido tiene q ue: 1. Tomar e, medlcamento como e~ sen,dado y no deben abandonar dosis ni tampocotomar dosis dob!es. 2. Cuidarel medicamento, nose d!"be vender, nose debe cambiar, no descuidar el rnedicamento para que sea extravlado o robado. 3. No acumular medicament□ en ei dormitorio. 4. Ser cumplido todo el tiempo. ·~a1 Date (b)(6); (b)(7)(C) Time 1 ~lla-01 Time 028 866 428 ALMAZAN-RUIZ, FELIPE ADM 09/08/17 Spanish Consen, Form DOB 06/26/66 July 2014 / mb 2020-ICLl-00006 4464 acidyour facility name t,,,n, Intake Screening and Testing Provid~rSpe~~~~/Spanisb/Other:._· ' - __.. :_~:;:_·__ - P~tientSpe~anish/Other._- !nterpre!er?, ~- Y N - ~a~e: □ TB - CLEAR D - - .-· · ------,----.------ ·_t?ngliage:_· ____________ __,_ __ AT PREVIOUSFACILITY- via (must have documentation of Negative PPD on file) Negative PPO- date completed ______ OR 0 TB - CLEARANCEREQUIREDAT THIS FACILITY D CXR required and scheduled (b)(6); (b)(7)(C ) Time Expiration-Date of Vaccine-::·._· Administered by (signature) ________________________ Date PPD Read __________ _ Results.____ mm lnduration Results Read by (signature) _________________________ _ Female Patients: Have you recently been Pregnant ___ Yes __ NO ( if yes, when): _______ Is there a possibility that you are currently pregnant? ___ Yes _ No --- * If pregnant PPD planted and read* Urine Pregnancy Test ___ Date Negative ___ Positive _____ Time Medical Staff Signature r 1 028 866 428 ALMAZAN-RUIZ, FELIPE ADM 09/08/17 DOB 06/26/66 Initials Date Allergies:~ Time '(.'{j~ 2020-ICLl-00006 4465 Rev1secMay2017/mb .• ·.. ; Facility: ALMAZAN -RUIZ,FELIPE ADM 09/08/17 DOB06/26/6G Patient Nar,.____ Time Da e Telephone Orders M e d ic al 028 866 428 _ _ __ __ Patient# ____ _ __ _ Signature Order: -- r-.11t-Of:011f di/ 111Pllirah~ns 1P\' 11< t>d.~d K~·ti - ~ ht! /Jr(.::>c)K\.okJ Neck Throat [! f C'\\ ({_I)/h--.;, ., 7:)O ~ \3:: CL:,;_V, Cv, cJ I' Abdomen Additional Findings REVIEWOF CURRENTMEDICATIONSc ___ _ -=-------,~f--'--r-f-' VPc / ASSESSM ENT(DIAGNOSIS) :_----1r-t-L -+-sf:i1-~t--?r~/Jfj---------,----------i=-:-_LL-+-· ~---..-.c---- ~ (.f) tJJf'cx "o5r iX PLAN:. _________________________________________ FOLLOW-UP: D PRN r:i 30 day r::90 days n 60 Oays _ □ Referral □ Other Medication (s) Order : Lab/Radiology Order: Other orders: Time Frame for any re uested consults EDUCATION: □ Diet o Signs ;i □ Patient u within 2 weeks o within 30 da s other: u Risk Factors and Reducers (b)(6); (b)(7)(C) enefits, and alternatives and agrees to the plan Provider Signature/ Title: ~l :::i Date/Time: t--- lnterpreter\jl N Name: Prov0id2e8r S8p6ea6ks4: ~_L__spanis.....,_ __ ~ ALMAZAN-RUIZ,FELIPE DOB 06/26/66 r ADM 09/08/17 ,____ c7 /( / Language: ~ /J·J/·?.Q ~~'°' J / ===--=:=--::::::·---:a:::-:::::..-:=·~~===:z:::.'.:'.a'.::ks:.:._: ....::E:.:_:n~gl~is.:.:_h !_/.:'.!S ~';;J;...!..../~O~th..'..'.e::...r·:::· ============; Allergies: ~~',\-RevisedJuly 2017 / mb II Emergency/ Injury Assessment Medical Date/Time injury: --'+;......;+-~-----1 Date/Time reported: ---=-~__,____,_\t\....:.....t,,,_ Subjective: n~ ..1...V\,!..:~ • Activity at onset:_u,,411..~~~~.1'_('\~~~b~-~ed_~_==_~_:... ___ J._tJ._'...!~c...~~:::l"S!!.ll.4~ U lnterpreter(:9 N (State wh;it occurred, who/ what/ where/ how) ca½\d::ta::tM1 !<-c,io be1A1JS0 o\tto1rLQ.t ~ r~~ "~n~'doo&. Pain Scale: (0-10) __ Objective: Date '1l.tt\n Time Temp Pulse t,\15 toll l~D Resp w BP ~r~ Sa02 BG q_;;... ___ _ Narrative fOO'f. \'\1~-V\0l HVt. ?'l -c1ti ,L\'MY) f-\-umtrr!h olrt:_af¾- nvrlot1A:tt q~r; nu---c~W 6k-' "'l-l- .r) Y\' ~( ,~ --,. V1.•'"!!!,,. 117_.r n /\ . -. ,~ AssessmentDecision:· . ~urth,i;r D No Further CJre Needed D Other _____________ Care-RequirE!d _ _ Plan: u Cleared lo Return to Current Hci.;sing in Facility per Provider:______________ Date/Time________ > ::mer~ePcy/ Injury 1\sses~mert, Treatment 2020-ICLl-00006 4469 1111 Timeline / Checklist - Depart from the Facility Medicai Departing Facility Via: Transport via VAN: Date .. Time q\\\\t1 ~~i Comments b )(6); b)(7)(C) (b)(6); (b)(7)(C) notified of need to transport via VANto Security SLpervisor ~AR o Progress notes f11-tL S\-,LU.~';) 9'1"at1ent left via van with security escort " Transport via EMS: Date Time Initials Comments 911 / EMSActivated Security Supervisor o MAR Returning to Facility: Vital Signs: Temp Pain Scale: (0-10) Date Time □ notif;ed of need to Progress notes Date/Time EMS arrived at facility c Returned frcm ER ____ Pulse ___ Initials Comments ~dm Resp --- tra11s~artv·,a ~MS to B/P itted to Hospital and returned ______ Sa02 (roomair) ____ _ Patient returned to the facility Hospital Records and Orders Received forwarded to medical provider for review o Continue previous orders 0 □ New orders from provider noted New medication(s) entered into pharmacy system Assessment/ Notes: _____________________________________ _ Telephone Order: 5 (b)( ); (b)(?)(C) lrder per Provider Medical Staff Signature Date/ Time 028 866 428 ALMAZAN-RUIZ, FELIPE ADM 09/08/17 Date/Time DOB 06/lG/GG Allergies: Y\V-,,OA- Medications: ~ VY\~ RevisedMay201S / mb Emerge1cy Tlmeliie/Checkiist 2020-ICLl-00006 4470 1111 Emergency Treatment Order Medical an Per Provider Trans ~ Date/Time -------1 Receiving staff member - Signature 1--- __ . C\ Date/Tlme_, ________ ........,.._~-- (b}(6); (b}(7)(C) N.ime Printed ~ l'\ I 1-----Title: k'V Y\ When the Patient is Released form the ER/Hospital, please do the following: /\DC F/\CII.ITY 5Pf'CIFIC INFO~MATION HcRr If you should have any questions regarding this Patient, please contact: HSA Name Phone# & Extension 028 866 428 ALMAZAN-RUIZ, FELIPE ADM 09/08/17 DOB 06/26/66 ~m ergency ·reatme ~t Order 2020-ICLl-00006 4471 \\ 1 ,zof 1111 M,2L1ical UM call prep Chronic Care: Yes/ No Last Visit ____ Riskfactors: \\•'\' Current Medications: ~ ,,, Compliant: Yes/ No CCDiagnosis (s)_______________ 'l',B ~' ~o..-~c.,..i;,,oe _ , ---------------------------------------- Tests prior to leaving (i.e. EKG- labs} Yes/ No If yes results ____________ _ Facility: Vitals ➔ Time-!, Temp Pulse Resp BP Sa02 Recent CC results - i.e. Ale - PT/INR I I I I Tests in the ERand results: ---------------------------------Medications received in the ER/Hosp.______________________________ Sa02 Return Vitals Notes _ Medication changes at Hosp: \ Temp ?a Pulse \\Sh,,c :be,,,e,>,~\:i~. Resp BP Sa02 -~ Seen upon return - Date Time By: ~I'.'\\\ c;\,\s ~~..Jc UM call May 201S / mb 2020-ICLl-00006 4472 T (b)(6); (b)(?)(C) (b)(6); (b)(?)(C) DETAINEENAME: XXXXXXXXXXXXXX ALIEN NUMBER: XXXXXXXXXXXXX DATE OF BIRTH: 06/26/1966 COUNTRYOF CITIZENSHIP:MEXICO DATEOF ARRIVAL:09/08/17 RELEVANTMEDICALHISTORY:Detainee with history of heavy alcohol use, last drank 3 months ago. Presented to medical reporting he was vomiting blood xS days, assessed by RN who noted blood in mouth. Reports history of this happening 7 years ago as well. Has history of cirrhosis of the liver with varices. DATEOF ADMISSION: 9/11/17 CURRENT DIAGNOSIS: G.,,.1B~Le-=E-=,ED=-=~-------. A TTE NDING PHYSICIAN:l(b)(5 ); (b)(?)(C) I CURRENTSTATUS:PT STABLEAT THISTIME. MOST RECENTVITALSB/P-99/58, P-75, R-17, 02-97% REMAINS AFEBILE.2UNITS OF PLATELETS GIVEN DUE TO CRITICALPLATELETLEVELOF 27. POSTTRANSFUSIONLEVELIS 55. All OTHERLABSREMAIN WITHIN NORMAL LIMITS. DETAINEESCHEDULEDTO HAVE EGOIN THE MORNING. DETAINEEWAS PREVIOUSLY RECEIVINGCARDENEDRIPVIA EXTERNALJUGULARLINE, HAS BEENSTOPPEDNOW RECEIVINGLISINOPRIL PO. DISCHARGEPLAN: NONE AT THISTIME REPORTGIVEN B b)(6); (b)(?)(C) CONROEREGIONALHOSPITAL 936) S39-1111r )(6); (b)(?)(C) AH-SADF-POLK _ivingston, Tx 77351 936-96. (b)(6); (b)(?)(C) m 936-96 - - ax 11.1,c,c cal 3 2020-ICLl-00006 4473 Heather Levins From: Sent: To: Cc: ~b)(6); (b)(?)(C) 1 Wednesday, September 13, 2017 5:35 PM RE: HOSPITALDAILY REPORT Subject: Hospital Daily Report Hospital day #J_ Detainee Name: Felipe Almazan Ruiz Alien#: A028866428 Date of Birth: 06-26-1966 Country of Citizenship: Mexico Date of Arrival: 09-08-2017 Relevant Medical History: Cirrhosis of the Liver Date of Admission: 09-12-2017 (correct date of admission) Current Diagnosis: Up er GI Bleed Attending physician: b)(6); (b)(?)(C) ~ii~iir, Current Status; (NOTE: me u e 1ta s, e s, Labs, etc.) report received fro at 1200 A+O x 4 BP 117 /58, P88, R19, T98.3, 100% on RA Afebrile, received 2 units of platelets hemoglobin is 11.2, platelets 27'"L Discharge Plan: NO DISCHARGE PLAN AT THIS TIME. PLEASECONTACTA-1EDICAL FORANY FURTHER INQUllllES. DWOODS-LVN From:jtb )(6); (b)(?)(C) Sent: Wcdnesdav Seotember 13, 2017 7:44 AM b)(6); (b)(?)(C) Subject: RE: HOSPITALDAILY REPORT I should also mention that you do need to have the detainee full name and A#. I always have to remove it when I am communicating out of the ICE network (to your emails) or encrypt the emails to protect PII per policy. You all however when you send me this information are sending it to an ICE email (in network). Very Respectfully, CDR ~b)(B); (b)(?)(C) c IBS:\1",CCNM Houston Field Medical Coordinator IC[ 1Iea~th Service C~rps / (b)(B); (b)(?)(C) 16038 V1ckery Dr, Suite 20 Houston, TX 77032 .______ __J 1 2020-ICLl-00006 4474 (b)(6); (b)(7)(C) l(b)(6); (b)(7)(C) From: Thursday, September 14, 2017 6:31 PM Sent: I !(b)(6); (b)(7)(C) To: !(b)(6); (bl(7)(S) Cc: Subject: Detainee Felipe Almazan Ruiz Hospital Daily Report Hospital day# Detainee Narne: (bl( 5l; (b)(?)(C) Alien #: A0288f-.mr-no:---------' Date of Birth: 06-26-1966 Country of Citizenship·. Mexico Date of Arrival: 09-08-2017 Relevant Medical History: Cirrhosis of the Liver Date of Admission: 09-12-2017 (correct date of admission) Current Diagnosis: u er GI Bleed Attending physician b)(5); (b)(?)(C) b)(6); (b)(7)(C) Current Status: (NOTE: include Vitals, Meds, Labs, etc.) report received fro ~-----' A+O x 4 BP 125/73, P 79, R 18, T 98.7, 99% on RA Afebrile, Continues to be on Lisinopril PO. Pain 8/10, reporting severe GERO. Discharge Plan: NO DISCHARGEPLAN AT THIS TIME. Than!lCAL/SURGICAL 1•11ur-......,. ............... ________ ---.J ro ·r.\L NO . ()II !'.\011'.i, INCLUOINCl C0V~I\, ; (936). 539•. (b){6) /bl/7)(C (936) 788-8037 PA-XtE.NTINFORMATION •PLE ASE KEEP CONFI DEN'TL\L,. ' faxand 1n1 files trartsmittd with it mrJ.yco nbln PRIVILEGED or CONrtDEN1'L\L · focm:uionand m:iy be rc:i. d or used only by the itltcnded ccd p icnt. I! you at e noc the in 11ded,ecipient of this f:i: CL I 95-105 11HO 1/L ! 09)14/17-0541 I I :> :t CO2 ,l 'I :> AHIO 6AP 25 I 21-32 111101/L 09/14/17-0541 4.0-15,0 GRPcalc I 09/14/17-0541 7,0 2020-ICLl-00006 4482 ' ,. I.', I, ~: ::v· :n:, ·.1. 111-----+------------------------------""S:1 Spe iNen Inquiry Report ~* CONFIDENTIAL k,l;,- 11ed.Oi rec tor: ! >< >;(bl<> _ A[CH ~..... (b_)(l_)(E_ ) __ PATIEHT: RUIZ,FELIPE FD: OD:ABBAL RESOR (b)(5); (b)(l)(C) ::"' Conroe~eoinnal MedicalCerer, ConroeTX 5 7 ANSNA Id CAPIZ11!30-01 'ffl f ':w,:' UI: BH00861890: •',i:· _____.I LOC: 8, HEOU AGE)S~:51/N ROOM: B. 141 STRTus:·AoM IH BEO:u REG:09/12/17 DIS: ·)u. I-:-.-;• ;~: .·➔; Coll: : 0~14:CR: B0871R COMPJ Test 09/14/17-0◄50 flee~: 09/11/17-0503 CRff0767◄936) .Result Flag SHe Reference i-l_ !,J.. ·:.:.._,; Uerlfled 'I : ! l> i tee UBC J ,J,· I I ' !> ' L 4 . I - 12. I k/ 11t13 09/14/17-0542 L I 3.8-5.5 M/nnJ RBC I O'.:J/14/17-0542 i I !> I HGB L I 10.6-15.8 6/0L I : HCT 25.5 ) ttCU 93 .1 L I I. 36.0-47.4 "/. SIi. 1-101, I fl I 09/14/17-0542 I 09/ 14/17-0542 -··~···-·•-.......- 2020-ICLl-00006 4483 •: ' i :: '. '• ' ' 09/ 14/ 17-0542 i> :·;~:; ::;;: ! : 1,:;~ i ::·' : : j : ' ',·; ' . ' Sp ciMen Inquiry Repart ~ ~ ConroeRe ional Mec:lical Center.. ConroeTX CONFfDENTIAL *~~ Med,Df rector: (b)(5 >; (bl(7 )(C) CAPlt21190-0 l ~ILOC: B.NEDU ' !PATIENTRUIZ,FELIPE r ' I FD: ! RESllR: ACCTlt:.... l(b-)(l-)(E_ >__ ABBAL I (b)(6); (b)(7)(C) ! ANSNR RGE/SX: 51/N STATUS: Aon·IH ROON: 8,141 BED:u if IJIS: :➔, ._.··, 0914:CRC600013R COHP1Coll: 09/14/17-0450 Heed: 09/14/17-0503 CRI07674936) ~~~~ Test Result i'f, Reference Flag :,~; Site ,- ... ....... Uerlflect > > PT PT ATJENT :.'...... · !l. I 1I .3 IttR H I 9.4-12.5 SECONDS 09/14/17-0538 H I 0.85-1 .11 INR Unit 09/14/17-0538 ----------------------------------------------------------Therapeuticrange for IHRls dependent upon the situation. I 2.B-3.0 Proph~Iaxls/ venous throttbOeHbolisNJ TreatHent af OUT,Acute Myocardial infarction stroke preuention, SysteHic eMbolisNpreuentlon In fibrillation 3.0-4.5 AH[recurrence preventlon1 SysteNlc enbulisM 'I 2020-ICLl-00006 4484 q ( · )f t±r1 drH: dC t 1 ! ••... ·, I •• ,,, '. I 11 ' L' ' Patient Information Form I Phone: !{936~ 539-111 1 HosptlalName: Jconroe Regional Medical Center HospitalAddress:lso4MEDICAL CE::'.'ITERBL VD co:KROE, TX 77304 ~----------------~--------------------------------- PatientDemO{lraphlcs ...,,Ad.,.,_m....,l"'"'t a=n....,d'--"Len=gt..,hc,...=,d_.S1ay=._,l"""nforma'-"'-'--:'~tl"';on;:.... ____ ____,: PatientName:!RUIZ,FELIPE l .....----Unit: CR MedloalRae #::=ju;::-2=92=4=53=1=6 ===;::::;]-;SSN;;;;;::;::-;;~=ss=-s=s=-j=ss:::::s===;I Admlt'fypa:!ELECTIVE Roorn=:-PB=_rc=u=4====4i Marttalstatus:!Single : Gander:jM Adml&Blon Date:[09.12-2c17 jBed:n.1crns Dateof Birth:,..::lo6=-2==6-=19=6=6AQe: js....:1 .... Eel OlsohargeDate:!09-14-20171 AlC ';.;;Oa.:::-:te.:-:.,: ====::::I! -·-1 I ======~ ==::;1 Rellgk>n:~:-io'1E Eplsode11¥ (b)(7)(E) 1' PL Functlonal status r,::--:-:- Prtor : Halght:j 1BedOnly PCP: (b)(6); (b)(7)(C) AttendingPhy&lolan:><5>; (b)(?)(C) weight:[ - PhoneNumber: ~----y-------ii Dlag0911s lgfao!11Uon: Rugs:L..__:_:_,]Pr1mary:,..ju-P-PE-,R-G-,I-B_L_EE-,D------.! Secondary:....._ ___________ · ModectTransportatlon:..._I ____________ WIii 1908lveradiationor dlalyslaoff-site? 0Yespatient O No .] _ Peyer Sou roe:_ ""·--:----=======··=-=·--·Schedulerl TreatmBl'lta: ,,_,,________ -'! Emergency eom1,,ct: Llvi1gArrangement. ________ FirstNama/M;..:.:;.:Jl:fipw=F.Fi=:1=,1::•:P:;;:-:J:'i.=-=:===:::=: ~Jl1 First Nam&IM,----1:/:JJJ; L=====-"''"=:J~ -~ ...... se'"""-le ..... ct ...... O'"'""ne-.LastNameqRl:1Z LastName: FacllllyName: stNet: r_:-:-:---7 S1reet.----1 , l}LOCTh! 350 SOUTH I . ____i ~--========! City:LIVINGSTON City: Natt rl Kin Patla1tAddrass 1 Straat:3400 FM 350 SOUTII ciw:LIVINGSTON - ?};--_=====:Q 35_1 i Stats/Zip:TX HomePhone:[2.'.?.6-967-8000 Work.Phone:999-999-9999 ~--,;;;;=======~ statalZlp:TX 77 351 HomaPhona:19 36-967-xooo Work.Phone: Ralatk>n: 01 0Emerg.Contact Siate/Zlp: ] HomePhon....._e-;::: WorkPhone: Ralatlon:.--~=======ll ======~ ,-=======:::::=::a POA □Emerg.Contact □POA J Payer lnformatlgni Ins.Group ID#:L________ Prtma,yPa)'er:!oVERRIDE wrn-I PAYOR KAME Memberg;;;:;a;;a lY (b)(6); (b)(7)(C) Cou::1ty: Country: Zip Cocie: United Sta:es - IN?A':'IEN':'{Inpati.ent) SCUTH Sex: s;~ot: ?1 S:.ngle TX of Arr.e 77351 Home l?hor.e: Work Phor,e: Emer I 6/26/1%6 MR'li: BH0086H9C F~c: Conroe Rcqio M'a.clo1l LIVINGS':'ON DOS: D2.te: Enc Type: 340C IQ - RUIZ 1 FELIPE - "~-, A::.:com.'l'toda ti on : Home Adcir: PATTENT Ccnroe. Name: 8:20AM CR-3 IN':'ENSIVE C B. :CUl8-1, 1 Room: Report ENC~~TNTER/ IICM DATA---------------------------===-=--=•••• =... Location: PAGE l HCA CoYporate Certific&tion Insurance 93E, 9E,"/ 999· 999 SSK: Cor,~aL:t.s: Hone Tel: Mame: RUIZ,FELI?E Rela~~on~hip: current HCM DRG: Admit 93€-967 Work Tel: - SOGO Self ::oJr.plaint: UPFER Gl S':ay: 1 GLOS: outlier: BL£.ED HCM Di;..gnosis: HCM Procedure: Dx ca::eqc ry: Adrni t P.eview: ,.,'·',_."'""'"'==================== 'PAYF,R ( S) ================== =========================== OVF.R?.Ir>E WITH Auth PAYOR NA'MF. State;:,;: P Cert? PAYOR NAME Statt:.s: s No: NR/: OVERi<.IDE WITH Aut:h No: NP./-:- Insur Cert? ~o: 028866428 I!lsur No: 028866428 ====== LJ:\.ST COMPLrTED REVIEW Q}J::,y ~eview Date S/12/2017 Care Date 9/12/2Cl 7 Ca::egcry 0 l(b)(6); (b)(7)(C) T I::ttensity Severity Reviewer Review Ccrn."T\e::1ts: (b)(6); (b)(7)(C) ---9/:2/2017 1531 by.__ ______ ~ Point cf Ent.ry: per cpoe ddm.:. L :::.:1pt: paye"'-· over1·ide 1,,i th ::~anster trom L.::.vingsto~ P~ese~ting symplcms: Gi bleed, Failec OP treatment: Vita.:. signs: p 93, p94, 77, bp 181/1C7, 184/95 1 203/95, Medications/route: ~abs/Cul::ures: h/h ::.2/30.1 Irnag.::.ng: :Jiel/Acliv.::.ty: ox~rgen: ?'l/C':'/ST: 2020-ICLl-00006 4486 payror 211/1J4 N;,.mc Referral From: Conroe Regional Medical Center From: !(b)(6); (b)(7)(C) Phone: (936) 539-~ Fax: (936) 788-8076 Comment: To: Attention: IAH Immigration b)(6); (b)(7)(C) 028866428 ins# our fax 936 788 8076 tax id 621 801 361 npi 196?455816 The following documents are included in this fax: Name Pages Patient Information Form (rev.7/2012) 09-12-17 03:37 pm 1 Insurance Certification Report - IQ 2 Patient Health Information Legal Disclosure: This facsimile transmission contains coniidential information, some or al: of which may be protected health information as defined by HIPAA (the federal Health Insurance Portability & Accountability ACT) or persona: information protected by state data privacy or security laws. This transmission Is intended for the exclusive use of the individual or entity to wncm It is addressed and may contain information that is proprietary, priviieged, contidentiai and/or exempt !rom disclosure under applicable law. If you are not the imended recipient (or an employee or agent responsible lor delivering this facsimile transmission to the intended recipien1), you are hereby notified that any disciosure, dissemination, distribution or copying of this information i · o · 'led and may be subje . al restrictiqn□ t sanctjon If vou receivedthis in error, please notif b)(6 ); (b)(7 )(C) at phone (936) 539 )~~)~~i r e-mail al (b)(5 ); (b)(?)(C) 6 arrange the return or destruction of the information and~:-'~-:~• ~-:~,:'-)(.C_. ._) .cc....._____ ~~i° q ((//o 91 \t){clS1o 9/12/2017 03:33 PM HCA corporate C.ti('nt 51Y DOB: 6/26/1966 ~.,n~P.r Medic~] =======-==="-===============LAST COMPL~TED F.EV~EW ONLY (conti!lt.:.ed) ===='~--=-==================="'= T::-ciltmcnts: :evel of care 9/12 cvzJ/TP~P.rri'l1~: rr.l hr, bp 2lfl/ cc1rdene gt:t, , er to~t<.Jrrow, bp cont:.~nl 1 F-rl , 1300 Yili Treatmen~ to ICU dx G: bleed, lef~ stabli; i:;latellets 27, plar: C":?.. rdene g-:.t tur:neci. of.t lisir..cpril ..--- :dh with ns al .i.:J f,E· EGD po staled 1~0 tociay at Plan.~: Commer.t s/Othec ·..--··-· -----==========LAST : NT EP.QUAL RE VIEW ONLY =="' "'-"'"' "'===========•••=~•~~~~~; 0 InterQu~l ReviBw ~evie~ Product: crj~er:.a •· •· • I ~~fb)~);'(b )ffl< Cl ID Version: Interc;-ua.H:: 2 Cl"/. 1 date: 09-12 2011 Status: In Primary LOC:Acute Adult subset: Ger.eral MeQical Cri~er:.a (Syrr.ptorr. (ixcludes status: Critical or ::i:i.ding within PC ~edications Select Day, 0,-.e: Epi$ode Jay~, One: CRITICAL, >= 8ne: General, >= One: IV medicat.io:i M~t 24h) unle5s noted) administration, Both: Medica~ion, >= One: Antihypcrtcn::,ive Admi:-.istration, Titr~1tion Int.erO.ual(t Corporation CPT only;;;: COKflBl:!N':' .:.1u,- ccnta.in.s > q1-2h Or.e: a:--.ci:m,.,:,:i::odng CareEnhance•.ct• Review M,mager ;c:, 20] 7 McKes.~on and/or one o::. it ..5 ~t:bs-.d~a.riec1. All Rights Reserved. 2016 Americar. YlHiical A.~sociat:..cn. AL_ Rights Rese:::ved. and proprietary 2 - JQ i:--,f orrna tion. Not intended 2020-ICLl-00006 4488 to::: external di.stribu::..on. ::: ::; Referral From: Conroe Regional Medical Center l(b)(6); (b)(7)(C) From: (b)(6); (936 ) 53 /h\/ 7 \/r\ (936} 788-8076 Phone: Fax: Comment: To: Attention: IAH 0ENTENTION l(b)(6); (b)(7)(C) CENTER I NOTES AS REQUESTFD The following documents are included in this fax: Pages Name Insurance Certification Report - IQ 4 0913_ 12:23:13 1 0913_ 12:23:04 4 Patient Health Information Legal Disclosure: This facsimile transmission contains confidential informatio n , some or al: of which May be protected health information as defined by HIPAA (the federal Health Insurance Poriability & Accountablllty ACT) or personal intorrnation protected by state data privacy or security laws This transmission is intended for the exclusive use of the individua. or entity to whom it is addressed and may conta in information that is proprietary, privileged, conlidenfal and/or exempt from disclosure under applicable law, If you are not the intended rec pient (or an employee or agent responsible for delivering this facsimile transmission to the intended recipient), you are hereby notified hat any disclosure, dissemination, distribution or copying of this information i · and may be subject to le al restrictiof or sanction. If you received this in error, please notil (b)(5 ), (b)(?)(C) al phone (936) 53 (b)(6); re-mail at (b)(6 ), (b)(?)(C) Ito arrange the return or destruction of the inlormation and all copies 2020-ICLl-00006 4489 9/13/2017 11:4l AM In.suranc:?.X: M SnlJ'l'E S7:at:: LIVINGSTON, o: '."tates An·.e Eorr,c i'hone: Work ?hone: ~!Iler Single TX ccunty: Countrjr: Un1.t.,od :S:.p Cod<".: 7735·1 SSN: Cont;,ct:s: Home Te~: Name: RTTJi,~~tT?E Relatio~5hip: Sel: HCM DRG: Admit Ver: 872 Co~plaint: HCM D:..agnosi Curren-:: Stay: 34 Work ':'el: 936-967-8000 1 ALOS; 4.5 GLOS: 3.8 o·-1.tlier: UPPER G- BLEEJ s: HCM Prcced1,.;re: clx Category: Adrr.i t Review: ===:===-- ==== ===:· ; ===:= ====-=========::: OVERRI!:JEw:TH PAYm NAME .D,..uth No: Statu."l: #Days Type 'Ihru Compa:-iy: SubmiL by: Submit P Cert? :nsur No: 028866428 s~atus Auth No Cert - P NP./ I From Ref No S~rvice 'lime: Jate: to: Fax: Phone: Statt.:.s: OVERRIDE "\IHTH PAYCR NJ\ME Auth No: :-.R/ I ~ Cert? l~3ur No: 02EBE6428 ========="""""'"'=="'===================•"' CURRSNT REVIEW---------------------------------="'"'"'=--Re·.ri ew Date S/13/ 2017 Review Care D;it'" 9/,.3/.?017 Ca::egory Reviewer Int ens:::. ty Cnr:lll'.ents: ---9/13/201"1 Vital 36.E, ID l(b)(6); (b)(7)(C) Sever.:.ty Reviewer 113:::l s:..qns: 57, 109/66 6 / 7.6/1 :JE6 blKb)(6);(b)(?)(C) TC 89/S,, 94 % 2020-ICLl-00006 4490 11:41 I,1tiur<1ncr-- AM Cc>r-::i ficatior. Report - Selected Review PA~IENT INFORYIATION CCNF:DENT:AL Fnr Ac.:r.:l Nu_: Far.:ili ?AGE 2 HCA Corpo:::ate 9/l3/2'Jl"/ ty: Facility: I l(b)(?)( E) con.roe Co~roe Pat.:..ent FEg1 one.l Mec.ical Regional NaJr.e: ~edical - JQ ~An~~r Age: '.l.UIZ,FELlPE SlY D03: 6/26/ : 966 Ce:i.ler .. ····-·--------=~=----~-~---------~--- ...---·------====:===ac=-- CURREN'lREV l f;'tl Mf'rlic;,t'ions/Route: PO MF.:JS, PROTON:::X IV, :EVAl;UIN 1 V, l V TRANOA'fF, PRN, IV ZOFRAN PRU, IV :10:l.PHH'E PRN, -:.... J'' s ~ :::VY @ 75 :::v CA.-l.DEN~ CC/ER, Labs/c·.i.:. tu res: H1.H 8.4/23.e, PLT 35, I~aging/Other test~: C'l'T TITRJ\TFD P'f/ :NR 16.f'..;s_,:_r, RBC 2.60, Diet/A.c::tivit.y: CL DIET Oxygen: AS NEEDrD PT/OT/ST: Other treatment.,; 3LOOD PRODUCT Leve: cf CJI.Jrn:o, care GI, TR1'.NSFUSHJK"- PLATELE':'S eval/referral$: CRI~ CARE Barriers to :V PLJU :Jr.e: IV mcdic.ation adm.ini~trat;._on, Bo-::>-i.: Medication, >= one: c~,lcium channe1 b1oc:,er Amr.inis-:rat1 on , >= one: Titra-:io~ ql-2~ a~d monito=ing I 0 InterQual·~' ::orpc·raticn CPT only and careEnhance0 and/or one cf ·.s: 2016 Rev:..ew Manager its s·-lbsidiarie:s. ll.mer i c an Mec.ica.:. Association. :;, 2017 McKesso n All Rights Reserved. Al: Rights Rc~erv<"----< 102 133.0 24 4.2 Laboralor Tests 09 '2 1530 ·09/12 1530 emist.ry .. 09 12 1530 90.0 *I I Amm6nia (11.b ~-32.0 mcM K-2 (l.0-3.6N l 4.9 JroponinJ (0.000 - 0.045 NG ML). 0.270 *H, B~Natriurctic Pc ti e (0.00 - ~_00.00PC_1_M------'U_.__ __ __._2_2_6.:..::..S_9_1_1,___ __ -, B( 09/12 1155 --~~~i Page 2 of 4 2020-ICLl-00006 4495 133.01 Patient: RUIZ,FELIPE Unit#:BH00861890 Date:09 12 17 (b)(?)(E) Potassium (3.5 - 5.T--mmol/L) · Chloride 4.2 102 24 95 - 105 mmol/L) e1)1-32mmo) 15 ,o GAP-c~a~----+-------7~.o,._..i !----,~-~~~~- -1 ·creatinfnc GiDL) (0.55 - 1.30 MG1DL; -----'.~~---------c---..---! 67 H 1 j6 H ate ( > 60.cst 1 5.3 ucose(70-11 MGDU 132H Ca.,....k:...,.....i u-m-+(8,,-_..,,..5-~,;,,::0.-::-1--.M"""77' 936-967-8000 SP.]~ f.CM DRG-: 872 Adrr,i. t sr.,nes united 7735·1 f:c,mp 1 aj nt: Ver: 34 UPPER GI CUrIC1".t Stay: 1 ALDS: No: 028566428 4.5 G:.os: 3.8 O'-ltlicr: BLEED HCM Dia7i~xA .l\, TV ioFRAN PF.N 1 :v MORPHINE PRN, :v· .;;: :V? @ 75 :v C:C/ER, Labs/ C'.il ture 1-J'&H8.4/23.8, CARDENE GTT Tl TRATED s: ?:.T Inaging/Other 35, REC 2.60, PT/ INR 16.6/~-~6 te~ts: Diet/Activity: CL DIET Oxygen: AS NEED~D ?T/OT/ST: Other ~realmenl:;: PRO:HJCT TRANSFUSION- PT,A'l'F,T,F.'JS Level of care cval/re~errals: CARD~O, ~l, CRIT C18.~ 3LOOD Barr~crs to IV ME:JS, PLAN STRES.~ WHF,N'HGR 10 Ciscr.arge: Corr.mer.ts /Ot'.'1er: --===========-----=============== IN':ERQUAL REVIEW HlS'l'ORY ------------------------.., ~;~~~~O~; t1(%i(6)'. (bi(j)(C)JD I I:,:~e::Qi.,;al·t 2017. 1 Inte:Qual Ver!io~: Review ca-:.e: 09 13 2Jl7 Review Sta::us: I~ Pr~ma::y Product: :.,oc:A.cu Le Adt;.l t CritEria sub.'3et: General Medic"'l Criteria status: Critical Me:: (Synp::om or ::i::-.ding within 24h) (Excludes ?O :uedication.':l lL'l.:..e.ss r.otec) Selec:: :iay, One: Episode Cdy :, One: CRIT:CA.I,, >= Or:e: Ge:-i.eral, >= One: :v medic.:i.ti c,n acin'J.ni s::raticn, Bot:-.: Medication, >,· One: ca: ci·.lll\ char.nel bl,-,c: kier Adrr.i,.istra-cior., >= Cne: Titrat~on ql-2h and moni t o r ing Inte.r;Qual 1~: ar.d Care&hanc.e0 Review Manager Corporation and/or or.e of i::s S\;.bsiciar.:.es. CP'I on:..y ;t,; 2016 Arr,e.!"i,,:.n Medi.sal Associ2..tion. :;, 201'/ All McKesson Rights Rcscrvec. Al l Right!l REsc.:-vcd. 2020-ICLl-00006 4501 =-------- ... 9/U/2017 11:C AM lns·,1r.,n~:"' Ce1:tificatior. 11::A Corporate Report - Pl\GE Selected Review - 3 IQ CDNFIDEKTIAL PA".'IENT INJORMATION For Ace t l... 1\1r, (b_)(_7)_(E_ )____ ~a~i'.ity: ConroE Facility: _, Peq~ona: Conroe Patien-: Medical - Co:-itains pr-opr:ieLe.r:y Nair.e: Meciical Center !l.UTZ, FE::_rp;,; Age: ~1Y DOB: 6/26/1956 CenLer =----------------------------------- CONF'TD"NTTAL Regional :ONflD~NT:ALTTY .1nfonr,at:..on. Kot: STATRVENT --------------------------:int'.f>nrl<'Sd -:°or exte::::i.al 2020-ICLl-00006 4502 distr::;.butior •. r b)(6); (b)(/ )(C) FAX: FAX: Patient Name: Campus: 936-585-4657 936-585-4657 Onit RUIZ,FELIPE No: C St: ADM BH00861890 EXAMS: 020697794 RAD/XR CHEST 1 V To be perfonned PORTABLE? Travel Mode: Isolation Type: Reason for Exam: le~cocytosis comments: *? Location: T 18 Chest x-ray CLINICAL exam, AP frontal HISTORY: Leukocytosis, Comparison ~one of t~e exams: projection, 9/12/2017 ICU patient. chest Elevation the right bemidiaphragm difficult to assess in terms of age given lack of prior exams. Probable scarring veroua atelectatic changes mainly at the right. lung base. No active CHF. Overlying lines obscure detail. No findings of high concern for pneumonia ** Signed by n~-< 102 133.0 4.2 Labora_toryTests_·-----------------=-=-=~-~ 09 12 24 097f2 1530 09/12 1530 1530 C:herni$try · Ammonfa--~1~1~.O~3~2~.=o-----.-.-~~-----+----+-----90.0 * H · 4.9 H i C T .(Ck-2)(1.0-3.6 --0.270 *H B- _ _____:__::---'-'---'----'-----'-L....O....__;'---'------'---'---'--......::..:..-L;:!...-l.... ____ 16.59 H 1 2_· 09 12 1155 ...____, __ ·stry m(i33 - 74:.:fmm 133.0 m (3.5 - 5.1 m 4.2 c (9 -Carbo -, 102 l Anion BUN"(~:----;c'-;----,--,,..,~~. ------'------+----~6=7 Page 4 of 8 2020-ICLl-00006 4512 24 7.0 H Patient: RUIZ,FELIPE Unit#:BH0O85l89O wb)(i )(E) 00 {J? 1,17 Acctt: 1.3n H 55 L reat'1nine. (O:S5- 1.30 M JI L) omeru ar Fi tr Rate (5-60 estGFR) ucose (70 - 110 M DL) Talcium-tB.5-10.1 J, LJ ····r.s Tota Bi iru in (0,0b- 1.(Jtf·'-M~=D~L)-------+-----~6~.5~6~H~ Direct i iru in (0.00 - 0.30 MG7DL) Tn-direct8il1ru 1n. -1., 3.35 H 3.21 AST (15 -37 Unit/L) A T(12-78Uni TotaTA 81 H !19 L) asp atase (45 -117 707 5.41 Tota ProTeln (6.4-~ 8.2 DL) A umin (3.4 - 5.0 G/DL) . 2.9 L Albumin/Globulin Ratio (1.2 - 2.2 RATIO) 1.2 cfmen A- --earancc(1 NORMAL lndex/DL), 3 SMALL--5~1 OMG. Specimen Hemo ysis (1 NORMAClndex/DL) I) TRACE10-25 MG. Laboratoryl ests 1· 09/121 1200. · Coagulation PT (9 A --,~2~.s~s=E~c=o~N=D~S~) ------,,=7,-,,.J,-,H-,-: INR(0.85 -1.11 INR Unit) I {52 H • PTT _(Dade)(24 - 37.7 SECONDS) - 29.4 j l Laboratory T_e_s_ts _______ _ ____ _ 09/12 1200 Hematology wsc·(~4--'-".1L___-, 2-.,-IJmmJ) 1s:TTT RBC (3 ,8 - 5~5 Mlmm3) 3,StlT Hct (3n.O - 47.4 %) 30.1 L ----,-:.-------------+---- Flgb (10.6- 15.8 G/D'""L,.....; ~--- 11.2 MCV (80.1 - lffL·-==-'1-r.L-c--)----------MLH {2'5.3 - 35.3 p-g) MCHC (12.7 - 35. 7 C/DL) ~RDW (12.2 - 16.4 %) _ ., Pit Count (155 - 337 K/mm3) MPV (7.6 - 10.4 f L) (}7,8 - 82.6 %) ·- I . .. re-ran¾ Lymph¾ (Auto, (14.1 - 4.5.4 °?;;) Mono % (Auto) (2.5 - 11 .7 %) -Eos% (Auto) (0.0 - 6.2 %; • ··-·--·Baso % (/\uto) 10.0 - 2.6 °l;,j Page ··-· ... -· ··-··· 0.5 5 of a 2020-ICLl-00006 4513 86,0 32.b-, ·~ --- 37.2 H 17.2 11 27 * L 7 0.3 fi.5.8 12.1 L 12.7 H 1.7 Patient: ROIZ,FELIPE Unit#:BH00861890 Date:09 12 Acct#: 17 b)(7)(E) 1ran 2.0 - 13.7 9.95 Fl' 1.82 1. 9-1 H mm3 l" m h :ff(Auto) (0.6 - 3.8 K/mm3) Mono # /Auto 0.11 --~-..:..,....,...--------- 0.59 K/mm3) rrim3) aso uto .... 0.0 . 1 mm3 ··--'----------------~(fiS. 0.08 MAN DIFF iNDI ATED SCN) 100 .0 - 2. o) . hils ¾ (40 - 75 %) 7.2 H ran °o -immature --· ymp 73 12L s%(Manual)(12.6-43.5% Monocyt.es % (Manua) (4.2 - 12.7 %) 14 H 1 Eo,;in'o . . ~Manua) (0.0 - 5.2 ¾) 0 Nuce olb.0-1.0 700V _°Jo Nucleate .s # (0.00- 0.05 k/mm3) Toxic Granulation (NONE ON SCAN Platelet ' Pt1'0_orp - 1.7Tl 0.25 H S :,;...:,-.=-.-......-.~;-r,"?.;.,....N".-------t-i=-.-...ii7--,,.._ CR L LRARE T _AN N) .. ~----'-~....,.,...,,_~~,.....;:....,....,...,.,.;;....,..-N~) -'---- T ·_ 1 T -----;..s~u~c~1=if------ scANf NE ON~SC~A~N~) ____ 1-----,---____....L..-'--=-~ S_CA_N_:_) _-- ____ RA~R=E____ j _.__RA_RE__ ... _,__,i LaboratoryTe,.c--sts'----------- 09 12 1530 Sero o Hepatitis A lgM A (Nonreact · ·nreactive He (Nonr~ac 1ve. He _____ __,y (Nonreactive Non Reactive G-NONREA _ NonReactive NR --l'lc Radiologydata: Recent Impressions: ULTRASOUND~ US ABDOMENLTD09/12 1637 *** Report Impression - Status: SIGNED Entered: 09/12/2017 1913 Impression: 1. Markedly limited examination due to poor br.am penetration. The liver, gallbladder, common bile duct and pancreas arc inadequately ?age 6 of a 2020-ICLl-00006 4514 Patient: RUIZ,FELIPE Unit#:8H00861890 Acct~: Date·Q9/J?/J7 rb)(7)(E) visualized on this examination. 2. Unremarkable right kidney and visualized portions of the abdominal aorta an_dIVC. ICbl( 6); (b)(?)(C) Impression By: t.SDR.RHl 61 '---------' Diagnosis. Assessment & Plan Free Text A&P: Consult:Hematemesis HISTORY OF PRESENT ILLNESS: The patient is a 51-year-oldHispanic incarcerated male, who was taken lo Livingston Memorial Emergency Room with complaiots of abdominal pain, and bcmatcmcsis. He has a past medical history significant for nonalcoholic liver cinhosis, generalized anxiety disorder, and depression. He bas been diagnosedw1thcirrhosis 7 years ago. He is currently in the Dcpamncntof Concctions. PAST MEDICAL HISTORY: As mentioned above 1 which includes, l. Nonalcoholic liver cirrhosis. 2. Depression. 3. Generalized anxiety disorder. SURGICAL HISTORY: None. ALLERGIES: NO KNOWK DRUG ALLERGIES. MEDICATIONSFROM JAIL: Reviewed. SOC:L'\.L HISTORY: The patient ii;;incarcerated. He is originally from Florida; however, because of the flooding , he was transferred to Texas Jail. F/\MILY HISTORY: The patient is unaware of any medical problems running in the family. REVIEW OF SYSTEMS: Otherwise negative. GASTROTh'TESTINAL:He present<;with right upper quadrantabdominal pain and Page 7 of B 2020-ICLl-00006 4515 Patie~t: RUIZ,FELI?E Unit#:BH00861890 rT(Y)('h a 9 / J 2 / 7 JI Ac:::t#: hematemesis. PSYCH: depression. Vitals as above: General appearance: alert, awake, oriented Head/Eyes: atraumat-ic, E0lv1I, icteric ENT: moist mucosal membranes Cardiovascular:regular rate & rhythm, normal he.artsounds Respiratory: clear to auscultation, no distress, no tenderness, aerating well Abdomeo/Gl: active bowel sounds, soft, non tenderness Extremities: moves all, no edema-all extemities Musculoskeletal:full range of motion Neun/CNS: alert, orientedX 3 Psychiatry:·unableto evaluate LABORATORY AND DIAGNOSTIC DATA: Reviewed ASSESSMENTAND PL/\N: A 51-year-oldincarceratedHispanic male with history of nonalcoholicliver cirrhosis,now presentswith bematemcsis Possible varices though PLTs are low will transfuse then have EGD possihle banding Agree with octreotidie and PPI drip with abx EG D planned tomorrow for now Follow up CBC in the AM )IFQ ---~L Jr::-b""' )(6,.,... );...,,. :>.::::::::::::: :--::'1:---, I >Ii<:•::::=:=•· ,·:-:-:-:•• •··· ··· 36 . 6 o,ff:i.:i/:i.t-~to:s.• G/DL I ••••••••••••••••••o:;i•Ji2/17:•;;;:.iQ .. 32 .7-35.1 \)?? +•.. ·.•.•.: ......... . 1_7_.2 __ l .._1_____ H 12.2-16.4 ........I'(}~.·=···· ()#:;. 2/ %- ·...........:.:.~~~=:.:.:.c;.c;.;.;__....;.;.;.;.;.,..;.;..; - ------~ • 69.9 11. 4 = . l ::• •···...... ... 1c·-·· 11.9 1~1 0:~rt •••·••• ••:L.••··•o•~:/?c2/ ;I7l;:J.:of ·..·..·. .... •.•.•.•.•.. •:i•,c:.·.·»_--.···· .:•\r ::·· ::::===: ::.· ::: ::::::::••· ? •~:~:;1~·/i7 ljj_6l····· .·.·. J'--.. ~-----------,-,----,-,--' 4.9 1 •··•··•·•'·•·· ...•...·7 .-;;i.1.os .L...... ••:-••:••<·•· .o.g-:112/1· .•.•.•.•.•.• Ji-'•·~"-'-=~~~~-----'-"--'-'---~~~= · \< i •...•..... 32.4 · =··=···=·=·· •· ==·=•::=•=·=· ]'----. ····+= I 105 .. .QSJ12/l7:f21Q:5 '.,, ............... ·.·.· ..·.·.·....1.•.:::::::::: 11 / 1 tL>>:~~1_ :~/: so.1-101.1 88.5 •···. 0Jji;2/17)~•1:0$·•::-=·•·· i •·~<7·•·: ..~.~a2.:"~\' .... MV:J~/:t7lJ\~s .. i 0.0-2.0 t ······ 1..... ------_-_./:\.:-:-:.:.:::.-::\:::: ...:: -·· -········ i:P:$.)ft~/J J::~iJJt-~)'.:'. .•.· L 114 1 45 · - -~ i >os=/:;l;f/17•1;2):¢:s•< .:: - . -::::::>====== :::::.i::"::r:r=:::.:/ . H .... H 2.s-1i.7 l/:::.:._:·: t% 0 ·. /:\\o: 9;;.;:;ij_\;:; 5 .. }L{ci:J/t.:ii~::1-L:1:o.s: 6 .i{j}: ·%····••\()b~!Jtlf7l:@qf /lOOWBCt I 0.0-1.0 >· · ·tt :,·····.: :::::: .•• :tt 6~Jijii?.t· 2::'liS: K/mm3 2.0-13.7 ····. :.:.:.:.·:: :nr<:/09.J1.:iiij>:f1.~s<·>· 0. 00-0. 03 K/rr,m3 :::::::::::: ·••·•·/://•? o~lfi/i:'7}2io)f · .··.· ..I:..o ..~ ~ ~:•::~.~(~'.113 ::••·•· . ·........... ·.· /99,hi/~J/.210~\< > H.i_ 0.~1-0.59 K/mm3 i 1 :2/t?+~i:9~/<'< ····.· ·· :•A~/ 2020-ICLl-00006 4517 ......... :•-~PE..ft> 09/12/17-2105 ·"'·· Nit:sff: :-:-:-:-:-:::·:::::::::::::::;:;:::;:: o·•-o···o ..... o.··:: •o·•s<_•_-.•K·_··. •1•,:mm·· .·._3:::::_::_ .._•_•_:_•_•.•_:• •_:_•_:_•_:_•_:_•_•.·•_ ·-n: <:•:•: : < -·•'·•·-. ::c_. __ :,:....:.. , 09/12/17-2 1 05 ·•u ..... 2020-ICLl-00006 4518 -1.. · .·•·•····· ... ·······S;p~1¥~en•·•£tW:±fy .••• ll46#){?••·•·•··{t•~l)~f6~: R~;•f.)~;\ll.••·~;Jfb~t·• Center-,·..···~-~)ii~6{jx••t> ;;,-_:.: [Cii.f#.2.119~~oi··•:: .··.·.·.· ...::· '*** CON!'Ii.').~~Ali :\/~ea;pi:i:~ctoJ:::J b)(6); (b)(7)(C) •::~;iktr: i/~~:I:Z '•F:m~~~~bo/ ~s ..F: 'R:lliSt>j;i b)(6); (b)(7)(C) l,:CR:BC0011419S Source: BLOOD > IBLOOD CU--~TURE .·.·.· ·..··.·.·--··..-.... ·.··t:·:·:· ::·:·r>:· ·•ACCT# ;·"'kb-,-ii;,::6 )'""' · '-;,(tl,;,., )(7=")-,'; (C;.,. ) -'-". -'-'-'-'---,(•r.oe}:>'.<::<:: : I)J:~f RES, Coll: 09/12/1,~1530 Recd: 09/12/17-1619 Deoc: PERIPHERA:., I Pf$~##r1~fy: w, (RU0~6,3570) o9 In/: NO GROWTH AFTER 12 HOURS 2020-ICLl-00006 4519 • . ,··. Fakhri,Alifiya 7 - 04 19 17:CR:BCDD1142DS Source: RES, Coll: D9/12/17-1530 BLOOD Recd: Desc: 09/12/17-1619 ..... -:·.·.·-:· :·.·.·.·.· Fakl-.ri,Alifiya o9 I 13 / 1 7 - 0419 CUL T!JRE-j 1':it~].:;i:ihi~~cy. NO GROWTH AFTER 12 HOURS : .. ·.. (R#Ory673570) PERIPHERAL .. ·.. . ..~#t!: llcm:z •; Fl!;t;t_p~••• WP•• -------;..;+~~--'-'-'',--'~ =I • 2020-ICLl-00006 4520 D913:CR:H00074R COMP, Coll: 09/13/17-0420 Recd: 09/13/17-0614 (Rll076"13571} .•.l I I •»>: )~J):i,)Ji)/o6'4f :: · · 35.1-43.9 I ON 09/13/17 1 2 5 . 3 - 35 -3 ..!-~-.,.,.,~~,....C.,..,,---'--"-~~ ;u\....... j •a~liib.i- :cfi(fi'( / ••>=f':o~/))}i1,@,~:i so .1-101.1 £L:::: : :::::: f :::: ·:.·.··:.•,•.········ ·.-:::::;;:::::::::::::::::::· .·..·.-.-.•.·.·· l:fJjibh ::::::::.1:::: : '""·.;.;._; fL ······•••··•• : . \ .::~~:::;\::: / CALLED TO ELAINA. HULL. The :;;,:~i~di'ntifuiiid':6.Yreia 1.i~c:k: 1-1f;;,t}~~i~)f#V < : . iJ._·9 ·..•~<:. .·. . : I H I 7. 6-10. 4 fL ..:1.•• ::::::::=::. .. ; : :=::=:::: 67.6 4 13 ::=•·=·:> : »:>>> ·....·..·. T 3 1. a - s2 . 6 L · r '=d9/:ii/i .. %- : :: 71()6J9\ .. 1· ..... ·.·.·o 6 /·•1· ·-,:•/"1 ..'··1 □ · ~-•·;, ·:.:;.·". . .-: 0·5--4 : : ·;;J:····· ....·.·.·.· ..· .·..·..··.·. ·. 1······· ::=:::•:::::::::. ·.·····.·. : 0 f;f/;1:3':/:i::'i-9:6:ig .···.: .• f4·_·1.:.,i:r:t%- ····· · · : ::t=/:os;f:t:a=tL::i::; oe;if: : ::: . :1 : .. 0.0-2.0 H ::::,:::: ,:::: :-:-: 't r.. · ,:: D:9/13/:t}':;:064:$ ••••.••• I ... ::::::~::1:: < :1::: . I ! /100WBC% ·············•o•fh-,s!:tt~oi4~ 3 ::::_)l~)):!}1'7.~0l.549:::•:•·•· m3 ·••9f/i3./i1.~:ci:~4-ti•···•· I 9:Ji~/1-7•~ q$J$•·•··•··•·•··: •··•··:••: Q 2020-ICLl-00006 4521 · <•:(b)(7)(E) ;.;::-tofJ>/ . ?. : )B,]:;S9)!:/ .,,, .. , .. ,., -:.::9/1.f ·.·.1·.·.·,•.·,· ''' :::::::::::::::::::: .. • •-:::-..-.•::::_._: __ :_:_:_:_11•. •.. ·.·.-.·.•.•.· .. ·.·. : ..xi:...... .·_•o· •_•,_·.o· .. . •_•1> o ;:i /~s :::::i:;:<· I The I ): {R#07673571) 23 : ::::( > 09/13/17-0614 Recd: 100 glome:nilar estimated ::=os/J)jj_"jl~f($~/ >60 estGFR filtration :rate ccmputed is using :;:::;:~:~Ji¥.ti!;;:::#.~-1~:;:;;~~~9~)::t~:ijjfiii;:i~~:,~r~:~-~##.::~:9-.#:~ ·.·.•--.·. needed data elements are missing the can not Laboratory :4i:>¥.iiu:fec•••~n::•.:.fb'.¼~:f:i'.9.ii\~t:•cii,,~f::1~~~:hi1.:i:f::tfl.tiit:icb The GFR value units= ml/min/1,73 meter squar~d. Estimated •&iii:=•:•;;,~iiiJJ• ..:C.JJ~}efo•==•1w:~.1a••:fa~:•••t,l,6~.7:piet:~c:i .:~s•••;=s=o, ••:n6ti ...... n exact number . .•.:} " ~' l)R_ri:G: :PMAii.(}@E:kf )/:;;2 : ) / Drug dosage adju~tments utiliz~ •p~f$] e=tfrs.\: ::<:t?/ ·· ::::::::: ············ j ••: I• I 0.81 <<::::::,i ==< ,: ··· ::-:::::::: Results n,ay be depressed : ············ '='·.•.•.•.•::: .·.==: : =.·.·= ,...: if is patient ta.king , ::::+ ••fe~/icil!:itfJ:~#i+~tn:i!f::Jiilili:cr 'a~4 Het:@iii61~.:..•.••.·•.:l•.s=-: ..... ···.·..· · 2. 4 LL ...·>:If<·········· ··•·:: ·;:?t:===:•:=-::·===· J .L ·.· ..·:-::t:..:.::,.:<;:;:::;:;:· 1 BILT BILD > BI:..I \:::::::· }t=::;::·:·····:'./. f 3. 4-5. 0 G/DL 1.2-2.2 RATICJ El.t{r1 :~==:-ir .·.:.:.=.:.·.:.:.·· .·..·.· i ,: :: : .·.·.·.·.•.•:•:-:•:-:•::.:··:• =:.:.:.:.11:.1 INDIRECT ······ ········· ·:':':':':'::·:,:>:] ......... : :::: :: ::=:~)1)::1;3)1t~os$:ci:?::::= : «ci~/))jf'/)~t.s::f// ........... 1.. MG/Df' ~~~n1~~? ... 091 .......... :::::::: :o!l/:i;~:/:L}:'~:!;isf:: :])iIPMi;ih,i\~ =•·····••??\9~/:ij•t4t:;.•~~·$ MG/DL eii/ii/tt I ~:$~•··:•· :,_;.;.....;.:..._;_;_;.;__;.;,...;.:.:.:_;_;_;_;_;_;_;·.:.;,.·••>) c (i. 2020-ICLl-00006 4523 sPEc >#! b)(7)(E) ogffdi:co@~}1f :/~iii~~~···R9#\Fm4~~g ' ·.·.·. '.-'.·'.·'.<•:-:- :tr::rtJ:t •:I/•X• ALKF••:toT@.):)::).:•:•: ···-········-· 09/13/1 :1:n+:ti3:j:<< I ........·r.1 / >/ :·>1, :•• ::: ./1 :,;:::):mii$():¢r~"iC:: ... ·:.i¢ori.H.#~~c11/ «< :=>2'!'RP.CE •4?~-Mtf • J ... liOR~lAL:.fiid¢i./:ri1••• ,.............. 09 ' = ::f l>TC,RM1l.L: :C:nde!x/Di, 09 2020-ICLl-00006 4524 0913:CR:CG00DlSR •••> COMP, Coll: C9/13/17-0420 Recd: 09/13/17·0614 (R#076?3576) .ft~LifTrENT .·.· ..·.·.·.·r§ t·••< .( .~ eB.P.i~}i¢: =~@?Cfl'e ,ib':tINR.1{=dfpe.t.1d~ti:t)~po~{\:1:ie()iitrti{ii)~ii\\: •·•· .·· 2. G-.3. rl Prophyl~xis / venous thromboe~'llbo] isrr:, Treatment of ········••??)•·· ·••kvti )1eiiit;#•••foi6¢~hli.M·•••i1li .ifrs c:J§..i:i•· s\#f.4.%~:•pfei/ell t:i§n}•··.·•· I Syst~~ic embolism prevention in fibrillation ..··.•Jc::-3<>0•.;'f/(}#ti f¥¢ilffffo:¢ :pi~v~µt:¥~#1: sJs~:~tf fi~i.tfoffa# :. :•:>I: •J-• o:-s:/4•• 1.!t..h.e.art i,1.v::i:~,1J;.J~~1~f 2020-ICLl-00006 4525 CONROE REGION.AL MEDICAL CENTER 504 Medic~l Center Blvd. Conroe, Texas 77304 0913-0004 PATIENT NAME: RUIZ,FELIPE 09/12/17 S.ICU18 ADMIT DATE: ACCO ONT NO~ !(b)(7)(E) ROOMNO: ! MEDICAL RECORD NO: BH0086l890 REPORT TYPE: ELECTROCARDIOGRAM ADMITTING PHYSICIAN: l(b)(B); (b)(?)(C) ATTENDING PHYSICIAN: ..__________ AGE: 51 SEX:: M ____,J Ordei:.-; 2Cl70912-00B5 Tes~ Reason; tropinemia Test Date/Time Stamp: Tue Sep 12 2017 17:17:29 ! Blood Pressure ***/*** Vent. Rate 070 BPM P-R Int 192 ms 416 ms QT Int QTc Int 449 ms ~oTl!lal sinus ~onspecific Abnol.--mal at outBide mmHG Atrial eR 070 078 -14 Rate QRS Dur P-R-T Axes BPM ms 009 032 degrees rhythm n ST and T wave abnormality ECG ~o previous Confirmed ECGs available By: Referred ____,Jlon9/13/2017 by~f b_)(_6 )_; (_b)_(7_)(_C_) _______ Confirmed (b)(B); (b)(?)(C) Electronically by Signed ~l__________ ~b)(6); (b)(7)(C) 7:14:36 AM 7 by;~l (b-)(-B)_; _ (b-)( _> <_ _ c>________ I ____,J09/J3/J7 at __, 0714 (b)(6); (b)(7)(C) ACCOUNT PATIENT NAME Patient Run: Care (PCI: Inquiry 0 9 /13 /17 -11: 21 br OE Database )(B); (b)(?)(C) COCCR) 2obo-1cu-oooos 4s2s Page 1 of 1 CONROE REGIONAL MEDICAL CENTER 504 Medical Ccnxoe, Center Texaa Blvd. 77304 ADMIT DATE: ROOMNO: 09/12/17 B.ICU18 AGE: SEX: ADMITTING 51 M PHYSICIAN;l (b)(6); (b)(7)(C) ATTENDING PHYSICIAN:~. ________ J ADMISSION DATE: 09/12/2017 ADDENDUMTO THE HISTORY AND PHYSICAL REPORT: Con:irmation Plea~e to #2035335 assessment and pla~ after DVT prophylaxis. Sepsis. The patient has ~ignificant leukocytosis wi~h a WBC count of 15.1 , failure, and the patient wa~ tachycardic upon arrival with a hearL iate of 108. We will initiate antibiotics. We will not give fluid liberally as the BNP level was more than 4000 a.t the outside ER. We will obtain x-ray and BNP level to reassess the fluid status. The patient does have symptoms of vo::..ume overload at pres~t. renal It has been a pleasure participating any questions, please do not have Dict:.ated NT: HP:B.HIM;j 09/12/20'...7 15:25:Cl 09/12/20'...7 19:14:36 7035363/DID#: 399106E of the patient. If yo~ (b)(6); _ INT.S PATIENT NAME: RITIZ 1 FELIPE Patient care Kb)(6); (b)(7)(C) B y\_ DD: DT: Conf#: in the medical hesitate to call. Care Inquiry (PCI: ACCOUNT#: OE Database COCCR) J b)(7)(E) L DRAFT COPY (b)(6); (b)(7)(C) Run: 09/ll/17-11:21 .___ ____ ____: 2=-= 0-= 20 .::.J IC Ll-00006 4527 Page 1 of l ....::···•1s~:~i~g~~~~~~R~1it ···••:il~d:;£1;~~•¥::~~~ ~f~¥c rrrC )~ciicgi.geh~erg;~i~i:dI~:f:' i~ri:sb~: ... ...... 17:CR:BOOl_SBOSR So·..i.rce: > RES, Coll: 09/12/17-1530 Recd: Desc: URINE fuR_rnE: CUL'T~gj >/~TAT.US: •AbM•IN> • Bll.D/:W} i:fo~H~Jna:rf ROUTINE WORKUP 09/12/17-1619 (Rij07673572) CLEAN CATCH 09/13/17-0910 ~10,000 CFO/ML GRAMPOSITIVE FLORA b)(7)(E) 2020-ICLl-00006 4528 CONROE MEDICAL CENTER (COCCR) Clinical Note REPORT~:0913-0215 REPORT STATUS: Draft DATE:09/13/17 TIME: 1024 PATIENT: RUIZ,FELIPE ACCOUNT#: 1~ (b_)(_7)_ (E_) ___ ~ DOB: 06/26/66 AGE: 51 ADM DT: 09/12/17 UNIT#: BHOO861890 1 RODM/BEG~:~B.....,__._C= -=-~--~ SEX: M b)(6 ); (b)(l )(C) ATTEND: AOTHOR:._ ______ MD * ALL edics or amendments must be made on the electronic/~omputer document* ClinicalNote Note: Seen9/13 See consult Admitted with GI bleed hypotension DEnies chest pain Tror mildly elevated EKG normal No H/O CAD stress test when H b close to 10 RPT #:0913-:)215 ***EN~ OF R~PORT*** Page 1 of 1 2020-ICLl-00006 4529 ~ REGIONAi., YJ:rn:C.AL CEt:tl'ER 504 Medical Center B~v~. Conroe, Tex~s 77304 ~O\'ROE 0913-007:. ADMIT PA'l'lE)J'l' NAMII: RlJJ?:, F'R~,TPR ACCOUNT NC1(b)(7)(E) MEDlC!\..:.., !foCORD NO: RH0086183 0 H.EPUR'.? TYH: ffi STORY AND :?IIYSICAL I 09/12/17 CATE: ROOM l\'C: 1:i. IC:T1.8 AGE: 5' SEX: M (b)(6); (b)(7)(C) I\DMll'l'ING PHYSTCTAN AT~ENDlNG ~HY$1CIAN ADDEKDUJv:: 'J'O 'f'HF: HISTORY Ccnfi::-:n;,_t.Jon i:'lease AND PEYSICJ\.L REPORT: 1/:l.035335 ~n assessment a:-.d plan a±ter CV'I' prophylaxis. 5ep~:s_ The patient has s~gnitican~ leukocytosis with a WHC count of ,~.1, rcna: failure, 1~d thA pat'.ent was tachycardic ~~on ~r~lva~ with a hear~ ratR nf :08. We will in~~ia~e ant~tiotics. We will not give ~l~id liberally as the RNP :eve: was ~ore t~an 400C at Lo rcasse.ss the f1uid status. the outside It h;i.,i hl',.en a pleasure part:.cipating have any quest.:inn8, please c.o r.ot D: ct,:;_ ten Ry f.... 5 b_>< _> _; _ ____ W'l': HP: 8. HIMN h\/ R\ · DD: 05/12/2C17 15:25:01 D'I': 0C./12/2C17 19:'..-1:35 CoY-.ft: 201S,6J/DTD#: ER. The ;,at:ent ln tLe hesitate We will obtain x-ray and l:iNP :evel does havte sy:.n?lODS' of vcl·.:mF>.rwl',_rload medica: care o:::: ~he pc1-:-.i Ant. to call. ___. IJTS 3991~68 (b)(7)(E) FJ>.Tl ENT }l/\M!,: RUI 2, FK, T P"R ACCOt,"1-J':' 2020-ICLl-00006 4530 :::f you :,l)lz;. t't'· I IP~/\ C:C'.Tl (b )(?)(E) SEX: This NU"'-S; D. :CU4 3ED: B.ICU18-i;; 06/26/56 AGE: is NU'l' pare o[ DOB: :vJ report NOTE: Truncated 51 the A'J''-1 D'< l(b)(6); (b)(? )(C) 09/12/17 rr.edical rec::,rd ADMIT: pen:12ment arP. p;e<"!A:1?..rt by ~9sults MR: llH808611:!30 t--> process Plc,ase 1 per Consult chart Company for I 'Polir.y. entire result. .i\:...-LERGES Coded A 1 · <,rqi.<"S Nr:, Known Rc,a.ct ~on 1111 e:·gies C:rRRRJ\7' M'P.D:C'A":'l ONS MED ::Jrder) :*D = Dea::::ti va':ed RO:JTE START STOP ST IJ:JS!,; SIG/SCH ;,,sc M!i JO MT, 50 M(s i\SDIR IV ;:llO PO BED':'IME FOLV:TE LEVAQUI~ 5~0MG/108ML 1 MG !J/1.lLY PO PO 1.0D Y!L O.24:-J IV MORPHINE SLFATE 1 MG 250 YIJ' ?R:11 rv MW.i.H./PRN lV 250 ASDTR Q1 ;.HR . ;:):.3H20M AS:JIR DA::..y --·>Q4E PRK IV -->Q4R DAILY ------------···. C'.ARDEKE-KACL 5·:J MG/250 C:-fRONu"LAC 20 GM/JC ML -----~--------~~-------- -------------~m, IV ------ DESYREL NORi'l1AL .'JAL:i:KE 250 ML NORMAL;;ALlNE 250 ML SOD"':UM CHI .DJ{ I SOD~UJ\1 CHLORL.JE ':'OP"-OI., w~ :J~: r:.~9% 10J0 8-9% 20ML XT. ZOLOFT - by Y.L lC ML 12. 5 KG 1~ MG 4 MG lJO MG 7Rfu"\'JDA':13: 7CPRAN 09/1?./17 Dic::ated )11, 1COO RADTO:DGY l~PKESS~GNS T:-LTRASrTr:,ri - 1·s ABDOh'EN Phys"i c i ;i (b)(6 ); (b)(? )(C) f FRCYI: LTD 10 /12 10/12 10/12 10/13 09/U lC/12 lC./12 C9 /1?. r.9 /12 1 ~ /1 2 l·J/12 PO C9 /,?. 1 [J /1.2 IV C9/:2 "':V ~9/:.2 '..0/1?. ~0/12 PO J9 /'. ?. '. 0 /17. -->Q4H 4C MG PR:..J'l'ONlX 09/12 09/12 09/12 09/13 09/12 09/12 09 /12 09 /12 ()9 /12 09/12/17 IV IV TV PRK' TO: 09/1~/17 REPORT STATU8: Signe.d 281-2H! (b)(6); ! 1mpreesion: 1. Markadl y l i ni 1.c,d cx.a:uina Li ,::,:c du., to poor bearr. 1 i ver, :;ral lb ladder, corr,mon b~ 1 P. dur.:-. ~nd pancrcaG visualized on this exarr.ination. 2. Unre:rnark:i.lble right kidney aorta a.nd IVC. and visualized LABORATORY:NFORMATION HEMA':'OLOGY WBC FRCJM: 09/12/:7 0'J/:2/"_7 20:20 1 S :] 8 penetra t io:-.. The are inu.dec.i:c..<1tely portion,<; 09/1?./17 o-" t.he OCOO 09/1~/17 12:00 abdomina: TO: J9/"_3/17 0236 J9 /'..2/1'/ 11:55 8.9 H 1:i.1 REC L 2.79 L J.SO HGB L 9.-J 11. 2 2020-ICLl-00006 4531 09/13 1~/12 .:., 24. 6 H"c. MCV MCH .MCHC 86. 32.4 ,2 H 3 6. 6 11 17 .2 11 50. 6 RDW RJW-SD PLT MCV ~ H C:'lAN '% lMM CRA:;J % LABORATORY % LYMPH H 11.9 EOS !'; .8 0. 1 DASO% )[REC% 0. 8 # GRAD 6.21 :CMM GRAN LYMPH -ft -ft EOS E O 4t, 1-01 E 1 . 06 0. 1 6 1".CNO # f BASO il- *L 27 1 [i. J 6'.c . B H 7 2 ?RON:: 09/12/17 800C. 09/12/17 :I 0. 07 NEEDED TOTAL CELLS 'l'O: 12: 0 8 09/U/1'1 09/17./17 02J6 11:55 L 12.1 H 12.7 l.'/ 0. 5 H 1. 11 9 . ', 5 ll 1. 06 N ::.82 "' "' " 0 "' 0 H ::_. ~ ::_ U. 2:0 0.01 KRBC# JVJ.JI.NDIFF E 49 .1 89/:'..2/'...7 1~:30 L 11 -4 % n 17. 2 11.::. 69 . 9 H 4.9 INFOR.''lATION 0 0 H ."l7 .?. 55 09/12/17 20:20 MONO L 30.1 S 8. E J. 0 E 2:i H 0 -->!½AN 0 CIFE' 9 100 SEC ~ 7, 0 ~•YMPH L 1?. MO~TOCYTE H 14 ' 1 N EO~ NREC SL.lC.E'l' SL.lCH'l' AN/SO SLIG::IT FEW RARC OV/\LOCYTES SCHI STO 8E.ANTJLAT ACAN':'.'IIOCYTR$ PLT EST PT.'T MORPH '.'.'.OAC~'l,A7TO'J PT PAI l~N'l' H~R F'l'T CJ:lP.MTS':'RY NA K CL CC?. N 0 H I POLYCHROM HYfC POlK TOXIC 0 ST,1Gcl'I' s::.,rGHT RARE L MRK DECR LARG!l RARE H 17. 3 1l 1 . 5 /. ;:9. 4 133 . 0 4. 2 :02 '4 k"!ION GLU GAF '. 0 H 132 H G, BON GFR CR.EAT L 55 II 1.36 L 5 .4 L 2.9 1 .2 L 7. f:. I-I 6. 5 6 II 3. 35 H 3.L T . .l'HO'l' ALB A/G li..ll.'110 CA BILT BILC BlLl AS'I' HJUiH.l::C'J' E ALKP 10, '":'CTA~, "E 9 C-. 0 A.>m H 226 .Y:9 RNC H 4.9 CKMB *H 0.2·10 'TROPI INVEX HEMOLYSIS INDEX IC'I'ERIC T.Lis 8::.. " i\.L'.L' repu.::-t NO'l'E: J.,; NO':' parl ·1rcmca•_cC. :::-c8ult.s or are lhc pcnr.anent. prece.:l,e.d :.ABORATCR.Y I:-JFO3.MA':'ION 09/12/17 2·J, 2 0 medi~al re.cord -process P:e.ase. by'-->'. FRCM: 09/12./17 09/12/:i 15:30 Cons·_;lt 'l'H/\.CI:: -->.O SY.ALL pe:::- Co:npany chart TU: OOJO -->2 tor 09/12/17 1 '.,: 00 11 : 55 Policy. enti;::e .::-esult. "' "' "' " 0 "' 0 0 09/13/17 O'J/l"J./'...'f 1 02.'lC 9 ~ 0 ' 0 INDEX -->1 LIPEMIA NORM'.AL -->NonReacti >NEG NOt:RE -->KonReacti Hl\VMJ\B HBSi\G /-il:l CCKI:: lGM: NR .'iCVAl:l V' L,.·, Signs OS/13/17 09/12/17 C9/13/17 02:00 C1: CO Temp F Temp C Pulse Fesp B/P, S?02!', N 0 N EEROLOCY F::l.OM: 59 OOCO TO, 09/13/17 0 C: OC 64 '" 12 13 86 /';,0 87 /SJ. '.14 0236 09 /12/1"1 23 , 00 09/13/17 96/5 " 75 38 " " 3 99 /5 5 97 09/'...2/'...7 09/12/17 09 /12 /11 O'.!/l"J./17 22: '...O :C:2: OU 21: 4.5 21,30 Te:tip 7emp Fulse Resp F :::' B/r: sron 6' 63 6S G4 1S 16 1G :6 98 97 G [) /5:l 09/12/17 21: 1':> ---------'Temp Temp Pulse Resp 9S 97 89/17./17 21: Cl 09/12/17 2::..: oc. F C 67 17 83 77 66 JO 29 13 95 9c 9 2 /66 E/P: 93 9, S.?02% 09/-:7./'.7 20 ;J 0 ---------'l'emp F Te.u1p C E-''J.lsc Re.up 09/12/17 20:15 09/12/17 09/12/1"1 20:00 1':! ,45 68 15 Ge H 68 69 , 44 _,, 1C6/56 R/P: FROK: 09/n/u 09/1Z/17 19:-, 0 Vital Signs C9/12/l'f ::..9 : 3 6 Temp 7 Ternp c Pulse Resp " 96 95 SPC?'a ---------- TU~008 09/17./17 19: 15 --------- 9~ 09/lJ/17 67 JO 58 ,, 27 17 96 n 98 07.36 09/:2/:7 '..9: C0 SP02% 09/12/17 18, 4.'i ---------- 09/12/17 18: J 8 18:30 ---------69 17 GB 76 Resi;: n 17 9 E. 6 ~ ·1 . [} n lGl/55 lC-0 JC. 8 B/.E: SI'02% 09/1:Z/17 1 8: 15 F 98 9 8. 2 'l ernp I:" Tc'-1:,p C Pu.:.i?e 09/12/17 18:00 72 26 '/1,. 18 :01/Y;, :oo 9' 09/:2/::..·1 17:JS ---------98 .:: 09/12/17 l '/: U~ 0 "' 0 0 0 ' 0 C9/12/17 -~s: 16 09/12/17 ""'"' " ~ 111/59 B/P: Terip OS/12/17 20:45 ' 0 N 0 N ~ '::'emp C Pulse Resp 76 73 20 2S 2ir: 10 99 09/12/17 16:00 Temp Temp I"ulse 09/'...2/'...7 15: 00 29 SP02% 09/12/17 14,30 09/12/:7 14:00 B/P: SP02% '.00 11.1/.59 96 09/12/17 1 J: J 0 :.::i: 4':J ---------- ---------- 88 84 19 14 87 15 96 i 1.1/58 97 117 /5 8 97 09/12/17 13; 15 96 C-9/12/17 ---------, 8 ReEp 118/55 % E5 .t'ulse " :a 116/56 09/12/17 14: 1':J '.'. 09/12i17 14: 47 18 117/~9 97 l:'/F: "j'C,,np 98 SC " ac"cp F 21 1:.1/:,':l 99 9 8. 3 F C Tc,up 74 73 18 '...11/:,~ :../:i:, 98 SFO2% G. 5 09/12/17 13, 00 114/55 C9/12/17 "' "' "' " 0 "' 0 0 09/12/17 12: 3 G '...2; 45 9 ~ 0 Temp Temp ' F C 0 N ?ul,;e ReGp 87 " 16 lC-0/S5 97 96 108/57 B/1': SPO2% 'l'hic repc,n. NO'l'J:;: '1'rUJical is NO'~' p"lrl c,d rcsu~ Vltal 'Tenp 9o o:: Lhe '. s a::-c prc,ccdcd Siqns '-->' by C9/17./17 FROM: 1S 16 record lc''...cc..s-c Conc:ull ':'O: 'J9j'.;.2/'..7 1 2 : 1 '.c 1 7.: 01 11 : 115 per Corupany charl for enlirc 09/13/~7 87.36 09/12/17 1, : ~ 8 F 96 19 '7.3/58 96 '1 G 8 97 '9 , , 1e 1311/E:C 114/5~ 99 97 N 96 -proceos OJOO 0 '.:.18/SS 96 09/12/17 Re Rf: SP02% rnodical n 113/57 09/12/17 '1 er:ir: C 1-'u· 11e R/f-: peIT!la:-.enl. , 9, , 1 00 '1 , 7.?./C,e sro2•, 99 100 09 /n/11 C9/12/17 09/17./17 '_0: 00 09: 5::0 01 93 9C 2' 25 1B6/te 2?; 218/1~5 201/91 '...00 lOC 100 09/12/17 09 :H 09/12/1"1 09:45 09/'...2/'...7 09:47 E2 " 19 ---------- F C 80 1E 93 Fulse ::i.esp 3/P: 47 10'4/':' 21:/104 8P02~, 4 82 75 26 203/95 CS 1 00 1 CC 1 7 0 /9 0 100 05/12/17 89/12/17 09/1 ✓./17 05 - 3 0 89: 15 09: 13 100 n 16 FI/P: 100 Vi:.a1 Signs 09/:2/:7 09 : 01 'l'E.rnp F Temp C '...00 FF.OM: 09/12/17 93 4E '...81/10·1 1 oc 77 84 18 23 184/9::, 184/87 100 173/92 182/92 S.c-'U2% 76 18 0000 TO: 10 C 09/13/17 0236 0 0 ' ~ 0 ' C J-iF.Sp "' "' "' " 0"' 0 0 N 0 N 09/12/17 09: 02 F r,e R/P: SFC2% 1 00 10 0 10 09 : 51 Pulse Resp 31 '.._42/71 09/12/1! 09/12/17 Fill " 1C-:15 137/60 lC 0 '.:'P02% 'l'cmp 'l'crup 105 2:. 135/65 F 2 F111se Re!:'p r,/p: 7erop ':'erup 1 ~: 3 ~ 99 134/55 120/'iB 09 /12 /17 100 51 Re~p ll/1': Te:up Te;;op J'J /:2/:_·1 10:45 09/12/17 11, 00 09/1:/17 11:15 =/0 INTAKE IV i/:1: lV);'.:ls IV #2: #3: ::3ld ?::-odu:: TOTAL oUTrUT 0700 ~-RCYI; - 1500 0?/12/17 1500 - r.e. ·l'OTAL F::.,UID BAf.A'\JCE TO: 23 00 C:9/:3/:7 C-70C U700 - 1',00 1500 - 7.300 9 00 9 00 6" 0700 24 H:\ TOTAL 825 lUU '5 825 100 '5 75 520 1565 :v J_rj 0700 2300 75 5?.0 2300 - 0700 1565 24 llR TOTAL ,oo 900 ----------~ 65 C- eo "' " 0 "' 0 0 9 ~ 0 ' 0 N 0 N 0912 0324 MEDICAL CENTER Center Elvd. ':'exa 1a1 '/"/3 0 4. C:ONRo:,: !i.l:JIONA:... ~n/4 Me~ica: Co:-.roc, !:~~;~1: ~tjm> ciiclilTz ~9/~ 2/n ADMIT DATE: E• I IF F T li.00)! ~!O: l(.ED:CAL RECORD NO: RHCl~.ifi'...89C REPORT' TYPE: EISTORY A::ID PHYSICAL D. ICUl 8 AGE: 51 SEX: I( (b)(5 ); (b)(?)(C) AI:Y.!ITT: ~G ?IIYSICIAN: ATTE~'D:NG ?HYSIC::-Ali: ADMHlSICN DA':'5: 09/12/20'..7 PR:MA.;i.Y CA.RE ?IIYSICIA'.'J: C.:HEF C::JM?LAINT: is 'The palicnl NO"'.P.. frc:r1 immigration jail cent-.f>r. :1e..-nati:m.es '- 8. H:~TORY O!' PRESEl.'IT ILLNRSS: Tte palicn::. ~s a; :.1-year-old l!isi;:a::ic Jncarr.P.n.ted :nale,. who was t.akan t-.<1 Liv~ngslon Memori.,_: Erae:c~ency Rocm with co:T1:::,l11ints of .;.bdomina.:. pain, :eight "lank pil.~n, _, and hern<1terr,esis. IIe .r.as a past. merHcal history sig~i::can'fnr no~alcoho:ic l~ver c~r~hos~s, gene:-aii£e'USCUT.OSKBJ,ETAL: Speech appears to be c:ear. J.ARORATORY AKD :JIAGNOS':'IC !JATA: From =..ivingston ER, soc..iun 12·/, potcts~ium 4 .3, ,,ON 85, ;;nn c.,..ea>::in'ne 1.5. Albu:n'..n c.ecrea.sed :.o 3 .3. AS':: 1J2, AL':' 6e, A.LKP :23, and ~otal bilirub~n '...0.8. CPK e:evated at 322. L:pase mildly elevated at 367. BNP P.'.evated at 1B5~. PTT 2,.1. ':'i:opon'.n I 0.07E. WBC 14.28, :t-.emoglobi~ :2.s, hematocrit 33 .2, and. platelets decreased -:.o 18. ASSESSMR:-J'T' Al\,T- P~.AN: A 5'...-year cld i~.ca.rcerated Eis;;:,anic ;::iale iv~-:.h hls-:.ory of r.ona1coho1ic liver cirrhosis, now presents with: G~strojntestina: bleed.. Cifferentia.:. d.'..agncs.'..s could be variceal, eso~hageal, or gastric t:leed.'..ng versus pept~c ulcer dlseuse vers~s ~astritis. The p~~lent :1as been started on octreotite drip. ~e will also iLitinte IV PPI and monito" ~emoqlobin/hernatocr~:: levels, so :ar are stajle. GI con8ul~atio~ has heen req'.:Ast.ed for evalua-:.ion of possible EGD. , . R i qht uppe:c quadrant at:dorr.i:-.al pai::, We wi 11 check t,epat 1th i,;a:!e 1 anatier.-:. is on Cardene drip. Lhiinopril was init:.c1.t-en. ';le wi 11 t'.trate medications as needed. We wi:l discontinue 1 i si~.opri :1 in view cf :?:"ena: :::ailure and ir.it.iate be::.a. !::locker in Vi<='w <..0£histor·y of 1:.ver ~~rrr.osts. 'l . r:;T a ncl deep vein thrornbos is prcp'.::yl ax:. s to be achievec. wi tL Proto::ix/ SC:Js , Unab:e ~.r. r,i Vf'. any hl ocd ttinne:::-s due to active gas-c:::-ointest:.nal b:eea.. C.ase disc.nssF>:"l ll have wit.'."-. t.·ne :iatient, the gua:?:"::.s, and hac1 bee:-i. a ,:--,1 ;,,a ~u,e part1 ci ;ia t'. ng in the :nedical any q-_iest'.ons, please do ~ct hesitate ~o call. t:r,e RN i::-. deta:.1. ca.re of the !Ji ct a -.:.ea Byl (b)(B); (b)(?)(C) (b)(7)(E) ACCOUlfT UT: 09/]2/10]7 J . 19:~B:18 2020-ICLl-00006 4539 Fe..tie:::.~. If you rnnf~: ?.035335/~IDt: 3991040 l(b)(7)(E) PATT RN'T' NA~E: RU:Z,FELIPE l\.CCOU;:.JT 1 2020-ICLl-00006 4540 ~alicnl llr.i t No: R~IZ,FELIPR ~ame: BHOJ8(189 J CPT CODE: ~XMtS: 020697791 7 57 05 US A3DCMEN ~,Tn si~e:R16 Li:ni ~ed Ab<'.ornin;; 1 lJJ :-.,a sow:a Hislory: Right l j vf.'r r.:\ rrr.osi upper Nn p:ricr C.o.npa.ric;Gn: ~'indings: exa~iration ~his ~hP. liver narkedly quadrant. siT'."dlar 1s markediy is measures limite-e.:na..-J<-a h 1 e.. Jmpre.ss4 rm: 1. Marked:y limitefi e.x11m1nat.io:: tue. ~o poor bea:n pe::etraticn. ~he 1 i ver, qa 1: h.1 adde,_, col'.lmor. bi le d"Gct and pancreas are inadequa te:.y vi~ual~zed en this exaninil~inn. 2. unrf'.rnarfrnr.le. ..-;qht. '.dc:ney 1o:-.d ·-risua~ized port:ons of the abdorr.inal acrla and :vc. "* Eler::~.ro:-,.ir..;lly Siqner'l hy Ror.eff~ '-':am, :v!D on 89/12/2817 at Reported and siqnec: byl~(b_)(_6_);_(b_)(_7_)(_C_) _______ 1989 •* _, _________________ l(b)(6); (b)(7)(C) cc l.._ _. •~•cc'>-:nc,lcq~si. : (b)(6); (b)(7)(C) Aqenr.y ':'rnscrb~ ,,,,,,,::~l:t~::::;~i~t; -~ii·J!ii~t~ni;~itt~ ~ ?.~\t;f~}~/::tt:~{ii:~:W\.I!~ ~: r:·:1\:;::~-~l~~i11t~r:1~1:{1t:)~:::2i~::i~ti!Jt [hf:r±~j~-~jf !Z:[·~~!f; Qi~~:g[:i\{ f-~ 1 H~if ~j{;;:0:0. 11ti~iiil 11n iitti~HgJ]ItirntliiigJJli mm:mtJmMr:tl1ti:~;:\\Fttt:i1ttzrrrn }t~ll'itJ~1:fM!t:t•i:i'~:wl:q:; :*{~[~:i~},1J!1iim111:§:~;, \1IiHI 1 1 :,, MCIIC . . . 1 34 . 1 . 32 . 7 - 3 5 . l G /DL C~i~ic~J v~lues after the first occurrence are excluded from ·:fIT\~::£:~~ :~f/f:i~~~~~~-~~7I~~rf l~,1~ ~"itt}¼!: Jf~~:;~:~f~~~i?fi~ii@!:-iti!:i1fl,t-jg,I~~~~H.~ii[!it~J.Jtt ~i'.'A~#.~::tefl~~:~f~~t~il~~~:~ .. ~nmr: i!KHm~v!.rt;rn;htJ!@itittiHtllrnl1?0::'i.~~:~iR;if\;t;1r;;t;tti;'.:ji\~:~.,;:;;.~~fi,?t])fil£it I , , o.9/i4/1?-os42 I . 0,114/17-os,2 I . 09;1,111-os12 ::::::~::::::::::1::::::[;;:i :::~ii! 1 ! - . · ~:::::,:::~::::~;:;:::~:::~:: 09/l4/17-0542 t~J; rl\fi~~:#@fti\~::[ffI1rn ii:i~mtim::mt: J11f·: mn1;ii~;1n:01~;y;~irii?$_:a~1r12nn11tsm~m;(Ot/t~tt!}tlt~@f@f¥~ m%t!~{1{:;~1'1illi 0:trti~ {\g@ 1 . · - [ · 09/lt/17-0542 i~EitH~~~'{#)g{ffrntPm1tm}rn:)rn:J,:rstiEtUUM%MtE%J\);~j~;,jJfi~~Mt?itl:fm\t'i-Jil~Iit~ i1i1)!j@\\i{Z®;{_$.J;:;t~~~ 1 I 09/14/11-0542 202Q-ICLl-00006 4542 :;;:;,::;~;;~:;;;;J::~;;~;;~;;;;~:~ }if~ti~ti~~dij_@tl·!ff:LII@};¼Uiif0hi1t,~'.;f~f/1;@m;rn:;gJnil]/plt~:~\)i\:mt~i::;~:@?rng \H'. Hi)i,~:~:~:~\f~N';'.p¥lI~{Mfuiil~''J: 1 I · 1 09/14/11-os,2 ,r 2020-ICLl-00006 4543 CONROE REGIONAL MEDICAL CENTER 504 Medic~l Center Blvd. Conroe, Texas 77304 0913-0070 PATIENT NAME: RUIZ,FELIPB ADMIT I ACCOUNT NO : !l h \/ 7 \/ F \ DATli:: ROOM NO: AGE: MEDICAL RECORD NO: BH0086l890 REPORT TYPE: ENDOWORKS R!PORT SEX: 09/12/17 B. ICU18 51 M (b}(6); (b)(7)(C) ADMITTINGPHYSIC ATTENDING PHYSICI Indications: Her:iatemesis Consent, The benefits, and informed consent (578.0). risks, and was obtair.ed alternatives from the to patient. the procedure ~ere discussed Pre-Sedation Assessment: Hand P completed, I have examined the patient on this date and have reviewed the medical history, drug his~or/, and previous aneslhe:;ia experience. Results of the re'.::evant diagnos-:.i'c studies have been reviewed_ Planned choice of anesthesia, risk, complica~ions, benefits and alternatives have been disci...:.ssed. Preparation: throughout :{.ep-;. NPO. the EKG, pulse, procedure. pulse Medications: See anesthesia Procedure: The gastroscope visualization The scope good. Hypertensive and antrum. and line was passed through the mo·.1th under portion of examined. direct the duodenum. The views ~ere Esophagus: The proximal third of the esophagu~, middle third of the and cijstal t-.h.ird of the esophagus appeared to be normal. Stomach: portal gastropathy was found in the fundus, body of the stomach, Duodenum: Patchy erythema in bulb and 2nd portion. Sent, None, unJess Entimated Blood Loss, Insignificant. JnpLanned Events: There Summary: Normal proximal a:1.d distal third of the the fundus, body ot the and 2nd portion. were othe:i:wise noted. no unplanned event3. third of the esophagus, ~iddle third of the esophagu3 1 esophagus. Hypertenaive portal gantropathy was found in stomach, and antrum (572.B). Patchy erythema in bulb ~ecommendations: Avoid all non-steroidal including but not limited to Aspirin, Return to floor. Resume low salt diet medications. PPI 20 mg daily. anti-inflammatory drugs (NSAID's) Ibupr~~en Advil, Motrin 1 and Nuprin. 1 as tolerated. Continue cur r ent • l(b)(7)(E) PATIENT NAME: RUIZ,FELIPE Run: were monitored The pat~ent waG report. Specime:is Patient blood pressure was inserted. and was advanced with ease to th~ 2:id withdrawn ~nd the mucoGa wan carefully was ~indings: esophagus, oxim~try, Ar. intravenous Care Inquiry 09/13/17-1:,21 .ACCOUNT (PCI: OE Database by~l(b_)(_5)_; (_b)_(7_)(C _)__ 1t. COCCR) ~~......... l 2020-ICLl-00006 4544 Page 1 of 2 By: The procedu1e As5isted Procedu;i:-e Codes: Version 1, 07:42 AM. [43235) ~as EGD electronically Electronically Signed by N/A. assist~d DJ b)(6); (b)(7)(C) "l ::1igned by 5 M.D. ~lon 09/13/17 b~~(b-)(- )-; (_b_)(?-)-(C_) ____ on 09/13/2017 at at 0742 .. : l(b)(?)(E) ACCO'IJN'T ,. . PATIENT NAME: RUIZ,FELIPE Patient Care I~quiry (PCI: OE Database COCCR) (b)(6); (b)(?)(C) Run: 09/13/17-11: 21 b Page 2020-ICLI-0 006 4545 2 of 2 I. Patient: RUIZ,FELIPE Unit#:3H00861890 ~ate:09/12/17 Acct:#: I (b)(7)(E) otassium (3.5 - 5.1 mm 4.2 Chloride (9 5 - 105 mmo 102 Car · · ····· Ani BUN ) . . ····-·· - 24. L) 7.0 ··-~. ,,-,-.,..,.._...,--.-~----+----__,,_,_3""'6,_H~ -·67H 132 H 7.8 L L) _ Direct I . MG/DU (0.00-0.30 .. ·· .. 2-1.3i A L) ) ) 49 . T. Alf< se(45-117Uni L) Tota Protein . - fl.2 G/D1~---'----l--------~5-,.4---.--, 107 A )Umin 3.4 - 5.0 G DL) Albumin u in Ratio --'-,-~~--__.;;....c---l-~-~---.......1 (1. Specimen H ·3.35H 3.21 H -'----~----~8~1~H--.-1 )'-- . A . 2.9 L rp~aranr:e tl N Spedmen Hemolysis (1 N Laboratory Tests 09 12 1200 Laboratory Tests ·- ···-·-- 09712 ----- .. Hematolqgy WBC (4.1 - 12.1 k/mm3) - .... -- ---- -··-- RBC (3 .8 - 5.5 MTmm3) ---- Hgb (10.6 - 15.8 G/DL) Hc:t O 6.0·=·47.4 °/~). MCV (80:T - 101.1 fl) MLH (25.3 - 35.3 pg) 1200 ···-··- 1.S.1 H 3.50 L . ·-·-- 11.2 3 Cl.1 L 86.0 .. 32.0 37.2 rr 17.2 H JVICI IC (32.7 ~-35.1 C/DL) ROW (12.2 - 16.4 ¾) PitCount (1j5 - 337 K/mm3) ~MPV {7.6 -~10.4 fl) -- ---- ·- Page 3 of 4 2020-ICLl-00006 4546 .. 27 ,!. L 1 D.3 Patient: RUIZ,FE~IPE Unit#:EH0086l890 Date:09/12/17 fb )(7)(E) Acct.fr: I (37.8 - 82.6 °lo % (Auto) (14.1 - 45.4 %) 0 Mono% (Auto) (2.5----,.------,c'-c11;,:·.,;...7 __ /4_!_o) ________ Eos 0 a ulo) (0.0 ~ 6.2 ¾J Baso % (Auto) (0. 0 - 2.6 %) 0 -+- __ 0.5 Diagnosis, Assessment & Plan FreeText A&P: GI Bleed: managP.mr.ntper Gl hypotension : better. RPT #:0912-0575 ***END OF REPORT*** Page 4 af 4 2020-ICLl-00006 4547 65.8 12.1 12.7 H --- 1.7 Patient: RUIZ,FELIPE Unit#:BH00861890 Date:09/12/17 f ~b)(7)(E) Nicardipine/Sodium Chloride 250 ML .STK-MED ONE IV (DC) General appearance:alert, awake Head/eyes:normocephalic, PERRL,EOMl 1 clear cornea Ned: full rangP of motion 1 non-tender, normal thyroid, supple/no meningismus, no bruit/NL carotids, no JVD, no lymphadenopathy Cardiovascular:regular rate & rhythm Respiratory/chest:dP.creased breath sounds Abdomen:soft, non-tender, no distention, no guarding, no mass/organomegaly, no rchound Extremities:moves all 1 normal caµillary refill, no edema Musculoskeletal:full range.of motion, normal inspection Results Findings/Data: Laboratory Tcsts 09/12/17 1200: 09/12/171155: >-< 102 133.0 4.2 Laborato Tests 24 -b-9/l'.2°--09/12 09 12 15301 1530 1530 Chemist 90Jf*H Ammonia (11.0 - 32.0 m --LR= --=rra -2 ( 1 .0 - 3 .6 4. 9 0.2 70 * H (o.ooo B- a riuretic Pepti ML) 226.59 H 09 12 11551 1em1slry :--SoaiumlT33- 144 133 .0 mmol/U Page 2 of 4 2020-ICLl-00006 4548 1@~~132H.,. ~ CONROE MEDICAL CENTER (COCCR) Pulmonology Progress Note REPORT#:0912-0575 REPORT STATUS: Draft DATE:09/12/17 TIME: l7l4 UNIT#: BH00861890 ROOM/BED: B.ICU18-W ATTEND :l(b)(6); (b)(7)(C) PATIENT: RUIZ FE~IPE ACCOUNT#: ~kb= )(7=)(=E l0____ DOB: 06/26/66 AGE: ADM DT: 09/12/17 * ALL edits document* or ____J 51 amendments SEX: M must be AOTHOR:~. ________ made on the electronic/computer Subjective ChiefComplaint: RFC: GI blced/lCu management. Objeclive Physical Exam VS/1&0: Last Documented: Rr.sut: Date Tern 98.3 Pulse x 100 0 2 Fl R~a~te-+-- 2 ·s P 11 7 58 ow I me 09 12 1600 0912 1447 . 09 /r 2 144 09 12 1400 88 09112 1400 ··19 09/72 1400 Pu se Resp Medications: Active Meds + DC'd Last 24 Hrs Folic Acid 1 MG DAILY PO Lar.tulose 30 ML BID PO (CKD) Pantoprazole 40 MG Q12HR IV TraLodone HCI 50 MG BEDTIM E PO Metoprolol Succinate 12.5 MG DAILY PO SertralineHCI lOOMG DAILY PO Sodium Chloride 250 ML ASDIR IV Labctalol HCI 10 MG Q4H PRN PRN IV Levofloxacin 100 ML Q24H IV Morphine Sulfate 1 MG Q41 l PRN PRN lV Ondansetron HCI 4 MG Q4H PRN PRN IV Sodium Chloride 250 ML ASDIR PRN IV Sodium Chloride 1o ML ASDIR IV Sodium Chloride 1,000 ML .QHH20M \V Lisinopril 20MG DAILY PO (DC) Nicard ipine/Sodium Chloride 250 ML ASDIR Page 1 of IV 4 2020-ICLl-00006 4549 _J :.:1:::~~·=e~~~±-~~=t~;0iI!!:~~~:.;1:;:~~=:~~r 71 (~;~dieaL¢erte.f~~~~t:o:~ ~~;~j; ):,,!~:~ #~~4n ,MEN). . ... :o~A.•~f.lis tg.;~~:~~: 11;~; ~,~x,swM 1 t-if)< /RESP~{ COMP, 0912:CR:S00025R Coll: 09/12/17-1530 Recd: 09/12./17-1619 (Rl!07673575) I SCREEN ·•:•.•·. :=i:i:::i/i2/:('i:~1'i!i:<:i:>> .•• •:~j:::112.J~;.;111 •• 8 ·.·.·.·.·.···.· .. ·.··.·.·.••·•·• =:•••••• ••• .SCREEN ....................... #W12#J::,l;'l@t:·•·· .. SCREEN : :%H;~:E_--'-'-'.~---'-'~-....,_;_~~ 2020-ICLl-00006 .. :.·.·.·. ·.. : .. ·.·...... . ...... . ·=•uriii#!3Hti6 iiia ..~()............. . 4550 CONROE MEDICAL CENTER (COCCR) Clinical Note REPORT#:0912-0490 DATE:09/12/17 REPORT STATUS: Signed TIME: 1522 UNIT#: PATIENT: ~OIZ EEJ.IFE ACCOUNT#:~~b)_(?_)(E _)_____ OOB: 06/26/66 AGE: ____. 51 SEX: M or amendments must be made on the electronic/computer document* **See Addendum** ClinicalNote Note: 2ms:-us J I b)(6); (b)(7)(C) pn 09/12/17 at 1 522 Electronically Signed b Addendum 1; 09/12/17 1524 l(b)(6); (b}(7)(C) b1~---~-------' 203 5363 (b)(6); (b)(7)(C) bn 09/12/17 at 1.17S Electronically Signed b RPT (b)(6); (b)(7)(C) AUTHOR: AD~ DT: 09/12/17 * ALL edits BH0C861890 ROOM/BED: ATTEND : #:0912-0490 ***EN~ OF REPORT*** Page 1 of 1 2020-ICLl-00006 4551 l(b)(6); (b)(7)(C) FAX: FAX: Nane: Pa-::.ient :::arr.pus: 9 3 6-5 BS-4657 'L'l6-'iA5-4fi:,7 _ RUT7,FRTTP8 U!:it No: EXAMS: T 18 ,cJc:.ad on: Chest x-ray CLIN:CAL Corrpar1 exarr., HISTORY: son oHC0861890 eE•"l' C.OlJ'::: 710:0 XR ~HEST 1 V C2069779~ C exar:is: AP frontal prO'je:::t:io:., T.euimcytosi !l, tJone of the 9/J 2/2rl:7 TC.U piltiA:,t_. che!lr. Eleva-::.10:1 t'.~.e riq".t r.P.m'.niaphra(Jlr, ii.ffic;,:lt to assess in terms cf li'!r.k of prior ex~ns. Probable ccarring versus a-::.e:ectatic changes rr.ai~ly at: the r'qht J·.:nq hi'!!le_ No ;ictive ~•:-rl-'. Overlying 1 i nP.;; nh;;c;11re tetail. Ne findingo c,[ high concern for p::eu11a0nia ago_ qive~ w• F.Jectr,:rically w* ~'.qnerl hy j~(b_)(_6_);_(b_)(_7_ )(C _)__________ _ 09 /12 / 2 O1 7 a:_ .,,·, ..,.1 ... 2.,,6,.......,,..,..,,,,,..,.,,-,--------"•""'•--------, Re:iort_P.rl anrl !l'.gne.d by ,l(b)(6 ); (b)(7)(C) on ~----------------~ cc r )(6); (b)(7)(C) Date/'T''me: tic-:::ated 09/1;;./n17 'J echnol (172fi; ! :-ic,i 8 t :j (b)(6); (b)(7)(C) 'Tnnscri:ied naEe/'r:rr,A: t19/1 L J',i:ii1 (1726) r.r;q Pri!:: D/1: S: 09/12/20:.7 :1729) CO~OF. MED CTR I~/U3S i,;{ b)(6); (b)(7)(C) Nl\ME: RGlZ.FELIPE PHYS: !(b)(6); (b)(7)(C) MED::.CAL D1/\GDJC -~ 0 I'., J'cKlI CJG '.~EN'l'ER 3::..VlJ COJ\ROF:, 'fF.XAS 77J 04 DOB: 06/26/1966 ACC'~' Nl(b)(7)(E) PH(;NE #: 336-53S-7026 EXA.'l DATE; #: 9'.lfi-5~S-76A1 RAD !\Cl: FAX PAG: 1 "igncd AGE: 5· 09 /12/201'/ Loe: SEX: M 3. 1 ::::ns w STATUS: ADM :N DC Dt; Repor-::. 2020-ICLl-00006 4552 Fax Server 9/18/2017 8:35:47 AM To: 1st F'ax: 9193696'18846 E'rom: CHKR PAGE A-nobody Phone Pages: IMNET/EPRS 45 (including fax banner) n=,quest. 2020-ICLl-00006 4553 1/045 Fax Server Fax Server 8/18/2017 8:35:47 AM PAGE . ,_ ··,~·. .·.--. 2/045 Fax Server ,-.....--:--1, , •.• ' .1-. 0 ""'fCHI St. Luke's Lufkin ,.J: Health. Livingston □ MEMORANDUM OF TRANSFER San Augustine SECTIONA (To Be Filled Out At Transferring Hospital) ----------'--------------------I. Nam(:of Hospital: ,---------'~-~-------------~ 8. I furtherhave determinedthal lhe patientwouldbenefitfrom transferto ~,ia- Address: '--· HI St.Lukc's~ealthMemoria)L\vingst Ph~ne Numuc,.. . 1717High.Qy59LOOpN Pat~cntInformauon(!f,kn~wp) , iv~:riosto Paucnl's Full ~ame: ~~-G'? ~~___:_2\] Address: ~~\Q(~ :E ~ ___ 2. Cw\.\¼!. ,t Of\ Phone rzber: (~ s~x: M . F Age: Na~o_nalorigin: /9]¥1!,'.'G Race: Rehg!on: 0 .. ''Pliysical HllJldicaps: - . 5/ , f\ ,spau , \( _;e, _____________ ' 3. . anolh~lh ____ can: facilitydue lo the followingreasoning: SpecialtyCarefor patient'sconditionnotavailableat lhis institution ____ Hospitalbed accommodations al lllisfacilitynot available k::::,, Patientand/or familyrequest __✓ __ Patientwould benefitfromhigherlevelof clinicalcm 1 furthc:rhavedclcnninedthe risks and bcncfiliof Lransfcranchave explained these to the patic t. These~ as follows: Risks: 1'-A;. _ ·\/'--------------------Nclitof Kin infonna~ {if known) 9, Ne~WfKin:---;;;,JI--------------Address: ::-4! 4. 5. ¢ ua 6. y transferringpit Date: __ ......,_.......c4-<-1---1 (b)(6); (b)(7)( Nameof aoccptingphysician: __,_ _____ y~~mpital . Time: (.m~stra 'n - - . (/(/() f~oV ! I. : ....... f(j _____ 9 / 1 17 IO. PhoneNumber:(jffj~~~----------Dateof Arri_val:Cj/U { f 7 Time: --&~\O_J.~---lni1ia! withreceivinghospital: () / :Date: ':1,.J tdJUJ 'lime: --~-.d-=..!~---Name (b)(6); (b)(7)(C) . . hospital: con~ Date: Nameo 12. N _ _.______ Address:-~~r-:-7#''=-i.-"-~~.,__=.a....,_.,,~~.,....;~=-...,_, _ 13. 7. ~:rn,,~rm Transfeningphysician'ssignarureor · physician'& orders: · ;,r actingunder 'all.ivjngsto Addrc..s:---------=="'-,.,..,..,,,.....,...,.,,...........,,..------ PhoneNumber:(__J _____________ 14. Attachments: MD ProgressNoles X-Ray__ ~Y..,..y.,....·=Nu~es Pro~s Noles.__ Lab Reports--~~;t.H & P __ _ __ _ M&lica.tion Record Other. __________________ -~X~,,---'?,._,. __ --~y__ __ _ ·rBYsICIAN CERTIFICATJON:IBased upon the informationavailable al the time of thUrlln r the medicalbe e IS aP.propriatemedical1reaunen1 at anothermedicalfllciliryoutweighthe inc:easedrisks of th (b)(B); (b)(?)(C) ~tbeen e,-aminedand is dctenninedto be: f,Sr~ble.;.\ (J Unstable · PhysicianSignarure:________ ..., cxpecledfromthe provisionof r, the unbornchild. The patient J'ATIEij;r,CERTIFICATION: I1,the undmigned,hereinafter referred to as the patient,ac-kn_o_\Vl_ed_ge_tha_t_the_ph_y_s_ic_ian_n_am_e_d_a_bo_v_e_h~ explainedto me rhe risks and bendit.sof-'atransferLOarmlhermedicalfacility.! fu b)(B) (b)(?)(C) benefitsof thetransferoutwdghtherisks.I herewith ' recordsav~lable a.1the timeof transfer,to the receiv J ' ·· n which naslhas not b~ensiabilizc:danrlthat the medi.-al d herebyconsentlo thereleaseof all 11.ppropri~ medical ~ Po1tienl or r- _______ Witness: ~-----------I. Dateflime ~~ Date/lime ~ ·;_.jjJ[ · · . ,... SECTIONB (To Be Filled Out At Receiving Hospital) - ------------- Nameof Hospital:_______________ Address.:__________________ _ Pt.oneNumber:(_ __J ________ _ _____ 2. Da1eof Anival:_____ _ Time: _ __ ___ _ _ __ _ ,.......---------------------------,--' 4. Receivingphysicianassumingpatientresponsibility: Date:----,--,---,---Receivingphysidan'5signature: lime: _ _ _ ___ _ _ _ _ ;\i\t\i~:s:umber: (_) •:.:_;t\\~'f.:response to transfer-~-ue_s_t _w_as_de--,-la-yc:d_bc_y_on--,d,...thirt-:-:-, -y-,(""30::7)-m--:i-nu-1 3. HospitalAdministration signature: Title;___ · '· :·'•'·docul'QCnt the reason(s}for the delay,includinganytime extensionsagreed •. •lo byJrailsferring_ho~piutl. U.sedditlonalsheets,if necessary. • r,,b, nUaUJ#dby,Tran.i/~rri•i forililji· · /09/()6/()6) Kwjk ',Qpy /',inr/,ig 0 WHtr£ · To 11~~/wng Fad/ii)' Y£LJ.OW 2020 -ICLl -000.06 : :_M A:::":5.64 'r. • _' • Fax Server 9/18/2017 8:35:47 AM PAGE Fax 3/045 Server FINAL (SIGNED) J~~ ~r CHI St. Luke's Health MMC LIVINGSTON Abdominal Pain Flank Pain ICD10, Transfer of Care Note add on I Sex: Patient: ALMAZON RUIZ, FELIPE Age: Male 09/11/2017 23:20 Room: DOB: 06/26/1966 51Y Bed: RM4 I r b)(6); (b)(?)(C) r .~- ~·. J Informant: s1301:1se Exam limited by: UReonseiousness 09/11/2017 23:20 ~ 10:06 PM date / time:09/11I2017 Creation Date: I I 0010282353 Visit#: 0300267948 A b)(6); (b)(?)(C) Physician I MR#: DOS: FMS arrival witness: para me dies- ffiCAia!impairmeAt unoooperauveness meAtal impaiFmeAt unsooper=a~i¥eness - intoKieation eommttniea!ion barFicr History limited by: uneenseiousnes&- iRlm1isation eoRciR'IUnisalisn barrier Transfer from: See transfer record Ci H Pl Complaint: Onset: 1 ~ obdomiRal paiA min ~ hrs gradual onset ~ 1le11'lk pain: ago Duration: waxing --R-min + hrs ~ waning since: gone now better ~ intermittent episodes -.ua11~I out gf country Context diarrhea sudden onset worse Timing: ~ rn Updated Reviewed lasting: bad foml reGent trauma Comments: 51 Year old male, with a PMHx of Hep C, presents to the ED with a complaint of vomiting blood. The patient reports that he has vomi~d blood about 3 limes_ He states that he has abdominal pain at a 7/10. The patient notes that he also has blood in his stooL The patient denies all other complaints. Severity: pain max: 0 pain currently: 0 1 2 3 4 5 6 (J) 8 9 10 Scale: ~ Wong Baker© 2 3 4 5 6 (!) 8 9 10 Scale: ~ Wong Baker© Documentation Cont. Next Page Circle ~ strikethrough [ NAM E: ALMAZON RUIZ, FELIPE - MRN: 00102821020.ff~,SQ Ae§ati.•es unmarked = not applicable QC,00d84' 55Sotember 12, 2017 5:18:14 AM- Page 1/20) Fax Server 9/18/2017 8:35:47 AM PAGE 4/045 Fax Server FINAL (SIGNED) °"' J~ CHI St. Luke's Health MMC LIVINGSTON Abdominal Pain Flank Pain ICD10, Transfer of Care Note add on Patient: ALMAZON RUIZ, FELIPE Quality: DOS: I Se" Male ~ MR#: 09/11/2017 23:20 ashing 0010282353 Location: burning cramping sbB9ing fullness ~ Associated Symptoms: shills nausea ~ X3 ~ B!omi streaks seffco grounds Migration (show migration: ---m~----, Siarrhea x ~ grossly 91oody l9ss ef appetite ~ s1:1pine mucous- ----GfieG!-.paifl- testicular pain uprigAt position A'IO'o'CffiCAtS walking R9Ck pain eough ----eeey-breaths ~ food uf}fight ~osition -sttptt'te"- antacids ~ --food- Siffiilar S:fA9pteA'lsprevio1:1sly: seen Recently: treated by Eloetor ~ Reviewed ROS CONST recent GI censtipation illness £1 Aospiklli:ceel Updated injUF) ~ blaek- stools: Comments:bloody stools per patient CVS pal19itations RESP shortness of bFCath GU urine: I MUSC bloody sough hurts to breathe ----eafk.- problCA'ISuriAaUA§ LMP date: pregnant post-menopausal joint pain SKIN LYMPH 5\>VOIICA gl □ Ads EYES problems ~¢Ith visio1, Circle UAhk S'#CJliAg -R- ~ strikethrough + AB!'JBB•,•es unmarked= not applicable [ NAME: ALMAZON RUIZ, FELIPE- MRN: 00102823282()?iretqd()(J00(5da,1,5861tember 12, 2017 5:18:14 AM - Page 2/20] Fax Server 9/18/2017 8:35:47 AM PAGE 5/045 Fax Server ·~ FINAL (SIGNt:O) ~f CHI St. Luke's Health MMC LIVINGSTON Abdorrnm:I Pain Flank Pain lCD10, Transfer of Care Nole add on Patient: ALMAZON RUIZ, FELIPE ENT sore throat NEURO heaelt!iehe Male diuiness PSYCH I MR#: DOS: I Sex: 09/11/2017 23:20 0010282353 light I 1eadeel1 ,ess depfessien ~ except as marked positive, all systems above reviewed and found negative ~ HISTORY Reviewed ■ Updated No ohFenie diseases Cardiac disease: Diabetes: At1b Type 1 CAD Type2 CHF Ml diet oral insulin Hypertension Peptic ulcer Gall stones Kidney stones Rladder infection Kidney infection lschemic bowel risk factors: valvular disease elderly low BP recent Ml Pancreatltis GERO Diverticulitis Abdomlnal aneurysm CVA TIA: deficit: R L Ectopic pregnancy Fecal impaction ~c Hyperllpidemia Intestinal obstruction Circle~ strikethrough !'lOgaWos unmarked= not applicable [ NAME: ALMAZON RUIZ, FELIPE- MRN: 00102823idzoE,rel~Q()(J~eda14~tember 12, 2017 5:18:14 AM- Page 3/20] Fax Server 0/18/2017 AM PAGE 8:35:47 Fax Server 6/045 FINAL (SIGNl::.D) 11,~ ~r CHI St. Luke's Health MMC LIVINGSTON Abdominal Pain Flank Pain ICD10, Transfer of Care Note add on I Sex; Patient: ALMAZON RUIZ, FELIPE Ovarian: cyst(s) Male MR#: 09/11/2017 23:20 0010282353 fibroids STD Pelvic infection: x DOS: Old records reviewed I summary Surgeries / Procedures: hernia repair R cardiac bypass none appendectomy cholecysteclomy endoscopy upper lower L cardiac stent hysterectomy BTL C-section tonsillectomy ·················· ..··············-···-···············--··--······················--··· ···············---······-······················· ·····-···-·--·········· ........ __ ._··-·..·····-1 Full Problem List ~ D IUpper GI bleed (2017) Reviewed I Allergies Updated ~ Reviewed Q Updated :&l Reviewed 0 Updated ~_. I Re~~w_e_d __ □_... _. _u_pd_a_te_d ________ f3 ■ Updated No Known Allergies . Home Medications [ t~.~~nizatio_n_s _____ SOCIAL HISTORY Reviewed --·-···----------------, _ Tobacco Use Never smoker b)(6); (b)(?)(C) None Reported : TOBACCO HISTORY Last Documented 8~ [Aicohol Use 09/12/2017 01:58 ________ I I Recreational D~~g Use FAMJLY HISTORY gall stones ~ Reviewed ovarian cysts Circle~ CAD ■ Updated ulcer strikethrough kidney stones Regatf,•ee aortic aneurysm unmarked== not applicable [ NAME: ALMAZON RUIZ, FELIPE - MRN: 0010282~.fi'C!fl!f.SOQCJOOd~5;t,Jtember 12, 2017 5:18:14 AM-· Page 4/20 I Fax Server 9/18/2017 8:35:47 AM PAGE Fax Server 7/045 ·~ FINAL (SIGNED) ~r CHI St. Luke's Health MMC LIVINGSTON Abdominal Pain Fiank Pain ICD10, Transfer of Care Note add on Patient: ALMAZON RUIZ, FELl?E 09/11/2017 23:20 Male VITAL SIGNS ~ Reviewed Last Set of Vitals: Interpretation: ! DOS: I Sex: MR#: 0010282353 ■ Updated nonnal hypoxic BP: 160/103 09/12/2017 02:31 Pulse: 94 09/12/2017 01:10 Temp:98.1 F 09t11/201721:36 Resp: 18 09/11/2017 21:36 02 Sat 99.0% 09/11/2017 21 :36 Additional Vitals: PHYSICAL EXAM ~ Nursing assessment revtewed CONST ~ distress: mild ~ anxious lethargic Comments: moderate severe Patient is alert and in no acute distress on exam. EYES ~nnorimiD scleral icterus EOM palsy pale conjunctivac R L anisocoria R L hearing deficit R Comments: Normal on exam. ENT ~ ~ pharyngeal erythema abnormal TM R L L Comments: Normal on exam. NECK ~ Comments: thyromegaly lymphadenopathy Norma1 on exam. RESP ~respiratory Circ!e I NAME: distre~ ~ ALMAZON RUIZ, FELIPE wheezes strikelhrough R L RB!ilatives rales R L rhonchi R L unmarked= not applicable MRN: 0010282~flc!n!t-'OOOffiJd~fi~!J)tember 12, 2017 5:18:14 AM~ Page 5/20] Fax Server 9/18/2017 f-lNAL (SiGNED} 8:35:47 AM PAGE Fax Server 8/045 "'~- ~r CHI St. Luke's Health MMC LIVINGSTON AbdominalPain Flank Pain ICD10,-rans fer of Care Note add on Patient: ALMAZON RUIZ, FELIPE I MR#; I Sex: DOS: Male 09/11/2017 23:20 0010282353 ~ Comments: Normal breath sounds on exam. CVS ~ ~ ~ irregularly irregular rhythm JVD present tachycardia gallop: murmur: grade S3 decreased pulse(s): 84 systolic /6 radial bradycardia R diastolic femoral L dorsalis pedis R R L L Comments: Normal heart sounds on exam. L!::GENO T G = Tenderness "'Guarding R m = Rebound =Mild l·. mod = Moderate sv : Severe • I ABO rigid distended tenderness guarding rebound ~ hepatomegaly ~ abnormal bowel sounds: ~ prominent aortic pulsation ~ McBumey's point tenderness generalized RUQ LUQ RLQ splenomegaly increased psoas decreased absent Rovsing's sign tyrnpanic obturator sign mass: Comments: No abdominaltendernesson exam. GU external inspection normal catheter present PELVIC EXAM normal external exam vaginal bleeding normal speculum exam cervical motion tenderness Circle ~ strikethrough RB!21ati¥es LLQ vaginal discharge unmarked= not applicable [ NAME: ALMAZON RUIZ, FELIPE- MRN: 0010282~O.oot!Ml00@6dat,56~ternber 12, 2017 5:18:14 AM- Page 6/20] Fax Server 9/18/2017 8:35:47 AM PAGE Fax Server 9/045 _._:., FINAL (SIGNl::.U) ~r CHI St. Luke's Health MMC UVINGSTON Abdominal Pain Flank Pain ICD10, Transfer of Care Note add on Patient: Male ALMAZON RUIZ. l=ELIPE normal bimanual exam I MR#: DOS: I Sex: 09/11/2017 23:20 0010282353 adnexal tenderness adnexal mass enlarged ute,us tender uterus L R MALE GENITAL normal inspection testicular tenderness R L testicular swelling R L inguinal tenderness R L inguinal swelling R L RECTAL non-tender tenderness heme negative stool stool: fecal impaction heme positive trace black bloody BACK ~ CVA tenderness R L Comments: Normal on exam_ SKIN ~ cyanosis diaphoresis <@ir~ skin rash zoster-like embolic lesions signs of IVDA (§_iiii) ® ~ pressure ulcer location: depth/ stage: 1 2 3 pallor 4 Comments: Normal or, exam. EXTREMITIES ~ ca!ftendemess R L ~ Haman's sign R L ~ pedal edema R L C'.,ommenls:Normal on exam. NEURO ~ ~~ormal .@:!.__21:> disoriented to: person place weakness R L facial droop R ~ speech abnormalities ~ sensory loss R time situation L cognition abnormalities L Comments: Patient is alert and orientedx 4 on exam. Circle ~ slrlkelhrougt, Aogati1•oc unmarked= not applicable [ NAME: ALMAZON RUIZ, FELIPE - MRN: 0010282~20fi€!.E!~OO@§da4~tember 12, 2017 5:18:14 AM - Page 7120] Fax Server 9/18/2017 I-INAL (SIGNl:::D) 8:35:47 AM PAGE 10/045 Fax Server J -~ - ~r CHI St. Luke's Health MMC LIVINGSTON Abdominal Pain Flank Pain ICD10, Transfer of Care Nole add on I Sex: Patient: ALMAZON RU(Z, FELIPE MR#: DOS: Male 09/11/2017 23:20 0010282353 PSYCH ~ depressed mood .•ee Status Collection Final Result Final Result Final Result Final Result Final Result Final Result Final Result Final Result Final Result Final Result Final Result Final Result Final Result Final Result Final Result Final Result Final Result 09/11/2017 23:29:00 09/11//017 23:29:00 09/11/2017 23:29:00 ------09/11/2017 23:29:00 09/11/2017 23:29:00 09/11/2017 23:29:00 ------------09/11/2017 23:29:CO 09/11/2017 23:29:CO 09/11/2017 23:29:00 09/11/2017 23:29:00 09/11/2017 23:29:00 -□ 9/11/2017 23:29:00 09/11/2017 23:29:00 09/11/2017 23:29:00 ---- 09/11/2017 23:29:00 09/11/2017 23:29:00 09/11/2017 23:29:00 unmarked= not applicable MRN: 0010282M0.fffil1!M)~da¥.,6iptember --- - 12, 2017 5:18:14 AM - Page 6/20] ' --- .. Fax Server 0/18/2017 8:35:47 AM PAGE 11/045 Fax Server FINAL (SIGNED) .Jb;, ~r CHI St. Luke's Health MMC LIVINGSTON Abdominal Pain Flank Pain ICD1 D, Transfer of Care Note add on Patient: ALMAZON RUIZ, FELIPE CBC PLATELET AUTO ,DIFF °CBC PLATELET AUTO DIFF DOS; I Sex: Male Nucleated RBC I MR#: 09/11/2017 23:2D •O (0-2 1100WBC) Neutrophils 10 L (42-75 } CKMB 7.49 HH (0.00-2.36 ng/ml) ' CKMB 0010282353 Decreased platelets, NO Platelet clumping , few large platelets seen on peripheral blood smear. RESULT CALLED TO Final Result Final Result 09/11/2017 23:29:00 09/11/2017 23:29:00 I Final Result 09/11/2017 23:29:00 (75-110 mg/di) Final Result 09/11/2017 23:29:00 09/11/2017 23:29:00 icb)(6); (b)(7)(C) '; I (ER) AT 0003 THEN READ BACK //HH/ . 127 H ;CMP COMPREHENSIVE ,METABOLIC PANEL ,CMP COMPREHENSIVE ;METABOLIC PANEL ,CMP COMPREHENSIVE METABOLIC PANEL CMP :coMPREHENSIVE 'METABOLIC PANEL CMP COMPREHENSIVE METABOLIC PANEL Glucose Polassium 4.3 (3.5-5.0 mmol/I) Final Result 09/11/2017 23:29:00 'CMP Chloride 95 L (98-107 mmol/1) COMPREHENSIVE •METABOUC PANEL •CMP ;COMPREHENSIVE 'METABOLIC PANEL Final Result 09/11/2017 23:29:00 CO2 (22-30 mmol/I) Final Result og11112017 23:29:00 (8.4-10.2 mg/di) Final Result 09/11/2017 CMP COMPREHENSIVE METABOUC PANEL 'CMP :COMPREHENSIVE METABOLIC PANEL 1 •CMP BUN 85.0 H (6.0-17.0 mg/di) Final Result Creatinine 1.5 I~ (0. 4-1.2 mg/di) Final Result Sodium . 127 L (137-145 Final Result mmol/I) · 22 23:29:00 " 09/11/2017 23:29:00 : Calcium : 8.6 ' 23:29:00 T Protein i 6.5 (5 1-8 7 gm/di) Final Result 09/11/2017 23:29:00 Albumin . 3.3 L (3.5-4.6 gm/di) Final Result 09/11/2017 23:29:00 (1.122) Final Result 09/11/2017 COMPREHENSIVE METABOLIC PANEL CMP COMPREHENSIVE METABOLIC PANEL -09111/2017 A/G Ratio Circle ~ 1.0 L strikethrough Ro~a~i¾•os [ NAME: ALMAZON RUIZ. FELIPE - MRN: 0010282~~0~tlf!00!J~d~~sptember unmarked= 23:29:00 not applicable 12, 2017 5:18:14 AM- Page 9/20] Fax server 9/18/2017 8:35:47 AM PAGE Fax Server 12/045 j--· FINAL (SIGNED) J oi'•,~ ~ ~r-CHI St. Luke's Health MMC LIVINGSTON Abdominal Pain Flank Pain ICD10, ..,.ransfer of Care Note add on I Sex: Patient: Male ALMAZON RUIZ, FELIPE CMP 'COMPREHENSIVE !METABOLIC PANEL ' !CMP COMPREHENSIVE METABOLIC PANEL CMP :COMPREHENSIVE METABOLIC PANEL ··-··- .. CMP 'COMPRFHFNSIVF: METABOLIC PANEL CMP [COMPREHENSIVE METABOLIC PANEL ....• :CMP ,COMPREHENSIVE METABOLIC PANEL CMP I MR#: DOS; 09/11/2017 23:20 102 H (11-36 U/L) Final Result 09/11/2017 23:29:00 ALT (SGPT) 68 H (11-40 U/L) Final Result \ 09111 /2017 · 23:29:00 Alkaline Phos 123 H (47- 114 U/L) Final ' Result . 09/11/2017 23:29:00 -- .. . ·-·-··-·---- . -· - ---- ; Tota] I:filirubin 10.8 H Globulin (0.2-1.2 mg/di) (2.3-3.5 gm/di) 3.2 . Final Result ; 09/11/2017 23·.29:00 . ---·· ·-··. Final Result 09/11/2017 23:29:00 Final Result 09111/2017 23:29:00 Final Result 09/11/2017 23:29:00 Final Result 09/11/2017 23:29:00 i .. Anion Gap 11 Calcium, Corrected 9.2 ____ , (8.4-10.2 mgidl) •COMPREHENSIVE !METABOLIC PANEL ' : ---···· CPK 322 H (30-135 U/L) {!PASESERUM lipase 367 H (8-223 U/L) PRO BNP B 'NATRIURETIC 'PEPTIDE Pro BNP(B-Peptide) 4850 (0-125 pg/m!) CPK 0C10282353 -· ·-·--· HH Various formulas exist for corrected serum calcium results, each yielding different values. This ; corrected result was based on the formula: Corrected Calcium= SerumCalcium + [0.8 • ( 4 SerumAlbumin)] -Flnar·--□9/11/2017 RESULT CALLED TO f b)(6); (b)(7)(C) I Result Final Result 23:29:00 09/11/2017 23:29:00 Final Resull 09/11/2017 23:29 :00 1rcr-<) A I UUUS !PROTIME PT INR Protime ·-· ----- THEN READ BACK /IHH/ 15.1 H (9.0-11.8 secon~sL Circle ~ strikethrougti .. - Ragati:i.ces unmarked = not applicable [ NAME; ALMAZON RUIZ, FELIPE - MRN: 00 l028232 /t ~cf-rb~fi.0 ~ 9001a.'4~\ember 12.2017 5:18:14 AM - Page 10/20] ···-- ~ Fax Server 9/18/2017 8:35:47 AM PAGE 13/045 Fax Server ,~!# ~J FINAL (SIGNED) CHI St. Luke's Health MMC LIVINGSTON Abdominal Pain Flank Pain ICD10, Transfer of Care Nole add on I Sex: Patient: ALMAZON RUIZ, FELIPE Male ;PROTIME PT INR INR PTTPARTIAL THRO_~.BOPLASTIN Th1 j aPTT I MR#: DOS; 09/11/2017 23:20 1.4 H 1221 L I 0010282353 INR results are Final intended ONLY Result to monitor Oral Anticoagulant therapy in slablized patients. The JNR Therapeutic . Range is 2.0 3.0 Patients with a mechanical heart, !he INR Range 1s 2}:i - 09/11/2017 23:29:00 3.5 (25.3-35.7 seconds) Final Result 09/11/2017 23:29:00 Documentation Cont. Next Page Circle~ slrikethrougl'i Aegaw. 37wk <37wk chronic R testicular chlamydia ovarian chronic R L with hematurla LIVER/ GB I PANCREAS Biliary colic: with gallstones Cholecystitis: acute chronic with: gallslones Hepatitis: acute chronic viral: A Pancreatitis: acute chronic alcoholic B biliary obstruction C alcoholic drug induced: idiopathic OTHER Dehydration Peritonitis, acute Pneumonia: aspiration viral: Sepsis, severe: atypical RSV bronchopneumonia influenza: A B interstitial lobar bacterial: with shock SIRS Circle ~ strikethrough Aogativos unmarked= not applicable [ NAME: ALMAZON RUIZ, FELIPE - MRN: 001'J28232€12cf-~'1:P-OCl8m:flal!l-~tember 12, 2017 5:18:14 AM - Page 17/20] Fax Server 9/18/2017 8:35:47 AM PAGE 20/045 Fax Server FINAL (SIGNED) ,J~ ~r CHI St. Luke's Health MMC LIVINGSTON Abdominal Pain Flank Pain ICD10, Transfer of Care Nole add on I Sex: Patient: ALMAZON RUIZ. FELIPE I MR#; DOS: 09/11/2017 23:20 Male 0010282353 SIGN / SYMPTOMS Abdominal pain: RUQ LUQ RLQ acute abdomen LLQ generalized with: rebound tenderness Fever Flank pain Nausea Vomiting Diarrhea Comments: [ Cu_r_rentProblems Upper GI bleed 18] Reviewed I&] Updated Upper GI bleed (2017) DISPOSITION Decision made at 02:35 AM To: Left department at ~ Horne Present on arrival: patient condition: Nursing Horne Police pressure ulcer UTI unchanged improved ambulatory active Admit Morgue Funeral Home Medical Examiner senous drinking fluid Care transferred to Dr Abas critical eating deceased pain controlled time: 05:15 AM Basis For Discharge Decision: patient exam: test results: stable improved unchanged tenderness migratory no rebound no abnormal no serious abnormal social support: adequate good follow up: available arranged Circle ~ no rigidity min abnormal mod abnormal excellent discussed with physician strikethrough Ao§ati,•96 unmarked= not applicable I NAME: ALMAZON RUIZ, FELIPE - MRN: 001028232()2CJlt®etl-O@Oel61a}4-S7i):l:tember 12, 2017 5:18:14 AM - Page 18/20 J Fax Server 9/18/2017 8:35:47 AM PAGE 21/045 Fax Server ,~ ~r FINAL (SIGNED) CHI St. Luke's Health MMC LIVINGSTON Abdominal Pain Flank Pain 1CD10, Transfer of Care Nole add on I Se" Patient: ALMAZON RUIZ, FELIPE Male I MR#: DOS: 09/11/2017 23:20 0010282353 Basis For Admit Decision: need for: further evaluation additional testing monitoring telemetry pain control IV hydration IV medication IV antibiotics culture results surgery I intensive care TRANSFER OF CARE Cheyenne Cooke Report given to Assuming Scribe: Relinquishing Mid-Level: Report given to Assuming Mid-Level: Relinquishing Mid-Level: Report riven to Assuming Physician: Relinquishing Physician: Reportgivento Assuming Physician: Relinquishing Scribe: Haven Mccain Brief history: Items pending that need to be checked and documented: Labs: X-Ray results: Pain conlrol: CT results: MRI results: US results: Procedure(s): other: Physician I consult arrival: Tentative impression of patient admit discharge transfer Pending results: Circle~ strikethrough RB§atiYes unmarked= not applicable [ NAME: ALMAZON RUfZ, FELIPE- MRN: 00102823;3(32CPl'®t:s:14000@&la'l1,5:ie}itember12, 2017 5:18:14 AM - Page 19/20 J Fax Server 9/18/2017 8:35:47 AM PAGE Fax Server 22/045 FlNAL (SIGNED) J~ ~r CHI St. Luke's Health MMC LIVINGSTON Abdominal Pain Flank Pain ICD10, Transfer of Care Nate add Patient: □n ALMAZON RUIZ, FELIPE . 0010282353 09/11/2017 23:20 Male TRANSFERRING SIGNATURE I MR#: DOS: I Sex: . . - . - . - - - - - - . . - . - - - . . - ·. - TransferringMid-Levelsigning out Signature Date/Time Transfening Physiciansigningout Signature Date/Time By signins my name b"low (b)(6 ); (b)(?)(C) l(b)(6); (b)(?)(C) I L_ ____ ....r----- f b)(6) ; (b)(7)(C) Mid-level Signature OR D,\a 09/121201 7 Time:02:35 AM 09/12/2017 05:17 Scribe Signalure Date!Time Emergency Physician Attestation rx··. , This scribe's documentation has been prepared under my direction and personally reviewed by me in its entirety. I confirm that the note accurately reflects all wor-1<,treatment, procedures , and medical decision making performed by me. (b)(6); (b)(7)(C) es have been reviewed and completed 09/1212017 05: 18 Dalerrime Circle ~ strikethrough Aogati>.•o,s unmarked:= not applicable [ NAME: ALMAZON RUIZ, FELIPE - MRN: 0010282~ijCitt!+(QCJOOOda4S,c.iptember 12, 2017 5: 18:14 AM - Page 20/20 J · -· Fax Server 9/18/2017 8:35:47 PAGE AM MMC LIVINGSTON LIV ED Triage R&port Printed: 09/1112017 21 :35: 16 Page 1 of 1 Fax Server 23/045 11111111111111111 11111 llllllllll1111111111111111111111 Visil ID: Patient ALMAZON RUIZ, FELIPE Age: 51Y Chief DOB:06/26I1968 Acuity; Sex: M Heai:1 Clrcum_: 1-iemoptys Is Co1np1alnt: T~eg• err 09/11/2017 21:25 lnfecllOl'I Control: EMS: Room/Bed: Radio Cell: EMS Llnlt Afrlva I □11: A!Tlwdfrom: 09/11/2017 21:02 Forensic Faclllly Mode of Amwt: Law Enforcement 0300267948 Med Rec: 0010282353 3 N Pre Hcspitl!IICa.re: Screening·. 'OomealioVlolenc:e, 'TB, Out us Lllot {None entere~ 300ay• NC Accompanied by: Olher Suldde Risk: Self Informant: Consent loTrest?: Sc'l!en~d - No S!Jclde Risk LMP: Pmgnant?: Stroke Asa11111ment lsat KnownWell: I\IPOslnoe: BP 149/97 mmHg Site: Ami,Upper LI P°"'. Pain Assessment Seore:7/10 Cheracier: stabblrig ""tlnt,iko D/T Lest Intake Solid: Height 15 61 in Qly: M-6 V-5 Weight Type: E-4 77.13 kg 98.1 F SIie: RelIIIV8dBy: Durman: Goal: NONI:, NONI: 0,Dal: FSBS I'CP: ,a Qlv: Scale: 7,'-umerlo S00le $g0,, Ra5,plrations 99bpm Dls1rlbLJlion: Dr. DfT LlqLJ\d: acs Pulae Tampareture Slle: Forehead I. DI Signed:091111201721:36:10 Fax 9/18/2017 Server -------------------------PATIENT: ALMAZON 8:35:47 AM PAGE 24/045 Fax Server CHI ST LUKE'S HEALTH - LIVINGSTON ABORATORY - CUA# 45D0697930 1717 HIGHWAY 59 BYPASS LIVINGSTON, TEXAS 77351 PH: (936) 329-8589 RUIZ, FELIPE MR#: V0010282353 DOB: 06/26!1966 SEX:MK ~b~)(7~)(=E )---~ LDC: ER LIVINGSTON ENCOUNTER #:l~--;====;======;;;==;;,====------~ =_:'~~:=~~;~~1~J b)(6);(b)(7)(C) L========~~z~~;=~:~;~~~~~~~--===========-=== HEMATOLOGY Collected 09/11/2D17 23:29' Ord Physician ZAHEER, WBC RBC Hemoglobin Hematocrit MCV MCH MCHC ROW Platelet MPV SYED J, MD 14.28 H 3.94 12.5 33.2 L L L 84.3 31.7 H 37.7 H 16.0 H 18 LP No1 Measured 2 NE% LY% 72.4 MO% EO% 11.9 7.8 BA% IG% NRBC, Auto Nucleated RBC Rafenmca L ,um ·10.Ro 10'-.1/ul -1.70-6.l0 ·IQh6t.lJ 1/4.0-180 4?.0 fiO.O gm/di 00.0-94.0 ,~ 27.0-3·).0 pg 33.0-37.0 gm/di •;·1.5-M.5 % '% '130-,!DD 10h3/ul 1.4-1 OA .42.0-75.0 'J.0-!\2.0 4.J-14.0 f~ % % % 0.9 L 0.6 L ,.J-3.D '. .J-3.D 6.4 H O.:l-0 <7 )(E) A TTD.PHYSICIAA: J~ ______ ~I PRINTED: 09/12/2017 1843 PAGE: 3 OF 8 2020-ICLl-00006 4578 Fax Server 9/18/2017 8:35:47 AM PAGE Fax server 27/045 CHI ST. LUKE'S HEALTH - LIVINGSTON ABORATORY ·CUA# 4500697930 1717 HIGHWAY 59 BYFASS LIVINGSTON, TEXAS 77351 PH: (936) 329-8589 ------==-=====------=================-----------------===-================ PATIENT: ALMAZON RUIZ, FELIPE MR#: V0010282353 003: 06/26/1966 -------~ SEX: M b)(7)( E) ENCOUNTER #:.__,_,, -,,=....,,..,.==,,.,...-------, ATTO.PHYSICIAN (b)(5 ); (b)(?)(C) LDC: ER LIVINGSTON ADMITTED:09111/2017 CHEMISTRY Collected 09/11/2017 Reft1rei1ce Units Ord Physician Sodium Potassium Chloride- CO2 Glucose BUN Creatinine T Protein Albumin Globulin A/G Ratio Calcium Calcium, Corrected Total 3ilirubin AST {SGOTJ ALT(SGPT) Alkaline Phcs. 12_7____.. _ )-;:_ • _______ _______________ • __ • _ • _____________ .. 137-·145 ;I _5.!;_ ~ 4.3 rnr:ic:111 mrJct1 98-'107 §J.5 ------ .I::--- --------------•••••••.. -..........-•-- • ------ 22-30 rmnd,1 as~ o-. ---H------------ ---- --. -.•. -• ------ -------------- 15-110 6.D-17.0 0.4 1./ 5:1 B.7 rr.g/dl rr..gldl mg,'dl 22 127•• - •• H - ----------- - -- - - - - - - - - - - ••• - _1.:~- - - - - )j - - - - ..........·•- - - - - - - - . - - - - - - . - - - - - - - - - - - - - . - ~ - 6.5 rr.mol,1 ---~------~~~~-~-------~---~------··---------------~~3.5-4.6 9"7/.-11 3.2 ?.'.?.-3.5 gm/di -1.1-2.2 % 8.4-10.2 f"lg/dl 8.4-10.2 r'l[}/r11 0.2-1.2 mg/di 11-::w'i 1, Ml U/L -H-114 U/L ?:~ .•- • - - _L:• - ~ -- --- • -- • - • - . --- -- -- - - •- • - ..- -- - --- -- - ... - ~--------------~·-~~··-------------------~-----------1.0 L - ........ - ~ ~ - - - - - - - - - - - - - i+ .... ~ .. - - - - - - - - - - - - • - •••• - ~- .... ~- - - - - - - - - 8.6 9.2" --------------------· - -----------·---~WMUM~~~-~-~------·······-·•~4•~--~------~~~-~--~-~~-------10.8 H 102 -----H- - ----------------·-··---·------------ -------·· •••-~••M•--••--•-••-----•---~--•-~-----~---68 H 123______ H ________ ·---------·············------------- gr,,'dl Lill 61/arious formulas exist for corrected serum calcium results, each yielding different values. This corrected result was based on the formula: CorreciBd Calcium= SerumCalcium + [0.8 .. ( 4 - SenniAlbumin)J = ---------:=== ALMAZON RUIZ, FELIPE PRJNTED: 09/12/2017 18:43 --=E'-'R...al;.:.IVI-N:,;::G=S'-'T..;::O'-------. REPORT: Final Chart Liv-ngston 6 7 L.f b_)<_>,_ _60 2 mUl'I" in/1. 73m'· 52" 2 CARDIAC SE.CTfON "Estimated Glomemlar Filtration Rate (eGFR) Rderence hi.tervals Decision Points for l 8 years and older and average body ma;,~: >= 60 30 - 59 Do~ not exclude kidney disease. Suggests model'ale chronic kidney disease and indicates the oe~d fur fiirther investigation including assessment ofproteiunria and cardiova5Cularfllctors. < 30 u~u11llyi11dicates?. need for referral for assessment and manaiemenf o: chronic kidney faiJure. - - - ---- -=== ALMAZON RUIZ. FELIPE ER UVINGSTO l(b)(6); (b)(7)(C ) PRINTED: 09:12(2017 18:43 REPORT: Final Chart Livingston PAGE: 5 OF 8 2020-ICLl-00006 4580 Fax Server 9/18/2017 8:35:47 AM PAGE Fax Server 29/045 CHI ST. 1.IJKF'S HFAI.TH - LIVINGSTON ABORATORY • CUA# 45D0697930 1717 HIGHWAY 59 BYPASS LIVINGSTON, TEXAS 77351 PH: (936) 329·8589 ==============~-------------=== --------------------------------------------------------~------------------------------------------MR#: V00,0282353 FA.TIENT: ALMAZON RUIZ, FELIPE DOB: 06/26/1966 SEX:M ENCOUNTER#: (b)(?)(E) ,.. (b-)(-6)-; (-b)-(7-)(_C_) _..__ LOC: ER LIVINGSTON ------------------------- ________ -----------------------------------------------------ATTD.PHYSICI ___ Collected ADMITTED:09111/2017 09/11/2017 23:29 ZAHEER, Cte Rh Antioody Screen x 2 Cross match (b)(6); (b)(7)(C) 0 Positive Negative C::impleted: Compatible PRINTED: 09/12/2017 18:43 REPORT: Final Chart Livingston PAGE: 8 OF 8 2020-ICLl-00006 4583 Fax Server 9/18/20 17 8 : 35 :47 AM PAGE Fax Serv er 32/045 .J-. ~r CHI St. Luke's Health BLOOD BANK TRANSFUSION RECORD . Lufkin• Livingston• San Augustine Mem o rial Spe cial ty Blood Band#: • Product Antibody Screen:~ Segment # : Donor Unit Expiry Dat e: Unit # ; fr tJ- t,-,), Crossmatch Inter retation: Tech b)(6); (b)(7)(C) l!EV. j011'lQl15) KWII< KO/>YPlll NT ,. t 2020-ICLl-00006 4584 Fa x Se rv er 9 /1 8 / 2 0 17 8: 3 5 :4 7 AM PAGE Fax Ser ver 3 3 /0 4 5 ·~ ~r CHI St. Luke's Health BLOOD BANK TRANSFUSION RECORD I,.ufkin • Livingston • San Augustine Memorial Sp ecialty Blood Band # : Antibo d y Scree n: Segm en t # : Exp iry Dat e: Unit#: Donor Unit Tech ID: /( WIK 1(0P Y Pf!ll'c- Product Tech ID 0010282353 51V M NOqto IJ.2.() Crossmatch Inter retation: b)(6); (b)(7)(C) Antibody Screen: °'J\\o\~ Segment#: EKpiryDate: Unit#: ~~ q{tff::r-0/~ Tech ID 1 ''..'·: '------,:d,rl Blood Band #: Datemme: 1 ~':f'~; ,-:.·~'~:~:?' ~•;,, -,~· "".'.~?(!fiiAif~u~J'iff!:fiYsJtftiiilf~:··,r/I r:.::,_.\?~JJ~?·,~T8???t e C?f!rti/y !hat priono transfusion we havt1 verifitld the identity h~VB che<;lctKJ ~ch item in the piesen<;e_ofthe;s_~lpienf x.___________ x.____ _,_________ pfthis unitand its ·intsht;ledrecipient . . 6ate.· _ ____ ' · Time. __ --;...,...-........,_2 ..... 0,..,2....,0.....,-IC....,[r'-rl .... --0 .... 0...,00 .... 6___,4..,...5'"'86~------,,---Date._·~--,-----TimB. __ _ _ Fax Server 9/18/2017 8:35:47 AM PAGE Fax Server 35/045 MMC LIVINGSTON Ambulatory Asa11ument/Hlatory 09/11/:ZD17 21:02 Patient Name: ALMAZON RUIZ, FELIPE Visit ID: 0300.267948 Admitted: 09/11/2017 21:02 ,.As._s•_ss_m_e_n_t D_a_te _____ Vit.Js Attending: --ll(b)(6); (b)(7)(C) Entered e..l 1-1 09/14/2017 04:01 00102B2353.------rv-......,.~...,- MR Number: t b)(6); (b)(7)(C) [ I 06/:Z6/1966 _ En_t_ry_D_a_t_a __ __, _____________________ I UNKNOWN_LOCATION Pl. Location: 09/11/2017 21 :36 Throogh Report UNKNOWN_BED Temp Pulse Resp BP 02 % Ht Wt 98.1 F 99 18 149/97 99.0% 61.00 lr, 77.13 kgs Ht Wt 09/11/2017 2 ';;36 Arm,UpperLt Forehead Ent.rad Bi(b)(5 ); (b)(?)(C) Pl Location: Temp I LIV EMERGENCY DEPARTMENTRM-04-A Pulse BF' Resp 02% 09/1212017 00:46 09/12/2017 00:50 Assessment Date Entry Date IV Medlcatiu,! b)(6); (b)(?)(C) Entan1dBy: Pl. Location: 09/12/2017 00:49 09/1212017 03:04 L LIV EMERGENCY DEPARTMENT RM 04-A Site: Jugular, Left Started ~,..,,. (b.,..., )(.,,.,. 6)-, ; (,...,. b)""' (7.,..,. )(C ""')-------, Fluid: octreot1de 25mcg 09/12/2017 00:49 120 25 09/12/2017 03:04 150 09112/2017 03:04 Started by: (b)(5); (b)(?)(C) Fluid: NSS started by: f b)(6); (b)(7)(C) 09/1412017 04:01 NOTE: All striileoutf. were executed by person making original entry. 2020-ICLl-00006 4587 Page 1 of 1 Fax Server 9/18/2017 8:35:47 AM PAGE 36/045 Fax Server MMC LIVINGSTON Dally Focus A&&esi;.ment Report 09/1112017 21:02 Through Patient Name: ALM.AZON RUlZ, FELIPE Visit ID: 03002679411 MR Number; Admitted: 09/11(2017 21 :02 Attending: f b)(6); (b)(7)(C) 09/14/21117 04:01 0010282353 DOB: 08/26/1966 I Assessmmt Date Entry Dele Actions l(b)(6); (b)(7)(C) I Ent&Nd By: _ _ Pl Location: ~L....,IV,----,,E,.,.M"""'E,.,.R""'G:-E-,-,-N"""'C--Y-□ ----E--P,....."'RTMENT RM-M-A 09/12/2017 00:47 Critical Value - Name: Plstlets Critical Value - Result 1B000 09/1212017 00:47 09/1212017 00:-47 Critical Value - Date/Time Received: 09/12/2017 00:48 I 09/12/2017 00:47 09/12/2017 00:47 CriticalValue - Name of MD Nolllled: Critical Value - Date/Time MD Notified: J(b)(6); 0!l/12/2017 00:48 09/1212017 00:47 Critic.al Vall.It! - Commel"lts/Orders No new orders 09/12/2017 00:4 7 Pl Visually Checked 09/1212017 00147 Received: Rounding Action No change from previous assessment by this clinician A&tiessmentDalo Entry Date ED Med Tlmets) . l!ntered 8y~ b)(6); (b)(7)(C) f Pt. Location: 09/12/2017 02:15 LIV EMERGENCY DEPARTMENT RM-04-A Pain Pain Location abd 09/1212017 03:02 As6&sGment Pain Scale 09/12/2[)17 02:15 Pain Score 5/10 Pain Goal acceptable pain reduction Name Of IV Push Med Givan octreotide Dose 25mog Time IV Push Med Given 09/12/2017 02:15 Re9ponse NoADR Asseissml!flt Dale 09/1212017 03:02 09/1212017 03:02 09/12/2017 03:02 09/12/2017 03:02 Entry Date Rounding l (b)(6); (b)(7)(C) EnteN!d By: ,__ --------~ Pt. uic.atlon: LIV EMERGENCY DE.PAR.TMENT RM-04-A 09/12/2017 02:33 Rounding Action Will continue to monitor patient for 09/12120'7 02:33 complaints orohange& In status. Personal needs met Other 09/14/2017 04:01 NOTE: All strikeouts wore executed by p11rsonmaking original eiitry. 2020-ICLl-00006 4588 Page 1 of 3 Fax Server 9/18/2017 8:35:47 AM PAGE 37/045 Fax Server MMC LIVINGSTO~ Dally Foc:u&Aasessm.nt 09/11/2017 21:02 Patient Name: ALMAZON RUIZ, FELIPE Visit ID: 0300267!148 MR Number: Admitted; 09111/2017 21 :02 At1endin": Through Report 09/14/2017 04:01 0010282353 DOB: 06/26(1988 I l(b)(6); (b)(7)(C) Erttry Date Rounding E.ntared l(b)(6); (b)(7)(C) 8yi Pt. Location'":--LI-V_E_M...,...E,...R_G_E_N_C_Y_D_E_P_'A_R __ TMENT RM--04-A 09112/2017 02;33 Group Note: As&i&ted to BR by guards with wheeh:hair. Dizzy when 11tanding.NSRon monitor Rounding Status No change from previous assassmentby this cWnician 09/1212D17 02:35 09/12/20 17 02:33 ~t resting, no complaints voloed el this lime Pt. denies any complaints et lhrs time. Assesi;mant Date !:ntry Dal• Rounding Entered By:l (b)(6); (b)(7)(C) LIV EMERGENCY DEPARTMENT RM-04·A Pt. Location: 09/12/2017 02;35 Round:ng Action ,.,,...,. □.,.,, th.,...e..,,r-:-=,,.,.,,.,----, Group Note: IV attempted x3. EJ J (b)(6); (b)(7)(C) Rouneling Slatus 09/12/2017 02:35 09/12/2017 02:36 Pt resting, no complaints voic1:1dat ttiis time 0911212017 02:35 Pl. denies any com plaints 111this time. Entry Date A911es11mentDate Rounding Entered By: r b)(6 ); (b)(?)(C) Pt. Location: 09/1212017 03;30 LIV EMERGENCY DEPARTMENT RM-04-A Rounding Action Rounding Status WIii continue to monitor patient for complaint& or changes in status. No change from previous assessment by this clinician 09/12/2017 06:18 09/12/2017 06:18 Pl resting, no complal nts voiced et this time Pl. danl&s any complaints at this 11rne. 09/14/2(117 04:01 NOTE: All &trllceouts were eKecut&d by person making orlglnal entry. 2020-ICLl-00006 4589 Paga 2 of3 Fax Server 9/18/2017 8:35:47 AM PAGE 38/045 Fax Server MMC LIVINGSTON Dally Focu& A&&assment Report 09/1112017 21:02 Patient Nama: Al.MAZON RUIZ, FELIPE Visil ID: 030D267948 MR Number: Admitte(j: 09/11/2017 21 :02 Attending: Through 09/14/2017 04:01 .... '"'D"~"~ l(b)(6); (b)(7)(C) I DOB: 08126/1918 I As$e55m,nt Date Entry Date Rounding~~~~~----~ Entered sj (b)(6); (b)(7)(C) Pt. Location; 09/1212017 06:57 LIV EMERGENCY DEPARTMENT RM-04-A Rounding Action Will continue to monitor patientfor 09112/20 17 05:5 7 complaints orchenges In status. Parsonalneeds met Rounding Status No change from previousasse&smentbythh; cllnlc!an Pt resting, no complaints voiced et this lime 09/1212017 05:57 Pt. denies. any complaints at this time. 09/141201704:01 NOTE: All strikeout& were el(ecuted by person making orlglnal entry. 2020-ICLl-00006 4590 Paga! of 3 Fax Server 9/18/2017 8:35:47 AM PAGE 39/045 Fax Server MMC LIVINGSTON Discharge AsSMsmant/Summary Patient Name: 09/14/2017 04:01 through 09/11/2017 21 :02 Report Al.MAZON RUIZ, FELIPE Visit ID: 0300267948 Discharged: 09/12/2017 07:00 I DOB: 001028f b)(6); (b)(7)(C) MR Number: Attending: I I 06/28/1966 Allergy ll111!11 Allergies No Known Allarglu 09/11/2017 Last Documenied by: B (b)(6); (b)(7)(C) Vlr.ls Entered By: Entry D11le Pt. Location: Pulse Temp 09111/2017 21:36 98.1 F Rup BP 18 02% Ht Wt 99.0% 61.00 In 77.13 kgs 09/11/2017 21:36 Forehead ,-----------1 v;tafs 1 _________ (b)(6); (b)(7)(C) Entered ~._ Pt. Location: Temp 09112/2017 00:49 , _. Entry Data 1 LIV EMERGENCY DEPARTMENT RM-04-A Pulse Rasp BP 02 % 0911212017 04: 1D Ht WI 09/12/2017 02'.37 91 142/109 09/1212□ 17 05;5B Ami,UpperU Transfer r b)(6); (b)(7)(C) EntryD111te EntentG Sy: Pt. Location: 09/1212017 06:45 LIV EMERGENCY DEPARTMENT RM-04-A Admit ta: ICU 09/1~.2017 06:55 Other 09112/2017 06:45 09/1212017 06:45 Group Nola: 17 Transported With: 09/12/2017 08:58 Oxygen 09/12/.2017 06:55 Cardiac I Apnea Monitor TR/DC with IV line iMact other 09/12/2017 06:45 09/ 1.2/201 7 06: 45 Group Note: Octreotlde infuain 09/1212017 Oti:56 Report Givan To Loretta Report Given On Current 09/1212017 06;55 IV Tllerapy Vital Signs Fall ? rer:autio ns 09/12/2017 06:45 09/12/2017 06:45 09/14.12017 04:02 Tran:ifer tc Another Facility Yes Nolilied of Discharge/Transfer other Group Note: MTC guards 09/12/2017 Ofi:57 MOT Ccmplelecj Yes Receiving ?hysician Abbass Receiving Facility Conroe Regional 09/12/2017 06:55 Page 1 of 1 Fax Server 9/18/2017 AM PAGE 8:35:47 40/045 Fax server MMC LIVINGSTON IV Site and Fluld Report 09/11/2017 21 :02 Through Patient Name: ALMAZONRUIZ, FELIPE Visit ID: 0300267948 MR Number: Admitted: 0!1/11/2017 21:02 Attending: IV Site: 09/1412017 04:01 D010282353 DOB: 16126/1966 l(b)(6); (b)(?)(C) Jugular, Left Started 09/12/2017 00:49 By gelb Pt Location: LIV EMERGENCY DEPARTMENT RM-04-A Type: Venous Entered Date: Catheter Sz: HI ga Position Modifier: Catheter Length: 09/1212017 00:49 Unsuecesstul Atten,pts: Lum11nsNo.: Note: Pt Location: ! IY EMERGENCY Dfl"ARTMENT Venous 18 ga NSS Entry For Date 09/1212017 03:04 By gelb I I IY EMERGENCY OF PARU~ ENT RM--04-A Pt Loceflon: Fluld Startad By: Lumen Used: (b)(6); (b)(7)(C) l . . Fluid Started Date: 09/12/2017 03:04 Entered Date: 09/12/2017 03:04 'I Rate: 150 mVhr IV Pump: Starting Volume: Bag No.: 1000 ml Volume Infused: Bag Complet. Date: l(b)(6); (b)(?)(C) Added By: E.ntryForDate: IOn 09/12/2017 03:04 :)9/12/2017 03 :04 Fluid: Pt Location: IVSitl'l; Fluid Started By: Starting Volume: NSS UV EMERGENCY DEPARTMENT RM-04-A Jugular, Lett i.:..! (b.:.... )(:....: 6).:.... ; (:....: b).(7 :.... .:.... )(:.... C.:.... ) ___ 09/1212017 03: 04 ...,bn 1000 Rate: 150 mVhr IV Pump: y octreotlde 25mcg Entry For Date 09/12/2017 03:04 By gelb Pt Location: UV EMERGENCY DEPARTMENT RM-04-A Fluld S1at1ed ay:j (b)(5 ); (b)(?)(C) [ Lllml!ln Us~d: Rate: Starting \lolurne: Bag No.: 09/14/2017 04:02 RM-04-A On 09/1212017 oo:49 Juguls,r, Left IV Type: Catheter Sz: Fluid: I l(b)(6); (b)(?)(C) IV Sile Started By: IVS!te: Fluid: bn 09/12/2017 00:49 l(b)(6); (b)(7)(C) Added By: 25 mc:g/hr 120ml Fluld Started Dat■: Ent11rad D•te: IV Pump: Volume Infused: 09/12/2017 03:04 09/12/2017 03:04 y Beg Complete Date: NOTE: All strikeouts were axacu1ed by parson making original entry. 2020-ICLl-00006 4592 Pagl'l 1 of 2 Fax Server 9/18/2017 8:35:47 AM PAGE Fax Server 41/045 MMC LIVINGSTON JV Site and Fluld Report 09111/2D17 21:02 Through D9114/2017 04:01 Patient Name: ALMAZON RUIZ, FELIPE Visit ID: 0300287948 MR Number: 0010282353 Admitted: 09/11/2017 21 :02 Attending: SYEDZAHEER Fluid: octreotlde 25mcg Entry For Date 09/1212017 03:IM By gelb Pt Location: I IV EMERGE!IICY Fluid Started sJ (b)( 5); (b)(?)(C) Lumen Used: DEPARTMENT 1 I RM-04-A . Fluid Started Dote: Entered Date: 09/12/2017 03°04 ':I Rate: 25 mcg/hr IV Pump: Starting Voluma: 120 ml Voluma lnfuaed: I ~b)(6); (b)(7)(C) '-------------11 Added By: Entry For Date: 11-----------------------' 1 '-------~_. 09/1212017 CJ:04 0n 09/12/2017 03:04 Fluid: oc::treotlde 25m cg Pt Location: IV Sita: LIV EMERGENCY DEPARTMENT RM--04-A I 1,ni ,!er I eft Fluid SlElrted By: Starting Valum&: Rate: IV Pump: 09/12/2017 03:04 Bag Complete Date: Bag No.: 0911.41201704~02 DOB: 06/2611966 ._l n , ar.ter ,e,:l In this faxed ~at ei,: repo rt: Is ~rt,a l i?and (Onfdentilll It" may co ntari Protected r'Cat~ tnrorrruitti n (PHI) dH1T1ea::o~h:tentEI b\, HIP.AAregue tio ns. IL 15:nten d~ :,nly fo r l~e ~~ of Con roe Rll!;ir:n«~ and t ie prn ieges are 'l::it waivad by v rtoe -~t 1:1IS_,,o:matlOn hav i,~ beer. direct!( printed er sent by feK. My use, d~l!fnr. att>n, c :st rlht1tb1 or ccpyln'ilof the la'orm ation :ont alned In thli ccmmun t a:ion osstrict,yptoh:lltted by anvone e>e: Name : Origin Fa ci!i':v: Ci➔! St. Lukes o' East Texa~ Street Add"'5S: 17l 7 Hwy 59 By ;i2,;s Patient Assessment suspected I~, City: LM'J :;;sTON Zip t 7735 l - - --- - - County POLK Phone# : 936mkle dr p .25mcg,'hr, 02 41pm vi.! Pain Salle~ NC, EKG N eurological Levet. A-,.OX~ Glaligow coma SCll>le:15' (Matar A.esp., 6 Verb•I Resp.: 5 Eye Ope l"tlng: 4) J of 2 9/J 812017, 9:2 1 A 2020-ICLl-00006 4599 Sep 1817, 09:24a Texan EMS 936-327-9116 p.3 ARCePCR - Almazan Ruiz- 842335-web 1./ill.concep:s.com Vital Signs & [nterventions Intervention<: Assessme,t, Cl'tlac mon~crng, "Nfluids, rvmedtaton, Oxygen Vitals BP Pulse Resp Sp02 +02 Time 151/tl7 87 20 10:J y 06:~~:28 ~50/90 92. 2D 99 y 08:13:35 M~me Dr;.,.,,,N b)(6); (b)(7)(C) Report Ends. 2of2 2020-ICLl-00006 4600 9/18/2017, 9:21 .' :; .' ·:. .' . . ' ~b)(6); (b)(7)(C) From : Sent: 21 Sep 2017 16:57 :36 -0400 l(b)(6); (b)(7)(C) To: Subject : RE: Transportation of Deceased body <• The original PCTW had a total of 5 death certificates noted and quoted. ' -: ' . - It was approve d that way. The reason it got my attention is the mortuary said we had a $9.00 surplus funds compared to the original quote. When I reviewed the PCTW , I just wanted to make sure there was no clerica l error. The check amo unt issued was correct and include s a total of 5 certificates. : They should be available in 2-5 days. : .. .... 1 (b-)(6 _)_ ; (b - )-(7-)(C _)_____ .·. - ., ··-·· ...... . .. , __,I .. ...... ·... - SDDO Mo ntgome ry County Detent ion Center Conroe , Texas : .'. ; .' ·-·· ... .: ··-·· ... Fro ml (b)(6); (b)(7)(C) Date: Thursda , Se 21, 2017, 3: I 8 PM To (b)(6); (b)(7)(C) Subject: ransportation o ·-·· .. .. . .. -·. ... . . . .'. :. .' . FYI /' . ·- . - : ..... .- <• <• ··-·· .I' /' • ..- ... -. .-. .. .I' .. .I'. .. . . .. . .. .. . .-: . ·._ .. . . •• .I' .. ··-·· .I' ....... . . . ... ,: . - .' ..... . . ·... · .I' .'. l :. .' . (b)(6); (b)(7)(C) From._ ______ __. Sent: Tuesday , September 19, 2017 2:01 PM .'. :. .' . . .. '-·, . 2020-ICLl-00006 .,._ ' - . . .. .-:. '-·, '. ··-·· 4601 : ._, .' :; .' ·:. .' . . ' f - ., ··-·· ...... )(6); (b)(7)(C) To· . ·.. - .. su· ject: RE: 1ransportauon or Deceased oody (b)(6); (b)(7)(C) <• Please update the PCTW for 5 death certificates and return to me for approval. Thanks! From~ ' -: ' . - Sen To: b)(6); (b)(7)(C) .: Cc: -..,........,------,---,-,--....,.....,,,....-----....,......... Sub1ect : Transportation o Decease ody : .. : Attac hed is PCTW for transportatio n of the deceased ind.ividual from Montgomery County to IAH onwards to MIA. Two observat ions: . -·· . ..... . ·... - : . .. , , .·. : .'. ; .' 2 PM (b)(6); (b)(7)(C) . ·-·· ... .: ··-·· ... b)(5) ... • •• .. -·. ,< r )(6); (b)(7)(C) • ··-·· ··-·· /' Mission Support Specialist Department of Home land Secur ity Immigration an d Customs Enforcement Office of Enforcement and Removal Operations 3400 FM 350 Sout h, Livingston, TX 7735 1 Desk: 936 -967 (b)(6); (b)(7J(Cl Fax: 936-967- ,I' • • . .... .'. :. .' . :. .' . . .. I'.-. ..- ... . -. ,< . . .' ..,,. .'. :. .' . .. - .. .'. :. .' . . ,,_ •••• .'. • ·._ .- . . ·... · ·.·: I'.-. • ,: <• . <• •< '-·, . . ,,_ •••• ,< ' - ,<. '-·, '. ··-·· 2020-ICLl-00006 4602 : ._, Beds Available -4 I LAST NAME FIRST NAME COUNTRY ALIEN# I DETHOUSING CLASS ASSIGNMENT Book-in Date 4 5 6 7 18 19 20 21 22 23 24 25 26 27 28 32 33 34 35 L (b)(6); (b)(7)(C) UI 02 6 8 XIC I 12 0 -32 Beds Available 21 LAST NAME FIRST NAME ALIEN # COUNTRY Book-in Date b)(6); (b)(?)(C) 2 3 4 5 6 7 8 9 10 12 13 14 15 16 17 18 19 20 21 22 23 24 26 27 28 29 30 31 32 33 34 ALMAZAN RUIZ 3 (b)(6); (b)(?)(C) FELIPE 028866428 MEXIC 07/12/201717:00 MH P6-34 Beds Available 10 KROME SPC POST: Pod 6 LAST NAME DAY : FIRST NAME Friday ASSIGNED: ALIEN# DATE : COUNTR Y 10/27/2017 Book-in Date b)(6); (b)(?)(C) 1 1 1 1 1 1 1 1 1 2 2 2 2 2 FELIPE 028866428 MEX IC 07/12/2017 17:00 MH P6-34 Beds Available 9 LAST NAME FIRST NAME ALIEN# COUNTRY Book-in Date (b)(6); (b)(7)(C) 2 3 4 5 6 7 8 9 10 12 13 14 15 16 17 18 19 20 21 22 23 24 26 27 28 29 30 31 32 33 34 ALMAZAN RUIZ 3 (b)(6); (b)(7)(C) FELIPE 028866428 MEXIC 07/12/201717:00 MH P6-34 Beds Available 3 LAST NAME FIRST NAME ALIEN# COUNTRY Book-in Date (b)(6); (b)(7)(C) 2 3 4 5 6 7 8 9 10 12 13 14 15 16 17 18 19 20 21 22 23 24 26 27 28 29 30 31 32 33 34 ALMAZAN RUIZ 35 (b)(6); (b)(7)(C) FELIPE 028866428 MEXIC 07/12/201717:00 MH P6-34 Beds Available 13 LAST NAME FIRST NAME ALIEN# Book-in Date COUNTRY (b)(6); (b)(?)(C) 2 3 4 5 6 7 8 9 10 12 13 14 15 16 17 18 19 20 21 22 23 24 26 27 28 29 30 31 32 33 34 ALMAZAN RUIZ 35 FELIPE 028866428 MEXIC 2020-ICLl-00006 07/12/201717 :00 4608 MH P6-34 Beds Available 13 LAST NAME LMAZAN RUIZ FIRST NAME FELIPE ALIEN# 028866428 COUNTRY MEXIC 2020-ICLl-00006 Book-in Date 07/12/201717 :00 4609 MH P6-34 Beds Available 1 LAST NAME FIRST NAME (b)(6); (b)(7)(C) 2 3 4 5 6 7 8 9 10 12 13 14 15 16 17 18 19 20 21 22 23 24 26 27 28 29 30 31 32 33 FELIPE ALIEN# COUNTRY Book-in Date Beds Available 0 DAY : KROME SPC POST: Pod 5 LAST NAME FIRST NAME Friday ASSIGNED: ALIEN# 10/27/2017 DATE : COUNTRY Book-in Date DETHOUSING CLASS ASSIGNMENT b)(6); (b)(7)(C) 2 3 4 ALMAZAN-RUIZ 5 b)(6); (b)(7)(C) 6 7 8 9 FELIPE 028866428 MEXIC 7/12/2017 1700 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 30 31 32 33 34 2020-ICLl-00006 4611 MH P5-04 Beds Available 4 FIRST NA ME 7 10 11 12 13 14 15 16 17 18 19 20 2 24 25 26 27 28 29 30 31 32 33 34 b)(6); (b)(?)(C) Beds Available -2 LAST NAME Bo ok-i n Date FIRST NAME DETHOUSING CLASS ASS IGNMENT (b)(6); (b)(7)(C) 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 30 31 32 AL 33 (b)(6); (b)(7)(C) 8 8 7/1 / 34 2020-ICLl-00006 4613 17 170 5-3 Beds Available -4 COUNTRY Book-in Date DETHOUSING CLASS ASSIGNMENT (b)(6); (b)(7)(C) 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 30 31 32 AL 33 b)(6); (b)(7)(C) 8 8 07/ 34 2020-ICLl-00006 4614 I 7:0 5-3 Beds Available -8 I LAST NAME FIRST NAME COUNTRY ALIEN# I DETHOUSING CLASS ASSIGNMENT Book-in Date b)(6); (b)(?)(C) 4 5 6 7 18 19 20 21 22 23 24 25 26 27 28 32 33 34 35 L b)(6); (b)(7)(C) UI 02 6 8 XIC I 12 0 -32 Beds Available -8 I LAST NAME FIRST NAME ALIEN# COUNTRY Book-in Date I DETHOUSING CLASS ASSIGNMENT b)(6); (b)(?)(C) 4 5 6 7 18 19 20 21 22 23 24 25 26 27 28 32 ALMAZAN RUIZ 33 (b)(6); (b)(?)(C) 34 35 FELIPE 028866428 MEXIC 07/ 12/2017 17:00 MH P4-32 Beds Available 10 I LAST NAME FIRST NAME COUNTRY ALIEN# I DETHOUSING CLASS ASSIGNMENT Book-in Date (b)(6); (b)(?)(C) 4 5 6 7 18 19 20 21 22 23 24 25 26 27 28 32 33 34 L UI 02 (b)(6); (b)(?)(C) 35r--------------,,---------~---------.--------.----------~---------'I 6 8 XIC I 12 0 -32 Beds Available -2 I LAST NAME FIRST NAME COUNTRY ALIEN# I DETHOUSING CLASS ASSIGNMENT Book-in Date (b)(6); (b)(7)(C) UI 02 6 8 XIC I 12 0 -32 Beds Available 10 I LAST NAME FIRST NAME COUNTRY ALIEN# I DETHOUSING CLASS ASSIGNMENT Book-in Date (b)(6); (b)(?)(C) 4 5 6 7 18 19 20 21 22 23 24 25 26 27 28 32 33 34 35 L (b)(6); (b)(?)(C) UI 02 6 8 XIC I 12 0 -32 Beds Available 1 I LAST NAME FIRST NAME COUNTRY ALIEN# I DETHOUSING CLASS ASSIGNMENT Book-in Date (b)(6); (b)(7)(C) 4 5 6 7 18 19 20 21 22 23 24 25 26 27 28 32 33 34 35 L b)(6); (b)(7)(C) UI 02 6 8 XIC I 12 0 -32 Beds Available 0 I LAST NAME FIRST NAME COUNTRY ALIEN# I DETHOUSING CLASS ASSIGNMENT Book-in Date 4 5 6 7 18 19 20 21 22 23 24 25 26 27 28 32 33 34 35 L (b)(6); (b)(?)(C) UI 02 6 8 XIC I 12 0 -32 Beds Available -14 I LAST NAME FIRST NAME ALIEN# COUNTRY Book-in Date I DETHOUSING CLASS ASSIGNMENT (b)(6); (b)(7)(C) 4 5 6 7 18 19 20 21 22 23 24 25 26 27 28 32 ALMAZAN RUIZ 33 b)(6); (b)(7)(C) 34 35 FELIPE 028866428 MEXIC 07/12/2017 17:00 MH P4-32 Beds Available -15 I LAST NAME FIRST NAME ALIEN# COUNTRY I DETHOUSING CLASS ASSIGNMENT Book-in Date (b)(6); (b)(7)(C) 32 L UI 33 (b)(6); (b)(7)(C) 34 35 FELIPE 028866428 XIC I 12 0 MH -32 Beds Available -10 I LAST NAME FIRST NAME COUNTRY ALIEN# I DETHOUSING CLASS ASSIGNMENT Book-in Date b)(6); (b)(7)(C) 4 5 6 7 18 19 20 21 22 23 24 25 26 27 28 32 L UI 33 (b)(6); (b)(7)(C) 34 35 02 6 8 XIC I 12 0 -32 Beds Available -ALMAZAN RUIZ FELIPE 028886428 MEXIC 1100 MH (MUHC) Beds Available -6 I LAST NAME FIRST NAME COUNTRY ALIEN# I DETHOUSING CLASS ASSIGNMENT Book-in Date (b)(6); (b)(?)(C) 4 5 6 7 18 19 20 21 22 23 24 25 26 27 28 32 L UI 33 (b)(6); (b)(?)(C) 34 35 02 6 8 XIC I 12 0 -32 Beds Available -6 I LAST NAME FIRST NAME COUNTRY ALIEN# I DETHOUSING CLASS ASSIGNMENT Book-in Date (b)(6); (b)(?)(C) 4 5 6 7 18 19 20 21 22 23 24 25 26 27 28 32 L UI 33 (b)(6); (b)(?)(C) 34 35 02 6 8 XIC I 12 0 -32 Beds Available -2 I LAST NAME FIRST NAME ALIEN# COUNTRY I DETHOUSING CLASS ASSIGNMENT Book-in Date b)(6); (b)(?)(C) 4 5 6 7 18 19 20 21 22 23 24 25 26 27 28 32 ALMAZAN RUIZ 33 (b)(6); (b)(?)(C) 34 35 FELIPE 028866428 XIC I 12 0 MH -32 Beds Available 0 I LAST NAME FIRST NAME ALIEN# COUNTRY Book-in Date I DETHOUSING CLASS ASSIGNMENT (b)(6); (b)(7)(C) 4 5 6 7 18 19 20 21 22 23 24 25 26 27 28 32 ALMAZAN RUIZ 33 b)(6); (b)(7)(C) 34 35 FELIPE 028866428 MEXIC 07/12/2017 17:00 MH P4-32 Beds Available 0 I LAST NAME FIRST NAME COUNTRY ALIEN# I DETHOUSING CLASS ASSIGNMENT Book-in Date (b)(6); (b)(7)(C) 4 5 6 7 18 19 20 21 22 23 24 25 26 27 28 32 33 34 35 L b)(6); (b)(7)(C) UI 02 6 8 XIC I 12 0 -32 Beds Available 0 I LAST NAME FIRST NAME ALIEN# COUNTRY Book-in Date I DETHOUSING CLASS ASSIGNMENT (b}(6); (b)(7)(C) 4 5 6 7 18 19 20 21 22 23 24 25 26 27 28 32 ALMAZAN RUIZ 33 (b)(6); (b)(7)(C) 34 35 FELIPE 028866428 MEXIC 07/ 12/20 17 17:00 MH P4-32 Beds Available -3 I LAST NAME FIRST NAME ALIEN# COUNTRY I DETHOUSING CLASS ASSIGNMENT Book-in Date (b)(6); (b)(?)(C) 4 5 6 7 18 19 20 21 22 23 24 25 26 27 28 32 A LM AZAN RU IZ 33 (b)(6); (b)(?)(C) 34 35 FELIPE 028866428 XIC I 12 0 MH -32 .. US Department of Homeland Security ~ ; , US Immigration and Customs Enforcement "«•.,,,,. •' Krome Service Processing Center Policy Numb er KRO/17.4.3 Related Standards/Information Subject ACA 4-ALDF -2A-15, 4C-0 I THROUGH 4C-3 1, 4C-34 THROUGH 4C-41, 4D-01 THROUGH 4D-21, 4D-23 THROUGH 4D-28 , 2A-45, 7D-2 5, Post Orders , PBNDS (Detention Standards) (Medical Care) , IHSC Policies and Procedu res Manual Medical Care Pages 29 I. PURPOSE To outline the medical services avai lable to deta inees housed at the Krome Service Processing Center (SPC). II . EXPECTE D PRACTIC ES A. General The Krome SPC shall direct ly or contractually provide its deta inee population with the follow ing: I. Initia l medical , mental health and dental scree ning; 2. Medically necessary and appropriate medical , dental and mental health care and pharm aceu tical services; 3. Comprehensive , routine and preventive health care, as medically indica ted; 4. Emergency care ; 5. Specia lty health care ; 6. Time ly responses to medical comp laints; and 7. Hospitali zation as needed w ithin the local comm unity. 8. Staff or profes sio nal language services necessary for detainees with limited Eng lish profici ency (LEP) during any medical or mental health appointment , sick call, treatment , or consultation. **Medical facilities within the detention facility shall achieve and maintain current accreditation with the Natio nal Commission on Correctional Health Care (NCCHC) , and sha ll maintain compliance with those standards. B. Designation of Authority A designated health services administrator (HSA) shall have overall responsibility for health care services pursuant to a ·written agreement, contract or job description. The HSA is a physician or health care professional and shall be identified to detainees. The designated clinical medical authority (CMA) at the Krome SPC sha ll have overall respons ibility for med ical clinical care pursuant to a written agreement , contract or job description. The CMA shall be a medical doctor (MD) or doctor of osteopathy (DO). (b)(6); (b)(7)(C) KR0 / 17.4.3 Medical Care 2020-ICLl-00006 4633 The CMA may designate a clinicall y trained profe ssional to have medical decision making authorit~ in the event that the CMA is unavailable. When the HSA is other than a physician , final clinical judgment shall rest with the Krome SPC 's designated CMA. In no event shall clinical decisions be made by non-clinicians. The HSA shall be authorized and respo nsible for making decisions about the deploym en t of health resources and the day-to-day operat ions of the health serv ices program. The CMA together with the HSA establishes the processes and procedures necessary to meet the medic a l stan dards ou tlined herein. The Krom e SPC shall provid e medical staff and sufficient support personnel to meet these standards. A staffing plan will be reviewed at least ann ually which identifies the positions needed to perform the required services. Health care personnel perform duties within their scope of practice for which they are credentialed by training , licen sure, certifica tion , job descriptions , and/o r written standin g or direct orders by personnel authorized by law to give such orders. The Assistant Field Office Director {AFOD) , in co llaboration with the CMA and HSA, negotiate s and maintains arrangements with nearb y medical facilities or health care providers to provide required health care not available within the Krome SPC , as well as identifying custodial officers to transport and remain with detainees for the duration of any off-site treatment or ho spital admissio n. C. Communi ca ble Disease and Infect ion Con trol 1. Gene ral The Krome SPC shal l have wr itten plans that address the management of infectious and communicable diseases , including screening , prevention , education , identificati on , monitoring and surveillance , immuni zation (when applicable) , treatment , follow-up , isolation (when indicated) and reporting to local, state and federal agencies. Plan s sha ll include: a. b. c. d. e. f. Coordination with local public health authoritie s; Ongoing education for staff and detainees ; Control , treatment and prevention strategies; Protection of detainee confidentiality; Media relations, in coordination with the local Public Affairs Officer (PAO); Procedures for the identificat ion, surveillance , immunization, follow-up and isolation of patients; g. hand hygiene b)(6); KR0 / 17.4.3 Medical Care b)(7)(C ) 2 Ir 2020-ICLl-00006 4634 h. Management of infectious diseases and reporting them to local and/o r state health departments in accordance with established guidelines and applicable laws; and 1. Management of bio -hazardous waste and decontamination of medical and dental equipment that complies with applicab le laws and policy "Environmenta l Healt h and Safety." The Krome SPC shall comply with current and future plans implemented by federal , state or local authorities address ing specific public health issues including communicable disease reporting requirements. Infectious and communicab le disease control activities shall be reviewed and discussed in the quarterly administra tive meetings as described in Section V. DD of this detention policy. Designated medical staff shall report to the ICE Health Service Cops (IHSC) Public Heatlh , Safety, and Preparedness Unit all deta inees diagnosed with a communicable disease of public health significance. 2. Tuberculosis (TB) Manage ment As indicated in this policy below in the section 11J. Medical and Mental Screeningof ·New Arrivals," screeni ng for TB is initiated at intake and in accorda nce with Cen ter for Disease Control and Prevention (CDC) guide lines. All new arriva ls sha ll rece ive TB sc reenin g within 12 hours of intake and in accordance with CDC guidelines (www.cdc.gov /tb). For detainees that have been in continuous law enforce ment custody , symptom screeni ng plus documented TB screening within one year of arrival may be accepted for intak e screen ing purposes. Annual or periodic TB testing shall be implemented in accordance with CDC gu idelines; annual TB screen ing method should be appropriately selected with consideration given lo the initial screening method conducted or documented during intake. Detainees with symptoms suggestive of TB , or with suspected or confirmed act ive TB disease based on clinical and/or laboratory findings , shall be placed in a functional airbo rne infection isolation room with negative pressure ventilation and be promptly evaluated for TB disease. Patients with suspected active TB shall remain in airborne infection isolation until determined by a qualified provider to be noncontagious in accordance with CDC guidelines . For all patients with confirmed and suspected active tuberculosis , designated medical staff sh al I: a. Report all cases to local and/or state health departments withi n one working day of meeting reporting criteria and in accordance with established guidelines and applicable laws, ident ified by the custodial agency and the detainee's ident ifying number of that agency (IC E detainees are reported as being in ICE custody and are identified by their alien numbers). KR0/17.4.3 Medical Care b)(6); b)(?)(C) 3 In 2020-ICLl-00006 4635 b. Report all deta inees with suspec ted or confi rmed TB to the ICE Health Service Corps (IHSC), Public Health , Safety , and Preparedness Unit within one working day of initial identificatio n with suspected or confomed TB disease. Reporting shall include names , aliases, date of birth , alien numb er, case status /classification , available diagnostic and lab resul ts, treatment status (including drugs and dosages) , treatment start date , a summary case report , and a point of contact and telephone number for follow-up . c. Promptly report any movement of TB patients , including hospitalizations , facility transfers , releases , or removal s/deportations to the loca l and/o r state health department and the IHSC Public Health, Safety, and Preparedness Unit. When treatment is ind icated, multi-drug , anti-TB therap y shall be admin istered using directly observed therapy (DOT) in accordance with Ame rican Thorac ic Society (A TS) and CDC guidelines. For patients with drug-r es istant or multid~ug-resistant TB, the state or local health department shall be consulted to estab lish a customized treatment regimen and treatment plan. Patient s receiving anti-TB therapy shall be provided with a 15 day supply of medication s and appropriate education whe n transferred , released or deported , in an effort to preve nt interruptions in treatment until care is co ntinu ed in another locat ion. Treatment for latent TB infection (L TBI ) shall not be initiated unless act ive TB d isease is ruled out. Designated medical staff shall coordinate with the JHSC Epidem iology Un it and the local and/or state health department to facilitate an international referral and continu ity of therapy. Designated medical staff shall collaborate with the local and/ or state health department on tuberculosis and other communicable diseases of public health significance. 3. Significant Communic able Disease Designated medical staff shall notify the IHSC Public Health , Safety, and Preparedness Unit of any ICE detaine e with a sig nificant communicable disease and of any contact or outbreak investigations involving ICE detain ees exposed to a significant communicable disease without known immunity. Sign ificant communicable diseases include , but are not limited to, varicella (chicken pox), measles , mump s, pertussis (w hooping cough) , and typhoid. 4. Bloodborne Pathogens Infection control awareness shall be communicated on a regular basis to correctional and medical staff , as well as detainees. Detainees exposed to potentially infectious KR0 / 17.4.3 Medical Care (b)(6); 4 2020-ICLl-00006 (b)(?)(C Int: ) 4636 body fluids (e.g., through needle sticks or bites) shall be afforded immediate medical assistance, and the incident shall be reported as soon as possible to the clinical director or designee and documented in the medical file. All detainees shall be assumed to be infectious for bloodbome pathogens, and standard precautions are to be used at all times when caring for all detainees. The Krome SPC shall establish a written plan lo address exposure to bloodborne pathogens; the management of hepatitis A, B, and C; and the management of HIV infection, including reporting. a. Hepatitis A detainee may request hepatitis testing at any time during detention. b. HIV A detainee may request HIV testing at any time during detention. Persons who must feed, escort, directly supervise, interview or conduct routine office work with HIV patients are not considered at risk of infection. However, persons regularly exposed to blood are at risk. Facilities shall develop a written plan to ensure the highest degree of confidentiality regarding HIV status and medical condition. Staff training must emphasize the need for confidentiality, and procedures must be in place to limit access lo health records to only authorized individuals and only when necessary. The accurate diagnosis and medical management of HIV infection among detainees shall be promoted. An HIV diagnosis may be made only by a licensed health care provider, based on a medical history, current clinical evaluation of signs and symptoms and laboratory studies. c. Clinical Evaluation and Management Medical personnel shall provide all detainees diagnosed with HIV/AIDS medical care consistent with national recommendations and guidelines disseminated through the U.S. Department of Health and Human Services, the CDC, and the Infectious Diseases Society of America. Medical and pharmacy personnel shall ensure that all Food and Drug Administration (FDA) medications currently approved for the treatment of HIV/ AIDS are accessible. Medical and pharmacy personnel shall develop and implement distribution procedures to ensure timely and confidential access to medications. Many of these guidelines are available through the following links: • • • http://aidsinfo.nih.gov/Guidelincs/default.aspx http://www.cdc.gov/hiv/resources/guidelines/index.htm#treatment ht1p:// www.idsociety.org/Co11tent.aspx?id=9088 Medical and pharmacy personnel shall ensure the Krome SPC maintains access to adequate supplies of FDA-approved medications for the treatment of HIV/AIDS KR0/ 17.4.3 Medical Care (b)(6); (b)(7)(C) 5 Int 2020-ICLl-00006 4637 to ensure newly admitted detainees shall be able to continue with thei r treatments without interruption. Upon release, detainees currently receiving highly active antiretrovira l therapy and other drug s shall receive up to a 30day supply of their medications as medically appropriate. When current symptoms are suggestive of HIV infection , the following procedures shall be implemented. 1. Clinical evaluation shall detennine the med ica l need for isolation . Detainees with HIV shall not be separated from the genera l population, either pending a test result or after a test report, unless clinical evaluation revea ls a medica l need for isolation. Segregation of HIV-positiv e deta inees is not necessa ry for pub lic health purpos es. 2. Following a clinical evaluat ion, if a detainee manifests symptoms req uiring treatment beyond the Krome SPC ' s capability , the provider shall reconunend the detain ee's transfer to a loca l hospital or other approp riate facility for further medica l testing , final diagnosis and acute treatment as needed , consistent with local operat ing procedures. 3. Any detainee with active tuberculosis shall also be evaluated for possible HIV infection. 4. New HIV-positive diagnoses must be reported to government bodies accord ing to state and loca l laws and requirements ; the HSA is responsible for ensuring that all applicable state requirements are met. The "Standar d Precautions" section of policy "E nvironmentaJ Health and Safety" provid es more detailed informa tion. D. Notifying Detainee s about Health Care Services In accordance with policy "Detainee Handbook ," the Krome SPC shall prov ide each detainee, upon admittance , a copy of the deta inee handbook and local supplement , in which procedures for access to health care services are explai ned. Health care practitioners should explain any rules about mandatory reporting and other limits to confident iality in their interactions with detainees. Informed conse nt shall be obtained prior to providing treatment (abse nt medical emergencies). Conse nt forms and refusals shall be documented and placed in the detainee 's medical file. In accordance w ith the section on Orientation in policy "Admi ssion and Release," access to health care serv ices, the sick call and medical grievance processes shall be included in the orientation curriculum for newly admitted detainees. E. Tran slation and Language Access for Detain ees with Limit ed English Proficienc y The Krome SPC shall provide appropriate interpretation and language services for LEP detainees related to medical and mental health care. Where appropriate staff KR0 / 17.4.3 Medical Care 6 2020-ICLl-00006 4638 (b)(6) ; (b)(7)(C) interpretation is not available, facilities will make use of professional interp retation services. Detainees shall not be used for interpretation serv ices during any medical or menta l health service. Interpretation and translatio n services by other deta inees shall only be prov ided in an emergency medical situation. The Krome SPC shall post signs in medical intake areas in English, Spanish, and languages spoken by other significant segments of the facility's detainee populat ion listing what language assistance is available during any medical or mental health treatme nt, diagnostic test, or evalu ation. F. Facilitie s 1. Examination and Treatment Area Adequate space and equipment shall be furnished in the Krome SPC so that all detainees may be provided basic health examinations and treatment in private while ensuring safety . A holding/waiting area shall be located in the medical faci lity under the direct supervision of custodial office rs. A detainee toilet and drinking fountain shall be accessib le from the holding/waiting area. 2. Medical Record s Medical records shall be kept separate from detainee detention records and stored in a securely locked area within the medical unit. 3. Medica l Hou sing In the Krome SPC, the Medical Housing Unit (MIDJ) shall be separate from other housing areas ; in the MHU detainee s are admitted for health observation and care under the supervision and direction of health care personnel; consideration shall be given to the detainee's age, gender , medical requirement s and custody classification and the following minimum standards shall be met: a. Care I . Physic ian at the Krome SPC or on call 24 hours per day; 2. Qual ified health care personnel on duty 24 hours per day when patients are present ; 3. Staff members within sight or sound of all patient s; 4. Maintenance of a separate medical housing record distinct from the complete medical record; and 5. Compliance with all established guidelines and applicable laws . (b)(6); (b)(7)(C) KR0 / 17.4.3 Medical Care 7 2020-ICLl-00006 4639 Int : Detainees in medical housing shall have access to other services such as telephone, legal access and materials , consiste nt with the ir medical conditions . Prior to placing a mentall y ill deta inee in medical housing, a determination shall be made by a medical or mental health professional that placement in medical housing is medically necessary. b. Wash Basins, Bathing Facilities and Toilets 1. Detainees shall have access to operable washbasins with hot and cold running water at a minimum ratio of 1 for every 12 detainees , unless state or local building codes specify a different ratio. 2. Sufficient bathing facilities shall be provided to allow detainees to bathe dai ly, and suffic ient bathing facilities shall be physically access ible for detainees with disabilities, as required by the applicable accessib ility policy. Water shall be thermostatically controlled to temperatures ranging from 100 F to 120 F degrees. 3. Detainees shall have access to operable toilets and hand-washing facilities 24 hours per day and shall be permitted to use toilet facilities without staff assistance. Unless state or local buildingor health codes specify otherwise: a. Toilets shall be provided at a minimum ratio of I to every 12 detainees in male facilities, and b. All housing units with three or more detainees shall have a minimum of two toilets. G. Pharmaceutical Management The Krome SPC, through IHSC , shall have and comply with written policy and procedures for the management of pharmaceuticals , to include: 1. A formulary of all prescription and nonprescription med icines stocked or routinely procured from outside sources; 2. Identific ation of a method for promptly approving and obtaining medicines not on the formulary; 3. Prescription practices , including requirements that medications are prescribed only when clinically indicated , and that prescriptions are reviewed before being renewed; 4. Procurement, receipt, distribution, storage, dispensing , administ ration and disposal of medications; 5. Secure storage and disposal and perpetual inventory of all controlled substances (DEA Schedule II-V), syringes , and needles; 6. Medicine administration error reports to be kept for all administration errors; 7. All staff responsible for administering or having access to pharmaceuticals to be trained on medication management before beginning duty; KR0 / 17.43 Medical Care (b)(6) ; I (b)(7)(C) 8 Int 2020-ICLl-00006 4640 8. All pharmaceuticals to be sto red in a sec ure area with the following features: a. b. c. d. e. A secure perimeter; Access limited to authorized medical staff (never detainees); Solid walls from floor to ceiling and a solid ceiling; A solid core entrance door with a high security lock (with no other access); and A secure medication storage area ~ 9. Administration and management in accordance with state and federal law ; 10. Supervision by properly licensed personnel ; 11. Administration of medications by proper Iy Iicensed , credentialed, trained personnel under the supervision of the health services administrator (HSA) , clinical medical authority (CMA), both; and 12. Documentation of accountabilit y for adm inistering or distributing medications in a timely manner , and according to licensed provider orders. H . Nonprescription Medications The AFOD and HSA shall jointly approve any nonprescription medications that are available to detainees outside of health services (e.g., sold in commissary , distributed by housing officers , etc.), and sha ll jointly review the list, on an annual basis at a minimum. I. Medical Per sonnel · All health care staff must be verifiably licensed , certified , credentialed , and/ or registered in compliance with applicab le state and federal requirements. Copies of the documents must be maintained on site and readily available for review. A restricted license does not meet this requirement. J. Medical and Mental Health Sc reenin g of New Arriva ls As soon as possible, but no later than 12 hours after arrival, all detainees sha ll receive , by a hea lth care provider or a specially trained detention officer , an initial medical , dental and mental health screening and be asked for information regarding any known acute or emergent medical conditions. Any detainee responding in the affirmative sha ll be sent for evaluation to a qua lified, licensed health care provider as quickly as possible, but in no later than two working days. Detainees who appear upon arrival to raise urgent medical or mental health concerns shall receive priorit y in the intake screen ing process. For intrasystem transfers , a qualified health care professional will review each incoming detainee's health record or health summary with in 12 hours of arrival, to ensure continuity of care. For LEP individuals , interpretation for the screening will be conducted by the Krome SPC staff with appropriate language capabil ities or through professional interpret ation services, as described in Section E of th is policy ("Translation and Language Access for Detainees with Limited Eng lish Proficie ncy "). KR0/17.4.3 (b)(6); (b)(7)(C) 9 Medical Care In 2020-ICLl-00006 4641 The screening shall inquire into the following: 1. Any past history of serious infectious or communicable illness, and any treatment or symptom s; 2. History of physical and mental illness; 3. Pain assessment ; 4. Current and past medication ; 5. Allergies; 6. Past surgical procedures ; 7. Symptoms of active TB or previous TB treatment ; 8. Dental care history; 9. Use of alcohol , tobacco and other drugs, including an assessment for risk of potential withdrawal; I 0. Possibili ty of pregnancy; 11. Other relevant health problems identified by the CMA responsib le for screening inquiry ; 12. Observation of behavior , including state of consciousness, mental status, appearance, conduct , tremor , sweating; 13. History of suicide attempts or current suicidal/ho micidal ideation or intent ; 14. Observation of bod y deformities and other physical abnormalities; 15. Inquir e into a transgender detainee 's gender self-identification and history of transition-related care, when a detainee self-identifie s as transgender ; 16. Past hospitalizations; 17. Chronic illness (including, but not limited to, hype rtension and diabetes); 18. Dietary needs ; and 19. Any history of physical or sexual victimiza tion or perpetrated sexual abuse, and when the incident occurred. Where there is a clinicaJly significant finding as a result of the initial screening, an immediate referral shall be initiated and the detainee shall receive a health assessme nt no later than two working days from the initial screening. Initial screenings shall be conducted in settings that respect detainees ' privacy and include observation and interview questi ons related to the deta inee's potential suicide risk and mental health. For further information , see policy "Significant Self-harm and Suicide Prevention and Intervention. " If, at any time during the screening process, there is an indication of need of, or a request for, mental health services, the HSA must be notified within 24 hours. The CMA, HSA or other qualified licensed health care provider shall ensure a full mental health evaluation, if indicated. Mental health evaluations must be conducted within the time frames prescribed in "O. Mental Health Program" of this policy. See "L. Comprehensive Health Assessment, " and ''N . Mental Health Program" below . b)(6); (b)(7)(C) KR0 / 17.4.3 MedicalCare h 2020-ICLl-00006 4642 II-ISC shall have policies and procedures in place to ensure docwnentation of the initial health screening and assessment. The health intake screening shall be conducted using the In-Processing Health Screening Form (IHSC 794) or equivalent and shall be completed prior to the detainee's placement in a housing unit. The Intake Screening Form attached as Appendix 4.3.A mirrors form IHSC 795A and may be used by facilities to ensure compliance with screening requirements in this polic y. Upon completion of the In-Processing Health Screening form, Medical staff will assess priority for treatment (e.g. urgent , today or routine). Limited -English proficient detainees and detainees who are hearing impaired shall be provided interpretation or translation services or other assistance as needed for medical care activities. Language assistance may be provided by another medical staff member competent in the language or by a professional service, such as a telephone interpretation service. K. Substance Dependence and Detoxificatio n All detainees shall be evaluated through an initial screening for use of and/or dependence on mood-and mind-altering substances, a lcohol, opiates, hypnotics, sedatives , etc. Detainees who report the use of such substances shall be evaluated for their degree of reliance on and potential for withdrawal from the substance. The CMA shall establish guidelines for evaluation and treatment of new arriva ls that require detoxification. Detainees experiencing severe or life-threatening intoxication or withdrawal shall be transferred immediatel y to an emergency department for evaluation. Once evaluated , the detainee will be referred to an appropriate facility qualified to provide treatment and monitoring for withdrawal, or treated on-site if the Krome SPC is staffed with qualified personnel and equipment to provide appropriate care. L. Privacy and Chaperones 1. Medical Privacy Medica l and mental health interviews, screening s, appraisa ls, examinat ions, procedures , and administration of medication shall be conducted in settings that respect detainees' privac y. 2. Same-Gender Providers and Chaperones KR0/ 17.4.3 Medical Care 11 2020-ICLl- 00006 4643 b)(6) ; b)(7)(C) A detainee's request to see a health care provid er of the same gender should be considered ; when not feas ible, a same-gender chaperone shall be provided. When care is provided by a health care provider of the opposite gende r, a detainee shall be provided a same-gender chaperone upon the detainee's request. A same-gender chaperone shall be provided , even in the absence of a request by the detainee , when a medical encounter involves a physical examination of sensitive body parts, to include breast, genital, or rectal exam inations, by a provid er of the opposite gender . Only medical personnel may serve as chaperones during medical encounte rs and examinations . M. Comprehensive Hea lth Assessment IHSC shall conduct a comprehensive health assessmen t, including a physical examination and menta l health screening, on each deta inee within 14 days of the detainee's arrival unless more immediate attention is requi1·eddue to an acute or identifiable chronic condition. Physical exam inations shall be performed by a physician , physician assistant, nurse pract itioner, RN (with documented training provided by a physician) or other hea lth care practitioner as permitted by law. Facilit y medical personnel are encouraged to use the form "Phys ical Examination/Health Appraisal" attached as Appendix 4.3.B when conducting the comprehensive health assessment. If documentation exists of such a health assessment within the previous 90 days , IHSC upon rev iew may determin e that a new appraisa l is not required. The CMA shall be respon sib le for review of all comprehensive health assess ment s to assess the priority for treatment. Detain ees diagnosed with a commun icable disease shall be isolated according to national standards of medical practice and procedures. N. Medica l/Psychiatric Alerts and Holds Where a detainee has a serious medical or mental health condition or otherwise requires special or close medical care , medical staff shall complete a Medica l/Psyc hiatric Alert form (IHSC-834) or equivalent, and file the form in the detainee ' s medical record. Where medica l staff furthermore determi ne the cond ition to be serio us enough to require medical clearance of the deta inee prior to transfer or removal, medica l staff shall also place a med ical hold on the detainee using the Medical/Psychiatr ic Alert form (IHSC834) or equivalent , which serves to prevent ICE from transferr ing or removing the detainee without the prior clearance of medical staff at the Krome SPC. The AFOD shall receive notice of all medical/psychiatric alerts or holds , and shall be responsible for (b)(6) ; (b)(7)(C) KR0/ 17.4.3 Med ical Care 12 Ir 2020-ICLl -00006 4644 notifying designated staff of any medical alerts or holds placed on a detainee that is to be transferred. Potential health conditions meriting the completion of a Medi_cal/Psychiatric Alert form may include , but are not limited to: 1) Medical conditions requiring ongo ing therapy, such as: a. Act ive TB b. Infectious diseases c. Chronic conditions 2) Mental health condit ions requiring ongoing therapy , such as: a. Suicidal behavior or tendencies 3) Ongoing physica l therapy 4) Pregnancy 0. Me ntal Hea lth P rogram 1. Me ntal Hea lth Services Req uired The Krome SPC shall have an in-house or contractual mental health program, approved by the appropriate medical authority that provides: a. Intake screening Form IHSC 794 (or equivalent) for mental health problems; b. Referral as needed for evaluation, diagnosis , treatment and monitoring of mental illness by a competent mental health professional. c. Crisis intervention and management of acute menta l health episodes; d. Transfer to licensed mental health facilities of deta inees whose mental health needs excee d the capabilities of the Krome SPC; and e. A suic ide prevention program . 2 . Me ntal Hea lth Provi der The term "mental health provider" includes psychiatrists , physicians , psycho logists, clinical social workers and other appropriately licensed independent menta l health pract itioners 3. Me ntal Hea lth Eva luatio n Based on intake screenjng, the comprehensive health assessment , medica l documentation, or subsequent observations by detention staff or medical personnel, any detrunee referred for menta l health treatme nt shall receive an eva luation by a qua lified health care provide r no later than 72 hours after the referral, or sooner if necessary. If the KR0 / 17.4.3 Medical Care 13 (b)(6) ; (b)(7)(C) 1111 2020-ICLl-00006 4645 practitioner is not a mental health provider and further referral is necessary , the detainee will be evaluated by a mental health provider within the next business day . Such evaluation and screenings shall inc lude: a. b. c. d. e. f. g. h. 1. J. Reason for referr al ; Hi story of any mental health treatment or evaluation ; Histo ry of illicit drug/alcohol use or abuse or treatment for such ; History of suicide attempt s; Current suicida l/homicidal ideation or intent ; Current use of any medication ; Estimate of current intellectual funct ion ; Mental health screenin g, to include prior history physica l, sexual or emotional abuse; Impact of any pertinent ph ysica l condition , such as head trauma ; Recomm end actions fo r any appropriate treatment , including but not limited to the following: 1. 2. 3. 4. Remain in ge neral population with psychotropic medication and counseling, "sho rt-stay " unit or infirmary , Special Management Unit , or Community hospitalization ; and k. Recommending and/or implementing a treatment plan , including recommendations concerning transfer , housing , voluntary work and other program participat ion. 4. Referral s and Treatm ent Any detainee refe rred for menta l health treatment sha ll receive an evaluation by a qualified health care provider no later than 72 hours after the referral , or soo ner if necessary. If the practitioner is not a men tal health provide r and further referra l is necessary, the detainee will be evaluated by a me ntal hea lth provider within the next business day. The provider shall develop an overall treatment /managemen t plan. If the detainee 's mental illn ess or developme ntal or intellectual disability needs exceeds the treatment capabi lity of th e Krome SPC , a referral for an outside mental hea lth facili ty may be initiated. Any deta inee prescribed psych iatric medications must be regularly eva luated by a duly licensed and appropriate medical professional , at least once a mon th, to ensure proper treatment and dosage; 5. Medical Isolation (b)(6) ; (b)(?)(C) KR0 /1 7.4.3 Medical Care 14 In 2020-ICLl-00006 4646 The CMA may authorize medical isolation for a detainee who is at high risk for violent behavior because of a mental health condition. The CMA shall be responsible for the daily reassessment of the need for cont inued medica l isolation to ensure the health and safety of the detainee. Medical isolation shall not be used as a punitive measure. 6. Invo lunt ary Administr ation of Psyc hotropic Medicatio n Involuntary administrat ion of psychotropic medication to detainees shall comply with established guidelines and applicable laws , and shall be performed only pursuant to the speci fie, written and detailed authorization of a physician. Absent declared medical emergency , before psychotropic medication is involuntarily administered , it is required that the HSA contact ERO management , who shall then contact respective ICE Office of Chief Counse l to facilitate a request for a court orde r to involuntarily medicate the detainee. Prior to involuntarily adm inister ing psychotropic medication , absent a declared medical emergency, the authorizing physician shall: a. Review the medical record of the detainee and conduct a medical examination ; b. Specify the reasons for and duration of therapy, and whethe r the detainee has been asked if he/she would consent to such medication; c. Specify the medication to be administered , the dosage and the possible side effects of the medication; d. Document that less restrictive intervention options have been exercised without success; e. Detail how medication is to be administered ; f. Monitor the detainee for adverse reactions and side effects ; and g. Prepare treatment plans for less restrictive alternatives as soon as possible. Also see the section on Informed Consent and Involuntary Treatment (Medical Care sections V and X) later in this detention policy. P. Referrals for Sex ual Abuse Victims or Abusers If any security or medical intake screening or classification assessment indicates that a detainee has experienced prior sexual victimization or perpetrated sexual abuse, staff shall, as appropriate , ensure that the detainee is immediately referred to a qualified medical or menta l health practitioner for medical and/or mental health follow-up as appropriate. When a referral for medical follow-up is initiated, the detainee shall receive a health evaluation no later than two working days from the date of assessment. When a referra l for mental health follow-up is initiated , the detainee shall receive a mental health evaluation no later than 72 hours after the referral. KR0 /17 .4.3 Medical Care 15 2020-ICLl -00006 4647 b)(6); b)(7)(C) In For the purposes of this section, a "qua lified medica l practitioner" or "qualified mental health practitioner" means a health or mental health professional , respec tively , who in addition to being qualified to evaluate and care for patients within the scope of his/her professional practice , has successfully completed spec ialized training for treating sexua l abuse victims. Q. Annu al Hea lth Exa min ations Any detainee in ICE custody for more than one year continuous ly sha ll receive health exam ination s on an annual basis. Such exam inations may occur more frequently for certain individuals , depending on their medical history and/or health condition s. Detainees shall have access to age- and gender -appropr iate exams annually , includin g rescreening for TB. R. Dental Treatme nt An initial dental screening shall be performed within 14 days of the detainee 's arrival. The initial dental screeni ng may be performed by a denti st or a properly trained qualified health provider. I. Emergency dental treatment shall be provided for immediate relief of pain, trauma and acute oral infection. 2. Routine dental treatment may be provided to detainee s in ICE custody for whom dental treatment is inaccessibl e for prolonged period s because of detention for over six months , includin g amalgam and composi te restoration s, prophylaxis , root canals, extractions , x-rays, the repair and adjustment of pro sthetic appliances and other procedures required to maintain the detainee' s health. Dental exams and treatment shall be performed only by licensed denta] personnel. S. Sick Call The Krome SPC has regularl y schedu led times , known as sick call, when medical personnel are available to see detainees who have requested medical serv ices. Sick call is conducted every day except Wednesdays. Request slips are made freely availab le by detainee housing unit officers for detainees to reque st health care services on a dail y basis. The request slips are made available in English, Creole and Spanish. The slip is completed by the detainee and must contain the detainee's name , full A-numb er, sex, age, country of nationalit y, and reason for reque sting a medical visit. The slip will be dated and signed by the detainee. If necessary, detainees are provided with assistance in filling out the request slip, especially detainees that are illiter ate or limited English speaking. The IHSC will triage the detainees in their housing units to determine when the detainee will be seen. Appointments are then scheduled for all those who do not requ ire same day b)(6) ; b)(7)(C) KR0 / 17.4.3 Medical Care 16 2020-ICLl-00006 4648 treatment. Sick ca ll requests wi ll be triaged by medical personnel within 24 hours, after a detainee su bmits the request. All detainees , incl udi ng those in Specia l Management Units, regardless of classification, will have access to sick ca ll. In addition to sick ca ll, if a detainee needs imme diate medical attention , the officers notify the medica l clin ic of the name, alien number and the description of the complaint. Medical staff will then make the determination as to whether the detainee shou ld report to the medical clinic. Prior to the scheduled visits from the JHSC med ica l staff: the Specia l Housi ng Unit Officer sha ll go to each cell and have the detai nees deposit sick cal l slips , if any , into the portable sick ca ll s lip inbox. This procedure will enforce the Health Insurance Portability and Accountability Act (HIP AA) Privacy Rule , which protects the privacy of individually ident ifiab le health informat ion. IHSC medical staff w ill then collect all sick call slips according ly. T. Emergency Medical Serv ices and First Aid I. JHSC shal l have a writte n emergency services plan for delivery of 24-hour emergency hea lth care. This plan sha ll be prepa red in consultat ion with the Krome SPC's CMA or the HSA , and must include the following: a. An on-call physician , dentist and mental health professional , or designee , that are ava ilab le 24 hours per day; b. A list of telephone numbers for local ambu lances and hospita l serv ices availab le to all staff ; c. An automatic external defibrillator (AED) shall be maintained for use at the Krome SPC and accessible to staff ; d. A ll detention and medical staff sha ll receive cardio pulmonary resuscitation (CPR, AED), and eme rgency first aid training annua lly; e. Deten tion and health care personnel shall be trained annually to respond to health-related situations within four minutes ; and f. Secur ity procedures that ensure the immediate transfer of detainees for emergency medica l care. 2. The health services administrator ensures that medical staffs have training and competency in implementing the faci lity's emergency health care plan appropriate for each staffs scope of practice or position . The facility administrator ensures that nonmedica l staffs have appropr iate train in g and competency in imp lementing the fac ility's eme rgency plan approp riate for each staffs pos ition. Training and competency assessment shall inc lude the following areas: a . Recognizing of signs of potential health emergencies and the required response ·s; b. Admi nisteri ng first aid, AED and cardiop ulm onary resusc itation (CP R); c. Obta ining emergency medica l assistance thr ough the Krome SPC plan and its requi red procedures; KR0 / 17.4.3 b)(6); b)(7)(C) 17 Medical Care 2020~1CLl-00006 4649 d. Recognizing signs and symptoms of mental illness and suicide risk; and e. The Krome SPC's established plan and procedures for providing "" emergency medical care including, when required, the safe and secure transfer of detainees for appropriate hospital or other medical services, including by ambulance when indicated. The plan must provide for exped ited entrance to and exit from the Krome SPC. 3. When a non-medical employee is unsure whether emergenc y care is required, he/she shal l immediatel y notify medical personnel to make the determination. 4. Medical and safety equipment shall be available and maintained , and staff shall be trained in proper use of the equipment. 5. The AFOD , in consultation with the des ignee for environmental health and safety, determ ined the number, contents, and placement of first aid kits, and established protocols for monthl y inspections of first aid kits. 6. Victims of sexual abuse shall have timely access to emergenc y medical treatment and crisis intervention services in accordance with policy "Sexual Abuse and Assa ult, Prevention and Intervention. " U. Delivery of Medication Distribution of medication (including over the counter) shall be performed in accordance with spec ific instruction s and procedu res establ ished by the HSA in consultation with the CMA. Writte n records of all prescribe d medication given to or refused by detainees shall be maintained. 1. IHSC wiU have medical staff on duty at the Krome SPC 24/7 to distribute all medication. 2. The Krome SPC shall maintain documentation of the training given any officer required to distribute medicati on, and the officer shall have available for reference the training syllab us or other guide or protocol provided by the health authorit y. 3. Detainee s may not del iver or administer medications to other detainees. 4. All prescribed medications and medically necessary treatments shall be provided to detainees on schedule and without interruption , absent exigent circumstances. 5. Detainees who arrive at the Krome SPC with prescribed med ications or who report being on such medications, shall be eva luated by a qualified health care profess ional as soon as possible, but not later than 24 hours after arriva l, and provisions shall be made to secure medically necessary medications. 6. Detainees shall not be charged for any medical services to include pharmaceutic als dispe nsed by medical personnel. V. Health Ed ucation and Wellness Information Qualified health care personnel shall provide detainees health education and wellness information on topics including, but not limited to, the following: 1. Dangers of self-med ication; KR0 / 17.4.J Medical Cu-e (b)(6); (b)(7)(C) 18 1 lnt: 2020-ICLl-00006 4650 2. 3. 4. 5. 6. Personal and hand hygiene and dental care; Prevention of communicable diseases; Smoking cessation; Self-care for chronic conditions; and Benefits of physical fitness. W. Specia l Needs and Close Medical Supervision Consistent with policy "Disability Identification , Assessment , and Accommodation " and the IHSC Detainee Covered Services Package , detainees will be provided medical prosthetic devices or other impairment aids , such as eyeglasses, hearing aids, or wheelcha irs. When a detainee requires close medical supervision , including chronic and convalescent care, a written treatment plan, including access to health care and other care and supervision personnel, shall be developed and approved by the appropriate qualified licensed health care provider, in consultation with the patient , with periodic review . Likewise , staff responsible for such matters as housing and program assignments and disciplinary measure s shall consult with the responsible qualified licensed health care provider or HSA. Exercise areas shaU be available to meet exercise and physical therapy requirements of individual detainee treatment plans. Tran sgender detainee s who were already receiv ing hormone therapy when taken into ICE custody shall have continued access. All transgender detainees shall have access to mental health care, and other transgender -related health care and medication based on medical need. Treatment shall follow accepted guidelines regarding medically necessary trans ition -related care. X. Notifications of Detainees with Serious llJoess and Other Specified Conditions The facility admin istrator and clinical medical authority sha ll ensure that the Field Office Director is notified as soon as practicable of any detainee housed at the facility who is determined to have a serious physical or mental illness or to be pregnant, or have medical complications relat ed to advanced age, but no later than 72 hours after such determination. The written notification shaJI become part of the detainee's health record file . 1. Serious Physical Illness For purpo ses of this subsection only, the following non-exhaustive categories of medical conditions may be considered to constitute serious physical illness: • Any terminal illness; • Active cancer, includin g but not limited to aliens undergoing chemotherapy; KR0 /17.4.3 Medical Care (b)(6); (b)(7)(C) 19 2020-ICLl-00006 4651 • Acquired Immuno- Deficiency Syndrom e (A IDS) or dia gnose d HIV-posi tive conditions requiring medication; • Multi-drug -resistant (MOR) or extensively drug -resistant (XDR ) tube rculosis disease; • Any cond ition that requires dialysis; • Any condition that requir es tube-feed ings , mechanical ventilat ion , an implanted card iac device , or an oxygen tank ; • Any chronic deteriorating condition requiring multiple medications, to include progressive immun e-suppressive conditio ns; • Any active cond ition that has caused repeated loss of consciousness; • Any condition that requires an immin ent medical procedu re or other medical interv ent ion to prevent deterioration ; • Any condi tion or infirmit y that requires conti nuous or near-continuous medical care , such as those who are bed bound or incapable of caring for themselves ; or any ongoing or recurrent conditions that have required a recent or pro longed hospita lization , typically for greate r than 14 days, or a recen t and prolonged stay in the medical clinic of a detention or correctional facility , typically for greater than 30 days; • Conditions requiring frequent care that is beyond the medical capab ilities of detention facilities where the alie n may be housed ; • Any condition that wou ld preclude the alien from being housed, typ ically for greate r than 30 days , in a non-restrictive setting (suc h as a genera l population housing unit , as opposed to a spec ial management unit or a medical clinic); or • Any other physical illne ss determined to be serious by facility medical pe rson nel or by IHSC. 2. Serious Mental Illne ss For the purposes of this sect ion, the following non -exhaustive categories of conditio ns should be considered to constitute a serious men tal illness: (a) Cond itions that a qualified medical provider has determined to meet the criteria for a "ser ious mental disorder or condition " pursuant to app licable ICE policies, including: • A mental disorder that is causi ng serious limitations in communication , memory, or general menta l and/or intellectual functioni ng (e.g. communicatin g, cond ucting activities of daily life, social ski lls); or a severe medical cond ition(s) (e.g. traumatic brain injury or dement ia) that is significant ly impairing mental function; or • One or more of the following active psychiat ric symptoms and/or behavior: seve re disorganization , act ive hallucinations or delusions , mania , cataton ia, severe depressive symptoms , suicidal ideation and/or behavior , marked anxiety of impulsivity. • Signifi cant symptoms of one of the following: D Psychosis or Psychotic Disorder: (b)(6) ; (b)(7)(C) KR0/17.4 .3 Medical Care 20 2020-ICLl-00006 4652 In □ Bipol ar Disord er; Schizophrenia or Sch izoaff ective Disorder ; □ Major Depressive Disorder with Psychotic Feat ures; □ Dem entia and/or a Neurocog nitive Disord er; or □ Intellectual Deve lopment Disorder (mo derate, seve re, or profound ). b) Any ongoing or recurrent conditions that have requi red a rec ent or prolon ged hospitali zat ion, typica lly for greater than 14 days, or a recent and prol onged stay in the medical clinic of a det ention or correctiona l facility , typically for greate r than 30 days ; c) Any condition that wo uld preclude the alien from bein g housed, typica lly for greater than 30 days , in a non-res trictive sett ing (such as a genera l population housing unit, as opposed to a special management unit or a medica l clinic); d) Any other mental illness determined to be serious by JHSC . □ 3. Pregnanc y The notification requ ireme nt in thi s sect ion applie s to all women who have been medically certified as pregnant, rega rdless of the stage of the pregnancy. Y. Restraint s Restraint s for medic a l or me ntal health purpose s may be authori zed only by the Krome SPC CMA o r des ignee, after determinin g that less restrictive meas ures are no t appropriate. In the absence of the CMA , qua lified medical personnel may app ly restra ints upon declaring a medical emergency. Within one-ho ur of initiation of emergency restraints or seclusion , qualified medical staff shall notify and ob tain an order from the CMA or designee. a. The Krome SPC shall have writte n procedu res that spec ify: 1. 2. 3. 4. The condition s under wnich restraints may be app lied; The types of res traints to be used; The proper use, application and medical monitoring of restraint s; Requirements for documentation , includin g efforts to use less restrictive alternat ives ; and 5. After- incident review . The use of restraint s requ ires documen ted approval and guidance from the CMA. Record keeping and reporting requirements regarding the medical approval to use restrain ts shall be cons istent with other provisions within these standards , includin g docume ntation in the detainee's A-fil e, detention and medical file. z. Continuity of Care The HSA must ensure that a plan is deve loped that provides for continui ty of medica l care in the event of a change in det ention placement or status. KR0 / 17.4.3 Medical Care (b)(6 ); (b)(7)(C) 21 2020-ICLl-00006 In 4653 The detainee 's medical needs shall be taken into account prior to any transfe r of the detainee to another facility. Alternatives to transfer shall be considered , taking into account the disruption that a transfer will cause to a detainee receiving medical care. Upon transfer to another facility , the medical provider shall prepare and provide a Medical Transfer Summary as required by " C. Resp onsib ilities of the Health Care Provider at the Sending Facili ty," found in policy "Detainee Transfers." In addition , the medical provider shall ensure that at least 7 day (or, in the case of TB medications , 15 day and in the case of mv/AIDS medications , 30 day) supply of medication sha ll accompany the deta inee as ordered by the prescr ibing authority. Upon removal or relea se from ICE custody , the detainee shall receive up to a 30 day supp ly of medication as ordered by the prescribing authority and a detail ed medical care summary as described in " BB . Medical Records " of this policy. If a deta inee is on prescribed narcotics , the clinical health authority shall make a determination regarding continuation , based on assessment of the detainee. The HSA must ensure that a continuity of treatment care plan is developed and a written copy provid ed to the detainee prio r to removal. AA. Informed Consent and Involun tary Treatme nt Involuntary treatment is a decision made only by medical staff under strict legal restrictions. When a detainee refuses medical treatment , and the licensed healthcare prov ider determines that a medical emergency exists , the physician may authorize involuntary medical treatment. Prior to any contemplated action involving noo-1:: mergent involuntary medical treatment , respect ive ICE Office of Chief Counsel shall be consulted . 1. Upon admission at the facility , documented informed consent shall be obtained for the provi sion of health care services. 2. All examinations , treatments , and procedures are governed by informed consent practices applicable in the jurisdiction. 3. A separate documented informed consent is required for invasive procedures, includin g surgeries, invasive diagnostic tests , and dental extractions. 4 . Prior to the administration of psychotropic medications, a separa te documented informed consent, that includes a description of the medication's side effects , shall be obtained. 5. If a consent form is not available in a language the detainee understands, profes sional interpretation services will be provided as described in Section E ("Translatio n and Language Access for Detainee s with Limited English Proficiency") and documented on the form. 6. If a detain ee refuses treatment and the CMA or designee determines that treatment is necessary , ICE/ERO shall be consulted in determining whether involuntary treatment shall be pursued. 7. If the detainee refu ses to consent to treatment , medical staff shall mak e reasonable efforts to explai n to the detainee the necessity for and propriety of the recommended treatment. KR0 / 17.4.3 Medical Care 22 2020-ICLl-00006 4654 8. Medical staff shall ensure that the detainee's questions regarding the treatmerrt are answered by appropriate medical personnel. 9. Medical Staff shall explai n 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 treatme nt. 10. The clinical medical authority and AFOD shall look into refusals of treatment to ensure that such refusals are not the result of miscommunication or misunderst anding. 11. The Krome SPC should make efforts to involve trusted individua ls such as clergy or family members should a detainee refuse treatment. 12. A detainee who refuses examinatio n or treatment may be segregated from the general population when such segregation is determined medically necessary by the CMA. Segregation shall only be for medical reasons that are documented in the medica l record , and may not be used for punitive purposes. Such segrega tion shall only occur after a determination by a component mental health professional has taken place that shows the segregation shall not adversely affect the detainee's mental health. 13. In the event of a hunger strike, see policy "4 .2 Hunger Strikes." Policy "Term inal Illness, Advance Directives and Death" provid es details regard ing living wills and advance directives, organ donations and do not resuscitate (DNR) orders. BB. Medical Records 1. Health Record File The HSA shall maintain a complete health record on each detainee that is: a. Organ ized uniformly in accordance with appropriate accr editing body standards; b. Avai lable to a ll practitioners and used by them for health care documentation; and c. Properly maintained and safeguarded in a securely locked area within the medical unit. 2. Confidenti ality and Release of Medical Records All medical providers, as well as detention officers and staff shall protect the privacy of detainees ' medical information in accordance with establ ished guidelin es and applicable laws. These protections apply, not only to records maintained on paper, but also to electronic records where they are used. Staff training must emp hasize the need for confidentiality and procedures must be in place to limit access to health records to only authorized individuals and only when necessary . Information about a detain ee' s health status and a detainee ' s health record is confidential , and the active medical record shall be maintained separately from other (b)(6); KR0/17.4.3 Medical Care 23 2020-ICLl-00006 (b)(?)(C) 11 4655 detention records and be accessible in accordance with applicable laws and regulatio ns. The HSA shall provide the AFOD and des ignated staff infonnation that is necessa ry as follows: a. To preserve the health and safe ty o f the detainee , othe r detainees , staff or any other perso n; b. For administrati ve and detention decisions such as hou sing, voluntary work assig nments , security and transport; or c. Fo r management purposes such as aud its and inspections. When inJormati on is covered by the Privacy Act , speci fic lega l restriction s gove rn the re lease of med ical informati on or records. Detainees who indicate they wish to obtain copies of their medical records shall be provided with the appropriate reques t form. ICE/ ERO . or the AFOD , shall provi de limited- English proficient detainees and detainees who are bearing impaired with interpreta tion or tran slat ion serv ices or other ass istance as needed to mak e the written request , and shall assist in transmittin g the request to the facility HS A. Upon his request, while in detention. a detainee or his designated represent ative shall receive inform at ion from their medical record s. Copies of health record s shall be released by the HS A dire ctly to a de tainee or their designee , at nu cost tu tht: tlt:tainee, within a reaso nable timefr ame after rece ipt by the HSA of a writ ten autho rizati on from the deta inee. A written reque st ma y serve as author izat ion for the release o f health information , as lo ng as it includes the following infonn ation. and meets any other requirements of the HSA: a. b. c. d. e. Address of the faci lity to relea se the information: lame of the indi vidual or institution to receive the information; Detainee·s full name . A-num ber. date of birth and nationality : Specific information to be released ,vith inclu sive dates of treatment ; and Detain ee's signature and date. ro llowi ng the release of health info1mation. the wr itten authori zatio n shall be retained in the health record. Detainees are to be informed that if they are released or removed from custody prior to labora tory results being eva luated. the result s shall be made available by contacting the Krom e SPC and providing a release of information consent. 3. Inact ive Hea lth Record Files KR0/17.-1 .3 (b)(6); (b)(7)(C) 24 h Medical Care 2020-ICLl-00006 4656 Inactive health record files shall be retained as permanent records in compliance with locally established procedures and the legal requirements of the jurisdiction. 4. Transfer and Release of Detainees ICE/ERO and the HSA shall be notified when detainees are to be transferred or released. Detainees shall be transferred , released or removed , with proper medication to ensure continuity of care throughout the transfer and subsequent intake process , release or removal (see "W. Continuit y of Care," abov e). Those detainees who are currently placed in a medical hold status must be evaluated and cleared by a licensed independent practitioner (LIP) prior to transfer or removal. In addition , the CMA or designee must inform the AFOD in writing if the detainee's medical or psychiatric condition requires a medical escort during removal or transfer . a. Notificat ion of Medical/Psychiatric Alerts or Holds Upon receiving notification that a deta inee is to be transferred, appropriate medical staff at the sending facility shall notify the AFOD of any medical/psychiatric alerts or holds that have been assigned to the detainee , as reflected in the detainee's medical record s. The AFOD shall be responsibl e for providing notice to desi gnated staff of any medica l alert s or holds placed on a detainee that is to be transferred. b. Notification of Transfers , Releases and Removals The HSA shall be given advance notice by ICE/ERO prior to the release, transfer or removal of a detainee, so that medical staff may determine and provide for any medical needs associated with the transfer , release or removal. c. Transfe r of Medical Information I. When a detainee is transferred to another detention facility, the Krome SPC shall ensure that a Medical Transfer Summary accompanies the detainee , as required in "C. Respo nsibilities of the Health Care Provider at the Sending Facility" found in policy "Detain ee Transfers: ' Upon request of the receiving facility, the sendin g facility shall transmit a copy of the full medical record within 5 business days, and sooner than that if determined by the receivi ng facility to be a medically urge nt matter. 2. Upon removal or release from ICE custody, the detain ee shall be provided medication , referrals to community -based providers as medically appropriate , and a detail ed medical care summary. This summary should include instruction s that the detainee can understand and hea lth history that would be meaningful to future medical providers. The summary shall include, at a minimwn , the following items: a. patient identification ; b. tuberculosis (TB) screening results (includin g results date) and current TB status if TB disease is suspected or confirmed; KR0/ 17.4.3 Medical Care b)(6); b)(7)(C) 25 Int. 2020-ICLl-00006 4657 c. current mental , dental , and physical health status, including all significant health issues , and highlighting any potential unstable issues or conditions which require urgent follow -up; d. current medications , with instructi ons for dose , frequency, etc., with specific instruction s for medication s that must be admin istered en route; e. any past hospitalizations or major surgica l procedures ; f. recent test results, as appropriate; g. known a llerg ies; h. any pendin g medical or mental health eva luations , tests, procedur es, or treatment s for a serious medical condit ion sched uled for the detainee at the sendin g facility. In the case of patients with communicable disease and/or other serious medical needs , detainees bein g released from ICE custody are given a list of commun ity resources , at a minimum ; 1. copies of any relevant documents as appropriate; j. printed instructions on how to obtain the comp lete medical reco rd; and k. the name and contact information of the transferrin g medical official. The LHSCForm 849 or equiva lent, or the Med ica l Transfer Summary attached as Appendix 4.3.C , which mirror s IHSC Form 849, may be used by facilities to ensur e compliance with these standard s. CC. Terminal Illnes s or Death of a Detainee Procedures to be followed in the event of a cletainee 's terminal illne ss or death are in policy "Term inal Illness, Advance Direct ives and Death. " The policy also addresses detainee organ dona tions. DD. Medica l Experimentation Detainees shall not participate in medical , pharmace utical or cosmetic research while under the care of ICE. This stipulation does not preclude the use of approved clinic al trials that may be warrant ed for a spec ific inmate's diagnosis or treatment when recommended and approved by the clinical medical director. Such measures requ ire documented informed consent. EE. Administration of the Medical Department 1. Quarterly Administrative Meetings The HSA shall convene a meeting quarterly at minimum , and include other facil ity and med ical staff as appropriate. The meeting agenda shall includ e, at min imwn, the follow ing: b)(6); b)(7)(C) KR0 / 17.4.3 MedicalCare 26 2020-ICLl-00006 In 4658 a. An account of the effectiveness of the Krome SPC's health care program; b. Discussion s of healt h environment factors that may need improvem ent; c. R eview and discu ssion of communicable disease and infectious control activities; d. Changes effected since the previous meetin gs; and e. Recommended corrective actions, as necessa ry. Minutes of each me eting shall be recorded and kept on file. 2. Health Care Internal Review and Quality Ass urance The HSA shall implement a system of internal review and qua lity assurance. The system sha ll include: a. Participation in a multidisciplinary quality improvement committee; b. Collection, trending and ana lysis of data along with planning , interventi ons and reassessments; c. Eva luation of defin ed data ; d. Ana lysis of the need for ongoing education and training ; e. On-site monitoring of hea lth service outcomes on a regular basis through the following mea sures: I. Chart reviews by the responsi ble physician or his/he r designee , including investigation of comp laints and quality of health records; 2. Rev iew of practic es for prescribing and administering medicati on; 3. Systematic investigation of complaints and grievances; 4. Monitoring of corrective action plans; 5. Reviewing all death s, suicid e attempts and illness outbreaks; 6. Deve lopin g and impleme ntin g correct ive-action plans to address and resolve ident ified problems and concerns; 7. Reeva luating problems or concern s, to detem1ine whether the corrective measures have achjeved and sustained the desired results; 8. Incorporatin g find ings of interna l review activitie s into the organization's educational and training activities; 9. Maintaining appropriate record s of internal review activities; and I 0. Ensuring records of interna l review activities comply with lega l requir ement s on confidentiality of records. 3. Peer Review The BSA shall implement an intra-or ganization al, external peer review program for a ll independent ly licensed medical profess ionals . Rev iews shall be conducted at least annually. FF.Ex aminations by Independent Medical Service Providers and Experts (b)(6); KR0/ 17.4.3 Medical Care 27 2020-ICLl-00006 (b)(?)(C) Int 4659 On occasion, medical and/or mental health examinatio ns by a practitioner or expert not associated with ICE or the Krome SPC may provide a detainee with information usefu l in adm inistrative proceedings. If a detainee seeks an independent medical or mental health examinat ion , the detainee or his/her legal represen tative shall submit to the FOD a written request that details the reasons for such an examination. Ordinarily , the FOD shall approve the request for independent examination , as long as such examination shall not present an unreasonable security risk. Requests for independent examinations shall be responded to as quickly as practicable. If a request is den ied, the FOO sha ll advise the requester in writing of the rationale. Ne ither ICE/ERO nor the Krome SPC shall assume any costs of the examination , which will be at the deta inee 's expense. The Krome SPC shall provide a location for the examination but no medical equipment or supp lies and the examinatio n must be arranged and conducted in a mann er consistent with maintaining the security and good order of the Krome SPC. GG. Tele-Health Sys tems The Krome SPC sha ll be operating at the optimal leve l, when equ ipped with appropriate technology and adequate space , and when able to provide for the use of services of the ICE Tele -Health Systems , inclusive of tele-radiology (rTSP), tele-psychiatry and Lele-medicine. I. The cost of the equipment. equipment maintenance , staff training and credentialing (as outl ined in the contract) , an-angcments for x-ray interpretation and admini stration by a credentialed radiologist; and data transmission to and from the Krome SPC , shall be provided by the facility and charged directly to ICE. 2. The AFOD shall coordinate with the ITSP to ensure adequate space is provided for the equipment , connectivity is available , and electrical services are installed. 3. Immediate 24-hour access , seven days a week , to equipment for service and maintenance by ITSP technicians shall be granted . 4. A qualified tele-health coordinator shall be appointed and available for training by the ITSP. Qualified , licensed and credentialed medical staff shall be available to provide tele-health services as guided by state and federal requirement s and restrictions. (b)(6) ; (b)(?)(C) KR0 / 17.4.3 Medical Care 28 2020-ICLl-00006 4660 Approval of Polic y (b)(6); (b)(7)(C) FEB2 7 2017 Date Ass istant Field Office Director /OIC KR0/17.4.3 Medical Care 29 2020-ICLl -00006 4661 Int: L"' De partm e nt of H om eland Sec u r it} US Immigrati on and Customs Enfor ce ment Krome en.ice Pr oce si ng Center ~pec ific P o~! Ord e rs Detain ee H ou in g l'nit Building 14A Yard Detaine e Hou sing U nit Buildin g 14A Ya rd Assume Post • Read and sign post orders and General Post Orders. • Receive a thorough briefing from the previous officer. Briefing should include any pertinent information that would affect the post. • Ensure that your communication radio is in good working order with a fully charged battery. • Prior to the outgoing officer exiting the post, examine the overall cleanliness of the unit. • Inventory all equipment. • Make official entry in the logbook stating you have accepted the post, and assume all responsibilities that go with the post. Review past entries in the Housing Unit logbook. • Conduct a security and sanitation check of the yard prior to relieving the outgoing officer; ensure that contraband and prohibited items are not present; notate all discrepancies in the logbook and submit the appropriate work order when applicable. Duti es and Resp onsibiliti es • Maintain care, custody and control of detainees housed in the Housing Unit. • Maintain surveillance of detainees in the building 14A yard. • Perform a thorough contraband search of the building 14A yard prior to, and after detainees occupy the area. • Do not allow detainees to tamper with the fence. • At no time should detainees be left unattended in the building 14A yard. • Ensure that the yard is free of contraband, trash, and debris. • Assist the desk officer i11 ensuring that all detainees are accounted for prior to them exiting the building for any reason, and upon their return. • All detainees will be awakened at 0500 hrs. • All detainee beds will be made neatly and in an orderly fashion no later than 0700 hrs. daily. • All dormitories will be clean and free of trash and debris no later than 0800 hrs. daily. • Dormitories must be maintained in a sanitary manner at all times. • Make frequent but irregular patrols of the unit. • Ensure that all detainees are searched upon exiting and returning to the dormitory for any reason. • A visual check will be made of each detainee's wristband every time they are pat searched upon enter their housing units. This check will verify; Correct detainee, good physical shape of the wristband; is it stretched, is the print in good shape, is it faded, and is the plastic clasp still on. • A Detainee with a wristband in poor condition or loose will be sent immediately to processing for a replacement. • Perform a minimum of five random searches of detainees in the unit, and their personal areas, in an effort to maintain the safety and security of the facility (individual shakedowns). • Do not perform shakedowns after ·'tights ouC, except in emergency situations or when authorized by a supervisor. Page I of :i 2020-ICLl-00006 4662 CS Department of Home land ecu rit) Immi gra tion and Cu.... toms Enforcement Kr ome Se rvice Proc e ing Center Spec ific Post Orde rs Deta inee Hou ing Unit Buildin g 14A Yard Duti es and Res ponsi bilities- continued • Log in the contraband logbook the detainee's name, A#, findings, exact location where contraband was found, type(s) of contraband and your name. Maintain and update the housing unit bed sheet. Ensure that all doors are functional (open and close securely). Ensure that all detainees are offered meals during the regularly scheduled meal. Ensure that the established housing unit guidelines are being enforced. During normal operating situations, unit doors are to remain secured. Ensure that detainees are escorted in one line and in one tight group. Do not allow detainees to stray apart in an out of control manner. A count of detainees will be conducted at the beginning and at the end of each escort to ensure accountability. Ensure that detainees who are being moved or released from the unit have the following in their possession I towel, all issued uniforms and linen. When patrolling, constantly be on alert for suspicious activities. Look for contraband and anything out of the ordinary. Patrols must never become regular and routine. If detainees can anticipate your activities, then they can plan prohibited activities accordingly. At any time if a female enters a housing unit or any area in which a detainee is likely to be showering, performing bodily functions or changing clothes the officer is required to announce to the detainees "Female on Deck" • • • • • • • • • • Do not vacate the post unless prope rly relieved. Note : Office rs will condu ct and annotat e in the logbook a Security, Safety and Sanitation check every 45 minutes to an hour at irregular times (24 hours a day). To ensure the Officer 's safety, wa tch calls will be conducted between the hours of 1800 a nd 0600 every half hour by notify ing the control post by telephone o r radio. Annotate in the log book that a wat ch call was conduct ed. Rec urring Du ties • Rounds are to be conduct d throughout the entire shift ensuring that beds are made proper!); common areas and living are clean and neat, etc. During patrols of the unit, ensure that the rear exit doors are secured, by depressing the locking bar. Note any movement of detainees from the unit in the logbook with the last name, first name, complete alien number, country and destination. Replenish hygiene supplies as needed. Maintain accountability of items issued (i.e. board games, pencils, etc.). • • • Cleaning Supplies and Equipm ent • • • Cleaning supplies and equipment will be inventoried before and after use and logged in on the proper inventory sheet. Officers will verify that detainee(s) are volunteer workers prior to issuing any supplies. Officers will ensure that the proper notation is made on the pay roster form once volunteer detainee workers have completed their assigned work. HOD 01( co ncurs: Jm=2 ~ ?.011 (b)(6); (b)(7)( Page 2 of5 C) 2020-ICLl-00006 4663 LS Departm ent of Homela nd 'ecuri~ U Immigration and Customs Enforcement Krome e r-de e Pr oce - ing Ce nt er ~pecific Po s t Order s Detain ee Hou sin g Unit Buildin g 14A Yard Sanitizing Mattresses • • The mattress and bed frame will be wiped down with sanitize wipes once vacated. Ensure that the detainee worker is wearing gloves when cleaning these items. Televisions • • • • Television hours will be determined by the posted schedule. Detainees are not allowed to have possession of the TV remote control. Televisions will be turned off during official counts, cleaning of housing areas, and when it will interfere with daily facility operations. Volume of television shall be kept at a reasonable level, so as not to disturb other detainees or daily facility operations. 1ST Shift Detain ee Telephone System Operational Checks • • • The Is, Shift 14 Alpha Yard Oflicer is responsible for ensuring on a nightly basis that detainee telephone systems are operational. All detainee telephones assigned to the housing unit will be checked before the 0200 scheduled count by utilizing the free call platform. Ensuring there is a dial tone is only part of what is required: I. Press I for English, or press 2 for Spanish 2. Enter the Pin Number assigned followed by the # key 3. Dial 6 for Pro-Bono 4. Once connected to the platform: 5. Enter any Speed Dial number from the Pro-Bono list provided to the detainees above the Telephones followed by the # Key. 6. Stay on the line and listen to the Pro-Bono provider 7. If all telephones are working properly, an entry will be made in the unit logbook identifying that the Telephone System is operational. 8. If any problems are identified, an entry will be made in the unit logbook identifying which Telephone is not operational followed by a Facility Work Order submitted to the supervisor. 9. Supervisors will ensure work orders are forwarded to the maintenance department. Haircuts • Haircuts will be determined by the posted schedule. Recreat ion • Recreation will be determined by the posted schedule. Religious Services • When advised, the housing unit officer will make an announcement for the detainees to prepare for religious services. The announcement will include which religious service is being provided and the officer will log the announcement in the log book. Law L ibrary Schedu le • Law Library hours will be determined by the posted schedule. Page J of 5 2020-ICLl-00006 4664 [ Department or Homeland ecu ri~ L" Immigration and Cu~tom Enforcem ent Krome e n ice Proce ing Center ·pecific Po:.1Orders Detainee Housing nit Building l~A Yard Chronological Activ ities: 0200 0400 0500 0530 0545 0600 0700 0745 0800 0830 0900 1020 1100 1130 1150 1300 1400 1530 1630 1645 1800 1900 2000 2100 2230 2300 2330 0030 Camp closes for detainee population count Insulin shots (until completed ) Lights on in the detainee dormitories (wake up time) Camp closes for detainee population count Cafeteria workers report to the cafeteria Detainee breakfast begins Televisions turned on Norma l telephone access begins Commence clean-up procedure ( continues upon return from cafete ria) Medication is issued in IHSC Law Library (0700 -1130/ see schedule) Outdoor recreatio n begins (unti l 11:00/see schedule) Medical Triage & medical appoi ntment s Unit inspection s begins Weekend/Holiday Visitation (until 1530 / see schedu le) Barbershop open (083 0-1100 M-F / see schedule) EOIR court sessions begin Detainee lunch begins / Commissary KTU / MHU Barber shop begins (until 1230) Outdoor recreation begins (until 1715/see schedule) Law Library (1150 -1915/ see schedule ) Camp closes for detainee populati on count Medication is issued in IHSC Barbe rshop open (Afte r population count- 1600 M-F / see schedule) Leisure Library (1400 - 1445 Fridays/ see schedule) Leisure Library (1530-1615 Wednesdays I see schedule) Detainee dinner begin s / Commissary Leisure Library (1645- 1720 Mondays / see schedule) Weekday visitation (until 2200 / see schedule) Religious Services (see schedu le) Medication is issued in IHSC Camp closes for detainee population coun t (face to photo) Issue razors (until 2250) All razors returned Normal teleph one acce ss ends Televi sions turned off (Sunday - Thursday) Lights out in the dormitorie s (Sunday - Thursda y) Televis ions turned off / lights out in dormito ries (Friday - Saturday) HOD 01( cnncur,: (b)(6); MAY a123 ion Page~ of :i ib)(?) (C 2020-ICLl-00006 4665 C Depa rtm ent of Homeland ·ecurir~ US Immigration and Cu toms E nforcement Kr ome Sen ice P rocessing Cen ter Specific Post Ord ers Detainee Housing Unit Building 1-tA Yard Detainee Living Area • • • • • Detainee(s) are responsible for keeping their living area neat and orderly. Towels and laundry bags are the only items allowed hanging from the beds. No pictures are allowed hanging from the walls or beds. Only authorized amounts of linen and clothing. No washing clothes in the housing units. Officer's Statio n • • The officer's station will be kept clean and neat with no detainees being inside it at any time, for any reason. Detainees shall not loiter around the officer' s station, take things from it or view any written material that is on or around the area. Hours: • The Bldg. 14A Yard Officer will be manned 24 hours a day, seven days a week. Tools • • Any maintenance and/or contract worker entering the housing unit will provide the housing unit officer with a tool inventory list before commencing work in the area. The officer will verify that all tools present are listed on the tool inventory list. Upon completion of work, the housing unit officer will account for all tools listed on the tool inventory list with the worker before he/she exits the unit. Post Closure • In the event that the post is closed due to no Detainee population, you are to report to your immediate supervisor to assist with camp operations. *** These post orders are to be used as a guid e for the successful completion of your duti es. It is not expected that these post orders wiJl cover every conceivable situation that you may be confronted with while pe rforming your assigned duti es. However, you are expected to exercise good judgment and good sense in th e application of these orders . Your duties ar e not necessarily limited to th ose described herein , and may be amen d ed orally or in writi ng wh en d eemed appropr iate. l~J(6J ;~Jm(cJ MA Y 2 3 2017 Date: ____ Approved Assistant Field Director /OTC \I 00 01( concur,: (b)(6); (b)(7)(C) ,Qq(e; MA , 2a io11 2020-ICLl-00006 4666 __ _ US Depa rtment of Homela nd Sec urity US Immi gration and C ustoms Enforce ment K rome Se rvice Process inu Ce nter Spe cifi c Post Orde rs Hos pital Deta il Hos pital Detail II I Ass ume Post • • • • • • • Read and sign post orders and General Post Orders. Receive a thorough briefing from the previous officer. The briefing should include any pertinent information that would affect the hospital post. Review past entries in the hospital detail logbook. Make official entry in the logbook stating you have accepted the post, and assume all responsibilities that go with the post. Inventory all equipment and notate the results in the logbook. Conduct a security check and sanitation check of the area prior to relieving the outgoing o fficer. Notate all discrepancies in the logbook. Ensure that proper restraints arc available, one ( I) handcuff, and one ( I) leg iron, one ( 1) belly chain and one (I ) handcuff key. Conduct a thorough search o f the hospital room to ensure that no dangerous contraband exists. Duties and Res pons ibilities • • • • • • • • Maintain care, custody and control of dctaince(s) in the hospital. Rooms must be maintained in a sanitary manner at all times. Perform security, safety and sanitation inspections of dctaincc(s) in the room, and their personal areas in an effort to maintain the safety and security of the hospital room. Log the detainee's name, A# and results. Ensure that all detainees are offered meals during the regularly scheduled meal. Ensure that the established hospital guidelines arc enforced. Friends, family and civilian visitation is not allowed unless authorized by the AFOD of Krome SPC. Officers will be posted inside the hospital room when possible. If conditions exist that prohibit oflicers from remaining in the room with the detainee, the officer will be positioned in a manner that enables visual contact with the detainec(s). Ensure that the supervisor is aware of this situation. • No tify the Control Ce nter once every hour to report a sec urity c heck an d the results or as needed to upd a te the stat us or locat io n o f the detaine e. • All detainees shall be restrained with leg irons and/or handcuffs at all times. Ifa medical condition warrants not using restraints, the ICE SDDO and Shift Captain shall be notified immediately and a logbook entry will be noted. Note: Leg irons and/or hand cuffs shall not be removed until a decision is made by the ICE SDDO or above; unless there is an immediate danger to the detainee. As soon as reasonable the detainee shall be restrained with leg irons and/or handcuffs attached to non- anchored or non-fixed beds (ex. hospital rolling bed). If the bed is anchored or fixed, utilization of leg irons and/or handcuffs shalI be applied to the detainee only. • • b)(6); (b)(?)(C) ,\ FOD/ OIC concurs l':1ge I of .t ,,,.,,3l:; IVJt-;.. 2020-ICLl-00006 4667 US Department of Homeland Security US Immigration and Custom s Enforcement Krome Sen ·ice Proc essino Cent er Specific Post Orders Hospital Detail Duties and Responsib ilities-co11tiu11ed • • • If the detainee requires using the restroom, utilization of leg irons and/or handcuffs shall be applied to the detainee. Precautions should be taken not to worsen the detainee's medical condition. Ensure the integr ity of the restraints at the completion of the detainee using the restroom and at all security checks. If a detainee is moved from his/her location, the officer must notify a supervisor at Krome SPC of the movement and log it in the logbook. The officer will escort the detainee to the new location. • Do not vacate the post unless prope rly relieved. • All incidents, room changes , etc .... shall be reported to the following departments at Krome SPC: 1. Contro l room at 305-207-2 15~b )(6); (b)(7)(C) 2 . Shift Supervisor at 305-2 1/h\ln\ I 3. Transportation Supervisor at 305-207-2183 FAX# : 305-207- 2192 • The following supporting documentation must be immediately forwarded to the Transportation Supervisor utilizing the hospital fax machine before departing yo ur post assignment or prior to your next scheduled shift: 1. Log pertine nt inform at ion in the logboo k.(do not fax) 2. Me mo randum 3. Incid ent Report 4. Use Of Force Fo rm 5. Photos if camera is avai lab le. Cond uc t sec urity inspection s. Constantl y be on alert for suspiciou s act iv ities. Loo k for contraband a nd anything out of the o rdinary . Sec urity inspec tions must neve r beco me regular a nd routine. If detai nees can anticipate yo ur activitie s, then they can plan prohibi ted act ivities acco rdingly. Hospita l Packs • When assigned to assume duties on a hospital post detail. the officer will checkout the required '·hospita l pack.. located in the Transportation Supervisor's office prior to leaving the facility. • Ensure that you have proper accountability of all items/equipment inside the bag prior to departure. Each pack contains: one (I) logbook, one (I) post order, one ( I) handcuff, one ( I) leg iron. one (I) belly chain and one (I) handcuff key. otate all items/equipme nt in the hospital detail logbook upon assuming the post. • When the detail is completed. the officer will return all equipment in the pack to the Transportation Supervisor·s office. (b)(6); (b)(7)(C) -. \ _FO_D _/_O_IC_ c_o_ncu-rs-+,:I Oare: 1--- -- --- - --- - - - - --------Page 2 of -t 3/;#J/f 2020-ICLl-00006 4668 US Department of Homeland Security US Immigration and Customs Enfo rcement Krome Service Proccssino Center Specific Po st Orders Hospital Deta il Ho spital Telephone Ca lls • • • • Detainees must submit a Detainee Request Form to make all telephone calls. The Officer on duty will check with the Medical Staff to ensure that there are no issues with the telephone calI. Detainee Request Forms wi ll be forwarded to ICE for final approval. Annotate in the Unit Logbook any request forms that are approved or denied. All requests must include name of person being called, telephone number, date and time the call will be placed. The Officer on duty will dial the telephone number requested by the detainee. The Officer on duty will verbally verify (to the greatest extent possib le) the identity of the person the detainee is trying to call. After verification, the officer on duty will give the telephone to the detainee. Telephone access will be from 8:00 am to 11:00 pm. • ALL PHONE CALLS WILL BE LOGGED IN THE LOGBOOK. • If during the duration of the telephone cal I, order and/or safety are jeopardized , the telephone call will be TERMINATED IMMEDIATELY. • • • • • Co nfidentialit y • • Any information overheard or otherwise obtained pertaining to a patient's medical or personal status will be kept confidential and in no case released, discussed or repeated. Medical records are not to be handled or read by the officer assigned to the hospital detail. Use of Firearms/Wea pons (Ar med Po st) • • • Armed personnel are required to carry their issued weapon while performing the hospital detail if permitted by the hospital in accordance with hospital regulations. The handgun shall be carried in a service-approved holster attached to your duty belt with all magazines full to capac ity at all times. Each Armed officer who is authorized to carry a firearm is responsible for normal cleaning and preventive maintenance of the firearms they use. Maintenance should only be done in accordance with the instructions provided by the National Firearms Unit or as described in the operator manua ls for that particular firearm. Disc harge of firearm s w ill not be authorize d in the appr ehension of a n esca pee, unless there is an immediat e threa t of immin ent phys ical dange r to yo urse lf o r anot her individu al. You are to be thorou g hly fa milia r a nd knowl edgea ble with regar ds to th e policy on the use of firea rms and und er what condition s yo u may use deadl y force; refe r to the (Interim) ICE Firea rms a nd Use of Force Pol icie s. DEADLY FORCE MAY BE US ED WHE N THE OFF ICE R HAS A REASONABLE BELIEF THAT THERE IS IMMINENT DANGE R OF DEA TH OR SERIOUS INJURY TO THE R ANOTH ER PER SON . b)(6); (b)(7)(C) r\FOD /O IC Page 3 of 4 Date: 2020-ICLl-00006 4669 US Department of Home land Sec urity US Im migration and Customs Enforcement Krome Serv ice Processinu Ce nte r Specific Post Orders Hospital Detail Me dica l Emerge ncy S ituat ion s: • • • • • Assess the detainee or staff member's responsiveness. Utilize hospital telephone or speaker to call hospital staff with location. Provide assistance to the detainee and/or staff member until medical personnel arrive. Inform the supervisor immed iately of the emergency situation. Document incident, time, detainees, staff involved (including responding staff) as soon as possible. Ho stage Situa tion • In the case of a hostage situation, any involved employee is without authority, regard less of rank. At no time will the hostage-ta ker be allowed out of the facility. You w ill not obey the demands made by the hostage-taker or the orders from the hostage, who may be under duress. Hou rs: The Hospital Detai l Officer, when utilized, will be manned 24 hours a day, seven days a week. Pos t C los ure • In the event that the post is closed due to no Detainee population, you are to report to your immediate supervisor to assist with camp operations. *** T hese post order s are to be used as a guid e for the succ ess fu l co mpl et ion of you r du ties. It is not exp ected that these post o rders w ill cove r every co nce ivab le sit uatio n that yo u may be confront ed w ith w hile perfo rmi ng yo ur ass ig ned d uti es. Howeve r, yo u are ex pected to exe rci se good j udgm ent and goo d se nse in the app lication of these orders. Your d ut ies are not nec essar ily limit ed to tho se describe d herein, and may be amended ora lly or in wr it ing when deemed appropr iate. (b)(6); (b)(7)(C) Date: Approv ed By: ,\FOD /OIC C l'agc-' of -' Dnte: 2020-ICLl-00006 4670 US Department of Homeland Secur ity US Immigration and Customs Enforcement Krome Service Processing Center Specific Post Orders ICE Health Service Corps Medical Housing Unit Desk ICE Health Service Corp s Medical Hou sing Unit Desk Officer Assume Pos t • Read and sign post orders and General Post Orders. • Receive a thorough briefing from the previous officer. Briefing shou ld include any pertinent information that would affect the Medical Housing Unit. Review past entries in the IHSC Medical Housing Unit logbook. • Make official entry in the logbook stating you ha ve accepted the post, and assume all responsibilities that go with the post. • Conduct a security check and sanitation check of the area prior to relieving the outgo ing officer. Notate all discrepancies in the logbook and submit the appropriate repair order when applicable . • Check keys and locks for accountability and proper operation. • Inventory all equipment and notate the results in the logbook. • Ensure that your communication radio is in good working order with a fully charged battery . • Review and maintain organization of the detainee bed card (3x5) book and confinn the head count ; ensure that a bed card is pre se nt for each detaine e in the unit. Dutie s and Responsibiliti es • • • • • • • • • • • • • • • • • __ ___ Maintain control and surveillance of the all Medica l Housing Unit doors. Maintain the highest degree of security possible while conducting operations of the Control Panel. Monitor unit operations via CCTV: report unusual activity to a Supervisor. Maintain care, custody and control of detainees housed in the Short Stay Unit. Officers must treat the Medical Housing Unit as a hospital environment and must maintain a low conversational tone when speaking. Unit must be maintained in a sanitary manner at all times. Supervise any cleaning crew as necessary. Ensure that all detainee reque st forms are submitted to the superv isor prior to the end of the shift. Ensure that all cleaning supplies and equipme nt are inventoried and returned to the secure sto rage area after each use; repleni sh hyg iene supp lies as needed. Ensure that all detainees are searched upon entering and exiting the unit. A visual check w ill be made of each detainee's wristband every time they are pat searched upon enter their housing units. Thi s check will verify: Correct detainee, good physical shape of the wristband; is it stretched, is the print in good shape, is it faded, and is the plastic c lasp still on. A Detainee with a wristband in poor condition or loose will be sent immediatel y to processing for a replacement. Ensure that all doors are functional (open and close secu rely). During normal operating situations. unit doors are to remain secured. Ensure that all detainees are offered meal s during the regularl y scheduled meal. Record all refused or uneaten meal s in the logbook. Report all refused and/or uneaten meals to shift supervisor immediate ly. __,( b)(6); AFOU/ OIC concurs (b)(?)(C) Page I of .t 'V~P1 ~ 2017 2020-ICLl-00006 4671 US Department of Homeland Secur ity US Immigration and Customs Enforcement Krome Serv ice Processing Center • • • Specific Post Orders ICE Health Service Corps Med ica l Housing Unit Desk Ensure that all detainees are offered a minimum of I-hour recreation daily. Ensure that detainees who are being admitted or released from the unit have at a minimum, the following in their possession ( I towel, all issued linen, 2 complete uniforms to include Tshirt and shorts). The IHSC Medical Housing Rover Officer must escort detainees to the recreation yard before allowing the contract custodians access inside the detainee's assigned rooms. The detainees must remain outside in the recreation yard until the custodian has finished cleaning the detainee's room. Do no t remove detainees out of the Respi ratory Isola tion Roo ms unless appr ove d by the Clini ca l Direc tor . • • • Ensure that all detainees are secured inside their assigned rooms when the contract custodians are cleaning the IHSC Medical Housing Unit's restrooms, hallways and any other areas outside of the detainee's assigned rooms. Detainees housed in the II ISC Medical Housing Unit who display vio lent or mentally disordered behavior shall be observed al least every fifteen minutes. Suicidal detainees shall be under continuous observation. Lights must be on in the Mental Health Unit rooms at all times. When patrolling, constantly be on alert for suspicious activities. Look for contraband and anything out of the ordinary. Patrols must never become regular and routine. 1f detainees can anticipate your activities, then they can plan prohibited activities accordingly. Ensure to notify nurse on duty of arriving detainee. Document in the log book the name of nurse notify. • Do no t vaca te the post unless properly relieved. • • • PREA: Whe n a detainee is broug ht to me dica l due to a PREA allegat ion it will be doc umented in the log boo k, w ho esco rted the deta inee, what time they arrive d, wh o from the medical sta ff wa s notifi ed and at wha t time the notificat ion wa s made. Note: Detainees housed in the IHSC Medical Housing Unit are not allowed to have medications in their possession unless the Clinical Director has approved it. Note: Officers will conduct and annotate in the logbook a Security, Safety and Sanitation check every 45 minutes to an hour at irregular times (24 hours a day). To ensure the O ffice r's safe ty, watc h calls will be co ndu cted betwee n the hours of 1800 and 0600 eve ry half hour by not ifying the co ntrol post by telephone or radio. A nnota te in the log boo k that a wat ch ca ll wa s co ndu cte d. Rec urrin g D uties • • • • • • Ensure that shakedowns are conducted in every cell except during the hours of 2200-0600 except in emergency situations or when authorized by a supervisor. Log all shakedowns in the unit contraband logbook. Annotate any movement of detainees from the unit in the logbook with name and complete alien number. Detainees shall be searched upon returning to the unit. Replenish hygiene supplies as needed. Maintain accountability of items issued out. (i.e. board games, pencils, etc.). -7--- -------------------------------- --------1 lrr (b:'ii )(R\ 6)::-; AFOO/OIC concurs (b)(?)(C) Pngc 2 of-' OaijAR 1 S 20\i~~ 2020-ICLl-00006 4672 US Depa rtm ent of Homeland Security US Immi gra tion a nd C ustoms Enfo rcement K r ome Serv ice Process ing Cente r Spec ific P ost O rde rs ICE Hea lth Serv ice Cor ps Med ica l Housing Un it Desk Suicide Watch Detail Room/ Observation Detail R oom • The Medical Housing Desk Officer will enter in the Medical Housing Unit logbook: I. The name of the Officer assigned to the detail. 2. The room number assigned to the detail. 3. Last name, first name, A# and country of the detainee. • Annotate any pertinent information. • When a detainee is medically cleared, ensure the Detainee is logged out of the Medical Housing Unit Logbook by annotating the date, time and the IHSC approving authority. • The Medical Housing Unit Desk Officer will make a copy of the DIHS-835 form and forward it to the shift supervisor. Mental Health Unit • Lights must be on in the Mental Health Unit rooms at all times. • Detainees housed in the 11ISC Medical Housing Unit who display violent or mentally disordered behavior shall be observed at least every fifteen minutes. Suicidal detainees shall be under continuous observation. Padded Cell • At no time will the padded cell door be opened, or detainee be permitted outside the cell without having two officers present. • Two officers should be present when the detainee is removed from the cell for any reason. A supervisor must be present when a known dangerous detainee has to be moved from the padded cell for any reason. • Two o flicers will be present when staff has to enter the occupied padded cell; moreover, the detainee will be handcuffed behind the back when staff has to enter the padded cell. • Detainees removed from the padded cell for any purpose will be, at a minimum, restrained behind his back. Important Guidelines for the Respiratory Isolation Rooms • All personnel who enter the anteroom or Respiratory Isolation Unit MUST WEAR A MASK. • When a suspected TB patient leaves the Respiratory Isolation Unit, he M UST WEAR A MASK BOTH INDOORS AND OUTDOORS. • A TB patient does not need to wear a mask inside the Respiratory Isolation Unit while the fan and/or Hepa filtration system is running. • A suspected TB patient may be used to clean the anteroom and bathroom, but MUST WEAR A MASK. Confidentiality • Any information overheard or otherwise obtained pertaining to a patient's medical or personal status wi11be kept confidential and in no case released, discussed or repeated. • Medical records are not to be handled or read by the officer assigned to the IHSC Medical Housing Unit. -- -- - ---1,(b)(6); (b)(7)(C) 1---- - ---- -- ----- - ---- AFOD/ OIC concurs '\UR l S 2017 - --------- - Page 3 of 4 2020-ICLl-00006 4673 US Department of Homeland Security US Immigration and Customs Enforcement Krome Service Processing Center Speci fic Post Orde rs ICE Hea lth Service Corps Medical Hous ing Un it Desk Recreation • Ensure that all detainees are offered a minimum of I-hour of recreation daily, unless otherwise spec ified by the Clinical Director. Law Library Schedu le • Law Library hours will be determined by the posted schedule. Detainee Feedi ng • Meal times are determined by the posted schedule. • Ensure that all deta inees receive their appropriate diets. Detainee Living Area • Detainee(s) are responsible for keeping their personal living areas neat and orderly. • No pictures are allowed hanging from the walls or beds. • Only authoriz ed amounts of linen and clothing. • No washing clothes in the Medical Housing Unit. Offic er's Statio n • The officer's station will be kept clean and neat with no detainees being inside it at any time, for any reason. • Detainees shall not loiter around the officer's station, take things from it or view any written material that is on or around the area. Hour s: The Medical Housing Unit Desk Officer will be manned 24 hours a day, seven days a week. Post Closure • In the event that the post is closed due to no Detainee populat ion, you are to report to your immediate supervisor to assist with camp operations. H* These post orders are to be used as a guide for the success ful completio n of your duti es. It is not expec ted that these post orders will cover every conceivab le situation that you may be confronted with while perform ing your assig ned dut ies. However, you are expec ted to exercise good judg ment and good sense in the application of these order s. Your dutie s are not necessarily limited to those described herein, and may be amended orally or in writin g when deemed appropr iate. (b)(6); (b)(7)(C) MAR1 3 2017 Date: __ Appr oved By: __ _ __ _ Assistant AFOD / O I C concur s b)(5); Page -I of -I MAiR: 1 3 2017 b)(?)(C) 2020-ICLl-00006 4674 US Department of Homeland Security US Immigration and Customs Enforceme nt Krome Service Proce ssing Center Specific Post Orders ICE Health Service Corps Medical Housing Unit Rover 1 & 2 ICE Hea lth Service Cor ps Medical Housing Unit Rover 1 & 2 Ass ume Post • Read and sign post orders and General Post Orders. • Rece ive a 'thorough briefing from the previous officer. Briefing shou ld include any pertinent information that would affect the Med ical Housing Unit. Review past entries in the IHSC Medical Hous ing Unit logbook. • Conduct a security check and sanitation check of the area prior to relieving the outgoing officer. Notate all discrepancies in the logbook and submit the appropriate repair order when applicable. • Check keys and locks for accountability and proper operation. • Inventory all equipment and notate the results in the logbook. • Ensure that your communication radio is in good working order with a fully charged battery. • Review and maintain the organization of detainee bed card (3x5) book and confirm the head count; ensure that a bed card is present for each detainee in the unit. • The IHSC Medical Housing Rover I Officer is the designated officer to remove detainees from the hold rooms in case of fire and/or building evacuation, or other emergency. Duties and Respon sibilities • Maintain care, custody and control of detainees housed in the Medical Housing Unit. • Assist IHSC Medical Housing Unit Desk Officer. • Unit must be maintained in a sanitary manner at all times. • Officers must treat the Medical Housing Unit as a hospital environment and must maintain a low conversational tone when speaking. • Supervise any cleaning crew as necessa1y . • Make frequent, but irregular patrols of the unit. • Provide security to nursing/medical staff during laborato1y procedures and medication administration. • Ensure that all detainee request forms are submitted to the supervisor prior to the end of the shift. • Ensure security flaps are utilized whenever viably possible for interaction with mental patients. (mea ls, drug administration, etc ..) • Ensure that all cleaning supplies and equipment are inventoried and returned to the secure storage area after each use; replenish hygiene supplies as needed. • Ensure that all detainees are searched upon entering and exiting the unit. • A visual check will be made of each detainee's wristband every time they are pat searched upon enter their housing units. This check will verify; Correct detainee , good physical shape of the wristband; is it stretched, is the print in good shape, is it faded, and is the plastic clasp still on. A FOD/ OtC concurs: (b)(6); D:it c: (b)(7)(C) Page I of 6 MAR2 S 20\7 2020-ICLl-00006 4675 US Department of Homeland Sec urity US Immigration and Customs Enforceme nt Krome Se rvice Processing Cente r Spec ific Post Orders ICE Hea lth Se rvice Co rps Med ical Housing Unit Rove r 1 & 2 Dutie s and Res ponsibiliti es - co11ti11u ed • • • • • • • • • A detainee with a wristband in poor condition or loose will be sent immediately to processing for a replacement. Ensure that all doors and security flaps are functional (open and close securely). During normal operating situations, unit doors are to remain secured. Ensure that all detainees are offered meals during the regularly scheduled meal. Record all refused or uneaten meals in the logbook. Report all refused and /or uneaten meals to shift supervisor immediately. Ensure that all detainees are offered a minimum of I-hour recreation daily, and escort those detainees to the recreation area. Ensure that detainees who are being admitted or released from the unit have at a minimum, the following in their possession ( I towel, all issued linen, 2 complete uniforms to include T-shiit and shorts). Escort detainees to the recreation yard before allowing the contract custodians access inside the detainec's assigned rooms. The detainees must remain outside in the recreation yard until the custodian has finished cleaning the detainee's room. Do not re move detain ees out of the Res pirat o ry Isolatio n Roo ms unless approved by the Clinical Direc tor . • • Detainees housed in the IHSC Medical Housing Unit who display violent or mentally disordered behavior shall be observed at least every ft~een minutes. Suicidal detainees shall be under continuous observation. Ensure that all detainees arc secured inside their assigned rooms when the contract custodians are cleaning the IHSC Medical Housing unit's restrooms, hallways and any other areas outside of the dctainee's assigned rooms. Check and ensure video camera is functional (battery, on/off power button, lens). Notate all results in the logbook. If repairs are needed, immediately notify the supervisor for corrective action. Maintain the laundry closet in a neat and orderly fashion. • Do not vacate the post unless prope rly relieved . • • Note- Detainees housed in the 11ISC Medical Housing Unit are not allowed to have medications in their possession unless it was been approved by the Clinical Director. When patrolli ng, cons tant ly be on alert for suspicious activ ities. Look for co ntra band and any thing out of the o rdina ry. Pat rols mus t neve r beco me reg ular and routin e. If detain ees ca n anticipate you r activ ities, then they ca n plan pro hibited activ ities acco rdi ngly. Note: Officer s w ill conduc t and annota te in the logbook a Sec urity, Safety and Sa nitat io n check eve ry 45 minut es to an hour at irr egular tim es (24 hour s a day) . To ensure th e O fficer's sa fety, watch calls will be conducted betwee n the ho urs o f 1800 and 0600 eve ry half hour by notifyi ng the co ntrol post by telephon e or radi o. Annotate in the logboo k that a watc h call wa s condu cted. AFOO /O IC concurs : Date: (b)(6); (b)(7)(C) ra ge 2 orG ~~R 2 8 ?.0\7 1 2020-ICLl-00006 4676 US Department of Homeland Sec uri ty US Immigration a nd C ustoms Enforcement Kro me Serv ice Processing Center Spe cifi c Post Orders ICE Hea lth Serv ice Co rps Med ical Housing Un it Rover 1 & 2 Detaine e Telephone Message Deliven · • Medical Housing Unit Rover I { 1st Shift) will receive at extension 2202 or retrieve from • • • • • • • • • • voicemail non-specific and/or emergency detainee telephonic messages and delivery to the detainee. Medical Housing Unit Rover 2 (2nd and 3rd Shift) will receive at extension 2202 or retrieve from voicemail non-specific and/or emergency detainee telephonic messages and delivery to the detainee. Detainee telephonic messages are limited to emergency or non- specific (call home, call your job. etc.) notifications that exclude inquiries of case starus. medical services, detention information. etc. Rover 2 must ensure that message boxes are checked hourly. Rover 2 must ensure that all messages are recorded in the Detainee Message Log book and a Detainee Message Form is completed. Rover 2 must ensure that messages are delivered by an Escort Officer. Rover 2 must ensure that detainee messages are delivered at a minimum of one time per shift. Ensure escorts return the Detainee Message Form to the Medical Housing Unit for filing and forward a copy to the Processing Officer I for inclusion in the Detention File. Detainee Message Form must be used to acknowledge receipt of message and upon completion must be filed in the Medical Housing Unit and a copy placed in the individuals detention file. Calls other than non-specific or emergencies will be directed to the appropriate department. I.e. Deportation. Medical Services, Detention and etc. All emergency calls will be delivered immediately to the Contract shift supervisor. Co ntr ac t shif t s uperviso r mus t di rect a ll sensitive eme rge ncy notifi ca tions (dea th, serious illness, etc.) imm ediately to the ICE SDDO o n du ty for furth er dir ection . Detainee Telepho ne Message Delive n • Proce dure • Receive or retrieve call from two (2) mailboxes 1 . Extension 2202 Yoice ma il Re tri eva l In stru ct ions • Lift Handset • Dial 2300 OR Press ..MESSAGE.. Button on the set • Enter your extension: 2202 PRESS# • Enter Password: 22021 PRESS # 2 . Detainee message system inbox Yoicemail R etri eva l In stru ctions • Lift Handset • Dial 2300 OR Press '·MESSAGE.. Button on the set • Enter your extension: 6424 PRESS # • Enter Password: 64241 PRESS # ,\ FOD/ O I C concurs: 0 (b)(6); (b)(?)(C) Page 3 or6 '1A R2 82017~--~ 2020-ICLl-00006 4677 US Department of Ho meland Secu rit y US Immigration and Customs En forc ement Krome Service Process ing Center Spec ific Post Orders ICE Health Service Cor ps Medical Housing Unit Rover I & 2 IDENTIFY IF IT'S AN EMERGENCY OR NON-SPECIFIC MESSAGE • • • • • • • • Emergency Mess age Request name and contact information from caller Immediately forward call to shift supervisor for notification to ICE SDDO. Follow established procedure. Record information in Log book. Non -S pecific Message Request name and contact information from caller Request message Complete Detainee Message Slip Record information in Log book Messages must be delivered at a minimum of once per shift Recurring Duties • Ensure that shakedowns are conducted in every cell except during the hours of 2200-0600 except in emergency situations or when authorized by a supervisor. • Log all shakedowns in the unit contraband logbook. • Annotate any movement of detainees from the unit in the logbook with name and complete alien number. • Detainees shall be searched upon returning to the unit. • Replenish hygiene supplies as needed. Confidentiality • Any information overheard or otherwise obtained pertaining to a patient's medical or personal status will be kept confidential and in 110 case released, discussed or repeated. • Medical records are not to be handled or read by the officer assigned to the IHSC Medical Housing Unit. Important Guidelines for the Respinitory Isolation Rooms • All personnel who enter the anteroom or Respiratory Isolation Unit M UST WEAR A MASK. • When a suspected TB patient leaves the Respirato1y Isolation Unit, he MUST WEAR A MASK BOTH INDOORS AND O UTDOORS. • A TB patient does not need to wear a mask inside the Respiratory Isolation Unit while the fan and/or Hepa filtration system is running. • A suspected TB patient may be used lo clean the anteroom and bathroom, but MUST WEAR A MASK. Mental Health Unit • Lights must be on in the Mental Health Unit rooms at all times. • Detainees housed in the IHSC Medical Housing Unit who display violent or mentally disordered behavior shall be observed at least every fifteen minutes. Suicidal detainees shall be under continuous observation. • Officers must utilize the security flap on the doors whenever possible. (Medication, food service, consultation, etc ... ) b)(6); b)(?)(C) Page 4 of6 2020-ICLl-00006 4678 US Department of Homeland Security US Immigration and Customs Enforcement Krome Sen ·ice Processing Center Specific Post Orders ICE Health Sen ·ice Corps Medical Housing Unit Rover I & 2 Padded Ce ll • At no time will,.Lilt:....I.Jli:ll.LI..Lt:i.L, Cell door be opened, or detainee be pem1itted outside the cell without having (b)(?)(E) present. ~(b)(?)(E) ~ould be present when the detainee is removed from the cell for any reason. A supervisor must be present when a known dangerous detainee has to be moved from the padded cell for any reason. • ~b)(7)(E) (viii be present when staff has to enter the occupied padded cell: moreover, the detainee will be handcuffed behind the back when staff has to enter the padded cell. • Deta inees removed from the padded cell for any purpose will be, at a minimum, restrained behind his back. Recreation • Ensure that all detainees are offered a minimum of I-hour of recreation daily, unless otherw ise 233 • Detainees will adhere to a recreation schedule and will only be allowed outs ide at the designated times unless approved by the clinical director. Religiou s Serv ices • When advised, the housing unit officer will make an announcement for the detainees to prepare for religious services. The announcement will include which religious service is being provided and the officer will log the announcement in the log book. Law Library Sc hedul e • Law Library hours will be determined by the posted schedule. Detaine e Feeding • Meal times are determined by the posted schedule. • Medical Housing Unit rovers will distribute meals to individual detainees. • Ensure that all detainees receive their appropriate diets. Deta inee Living Arca • Detainee(s) are responsible for keeping their personal living areas neat and orderly . • No pictures are allowed hanging from the walls or beds. • Only authorized amounts of linen and clothing. • No washing clothes in the Medical Housing Unit. Officer 's Station • The officer's station will be kept clean and neat with no detainees being inside it at any time, for any reason. • Detainees shall not loiter around the officer·s station. take things from it or view any written material that is on or around the area. - - - - ---i( b)(6); (b)(7)(C) i\FOD /OI C concurs: Date: Page 5 of6 MAJt 28 20\11 2020-ICLl-00006 4679 US Department of Hom eland Securit y US Immigration and Cu stom s Enforcement Krome Sen-ice Proce ssing Center _H_o_u_r_s_: -------------1Cb)(?)(E) • The Medical Housing Unit Rove • The Medical Housing Unit Rove days a week. Specific Post Orders ICE Health Service Corp s Medical Hou sing Unit Rover I & 2 will be manned 24 hours, seven days a week . wi II be manned from 6:00AM to I0:00PM, seven Post Closure • In the event that the post is closed due to no Detainee population, yo u are to repo1t to your immediate supervisor to assist with camp operations. *** These post order s a re to be used as a guide for the successful complet ion of your dutie s. It is not expec ted that these post orders will cover every conceivab le situation that you ma y be confronted with while perform ing your assigned duti es. However, you are expected to exercise good ju dgm ent and good sense in th e app lication of these orders. Your dutie s are not necessa rily limited to those describ ed herein, and ma y be amended ora lly or in wr iti ng when deemed appropriat e. r 6);(b){7)(G) MAR 26 2017, Date : ___ Appr oved By: ___ _ _ Assista nt F ield Directo r/OTC b)(6); -------«b)(?)(C) A FOD/ OI C concurs: Page 6 of 6 ~~itl& 'l.G\11 2020-ICLl-00006 4680 ANNUAL REVIEW (b)(6); (b)(7)(C) mm1strator ate b)(6); (b)(7)(C) perat1ons Date Krome Krome Staffing Plan Position Admin Asst 1 AHSA ---- CD Dentist 1 1 HSA MHP MLP MRT 3 2 1 1 1 3 3 3 1 Nurse Mgr Pharm Tech 2 1 Pharmacist Physician 1 1 Prog ram Mgr Psych RN Psychiatrist RN 9 1 10 RAD-TECH iTotal 1 1 1 Dental Asst LPN/LVN 1 1 1 1 31 2020-ICLl-00006 1 5 4681 8 3 21 4 1 1 4 5 4 4 1 2 1 1 1 9 1 21 1 61 ANNUAL REVIEW r b)(6) ; (b)(7)(C) Health Services Administrator/ Date l(b)(6); (b)(?)(C) Unit Chief of Health Operations/ Date Krome Krome Staffing Plan Position Admin Asst ·1111111m...am-.1111111m AHSA 1 CD 1 1 Dental Asst 1 1 Dentist HSA LPN/LVN 3 MHP 2 1 1 MLP MRT 1 3 3 3 1 Nurse Mgr Pharm Tech 2 1 Pharmacist Physician 1 Program Mgr 1 RN 9 1 10 RAD-TECH Total 31 Psych RN Psychiatrist 1 1 1 1 1 1 1 8 3 21 4 1 5 2020-ICLl-00006 4682 4 5 4 4 1 2 1 1 1 9 1 21 1 61 LOCAL OPERATING PROCEDURE Emergency Response LOP8.10A (REV: 09/16) PURPOSE: To establish a standardized approach to respond to medical emergencies in the camp o ulation. I. Notification of Medical Emergencies A. ICE or AGS security will contact medical, at extension 2170, to notify medical of an emergency. B. The following information will be provided to medical 1. Patient's Name and Alien Number 2. Type of Emergency (Medical vs. Psychiatric) 3. Patients Symptoms and Level of Consciousness 4. Location of the Patient C. The officer receiving the medical emergency notification will announce the emergency over the intercom system and then physically locate and notify a medical provider II. Response to Medical Emergencies ( Providers must respond within 4 minutes) A. The medical staff notified oflhe medical emergency is responsible to ensure that an . emerpencv te;:im jc;:.cienloverl. ~ ~ ~ I. Day Shift-Emergency B. C. D. E. F. Team #I or #2 will deploy 2. Evening Shift-the medical provider notified will deploy 3. Night Shift-the medical provider notified will deploy The medical team responding will notify the security officer if additional back-up is needed (i.e. psychiatry, wheelchair, stretcher, etc). The trauma bag and AED will be brought to the scene of all emergency responses. Vital signs (blood pressure, pulse, and temperature) will be obtained on patients, upon arrival to the scene of the emergency. Medical providers responding will assess, diagnose and treat while on the scene. If the injured party is an ICE officer, security officer, visitor, student or IHSC staff, treatment is limited to preventative and/or emergency medical care. Medical treatment recommended by IHSC medical staff beyond the scope, identified above, will be referred to the community. III. Transportation to the Medical Clinic A. If the medical condition of the patient permits the patient will be brought to the medical clinic by appropriate means (i.e. ambulatory, wheelchair, stretcher, or vehicle). B. The patient will be placed in the Urgent care room if on-going treatment is required. C. On day shift the following staff will have functional roles in the care of the emergency: I. Triage Nurse (or other designated emergency team member) Page I of2 LOP Emergency Response 2020-ICLl-00006 4683 a. Designate another provider to administer IV fluids, manage medications, obtain vital signs, perform clinical procedures as assigned b. Designate a provider to document care (ifno other staff is availablehe/she will performthis function) c. Notify the physician of the emergency d. Access the patient's medical record e. Request any medications from the pharmacy f. Contact 911 if necessary, notify the camp supervisor, assure the patient is transported with ICE security as an escort 2. Physician (NP/PA in physicians absence) a. Supervise and direct all patient care activities during the emergency b. Designate a NP/PA to assist c. Refer the patient to an outside facility (if required) and complete the necessary forms IV. Documentation A. Incident Report - will be completed on all emergency responses in the facility. B. Progress Note- care provided on emergency responses will be documented in "S.O.A.P" format in the electronic medical record (eMR) or on the SF-600, progress note. LOP Emergency Response Page 2 of2 2020-ICLl-00006 4684 Chapter 8 MEDICAL January 2014 Update: Section 8.7- Health Evaluation of Detainees in Segregation, has been archived and replaced by new IHSC policy 03-06: Heallh Evaluation of Detainees in Special Management Units. 8.1. Medical Initial Screening. Medical in-processing health screening shall be performed on all detainees upon their arrival at an SPC unless ICE declares that the detainee is transient and will stay at an SPC for less than twenty-four (24) hours. Detainees will be screened within 12 hour:; of arrival at the facility in accordance with ICE Detention Standards. Transient detainees are not usually placed in the general population. If transient detainees are to be placed in general population, a medical in-processing health screening must be performed. Medical in-take screening is necessary to prevent newly-arrived detainees who pose a threat to their own or others' health or safety from being admitted to the general population and to get them immediate medical attention when necessary. Under special circwnstances such as a mass influx, facilities where medical personnel are not available 24 hours per day and seven (7) days per week or upon special arrangement with the Division Director through the Medical Director, specially trained ICE or Security officers may do medical in-take health screenings. Fonn IHSC-794, InProcessing Health Screening, will be completed on all detainees, including juveniles (defined as those seventeen (17) years of age or younger), at the time of the ICE in-take. Health screening is perfonned by a medical provider or a specially trained officer. • If screening is done by a specially trained officer, patients responding "yes" to any of the screening questions will be referred to the medical facility or off-site health care provider for medical care and/or follow-up. 8.1.1. Medical Recommendations for Placement. Recommendations are made for placement of a detainee in the camp setting based on the In-Processing Health Screening. • General Population - detainees presenting with no symptoms of TB or any other infectious diseases. • General Population with Referral to Medical Care - detainees with no symptoms of TB or infectious disease but who report that they have a chronic condition requiring further evaluation. • Referral for Immediate Medical Care - detainees who present with urgent conditions that require immediate treatment. • Isolation Until Medically Evaluated - detainees who present with signs and symptoms of TB or other infectious disease. 8.1.2. Initiation of the Medical Record. Official medical records are maintained to document all medical services that are delivered to detainees. Official medical records may be of two types: • The ambulatory health record • The abbreviated ambulatory health record IHSC-794 (Mass Influx) 2020-ICLl-00006 4685 Chapter 8, Page 2 January 2014 The ambulatory health record is initiated for all detainees who are likely to remain in an ICE SPC for more than seventy two (72) hours. The IHSC-794 is initiated for detainees who are likely to remain in the SPC for more than 24 hours and less than 72 hours. An official Medical Record will be generated upon completion of the intake screening process. In cases where there is no face-to-face contact with a member of the IHSC staff, the IHSC-794 will be filed and maintained in A# order. IHSC-794 forms, for detainees who leave the SPC prior to any face-to-face contact with a IHSC team member, will be retained in A# order in a single file folder. Information received from the ICE on detainees who have departed the SPC will be recorded at the bottom of the form. See Initial Medical Screening SOP 8.1.2 for a detailed description of this process. In-processing 1 < 24 hour.; I I I Healthy I I I Sick 24 to 72 hours Heaitity < 24 hour.; Healthy Sick screening no MR '-H_ea_I_lh_Y _ _,I j Sick 24 to 72 hours Healthy I No > 72 hours I > 72 hours ' I I Sick Healthy \ Refer to Screen Refer to Screen Physician MIDHR Physician MIDHR Complete MIDHR Sick MR Refer to Physician Complete MR 8.2. History and Physical Examination. This section has been archived and replaced by new IHSC policy 03-07 History And Physical Examination, located on the Global Drive at Policies and Procedures In New Format- Disseminated to Sites\03-07 History and Physical Exam.pelf. 2020-ICLl-00006 4686 Chapter 8, Page 3 January2014 8.2.1. Documentation. This section has been archived and replaced by new IHSC policy 03-07 History And Physical Examination, located on the Global Drive at Policies and Procedures In New Format- Disseminated to Sites\03-07 History and Physical Exam.pdf. 8.2.1.1. Physical Examinations Conducted by Registered Nunes. This section has been archived and replaced by new IHSC policy 03-07 History And Physical Examination, located on the Global Drive at Policies and Procedures In New Format- Disseminated to Sites\03-07 History and Physical Exam.pdf. 8.2.2. Health History. This section has been archived and replaced by new IHSC policy 03-07 History And Physical Examination, located on the Global Drive at Policies and Procedures In New Fonnat- Disseminated to Sites\03-07 History and Physical Exam.pdf. 8.2.3. Body Scan and Injuries. This section has been archived and replaced by new lHSC policy 03-07 History And Physical Examination, located on the Global Drive at Policies and Procedures In New Fonnat- Disseminated to Sites\03-07 History and Physical Exnm.pdf. 8.2.4. Pelvic Exams/PAP Smears. This section has been archived and replaced by new IHSC policy 03-07 History And Physical Examination, located on the Global Drive at Policies and Procedures In New Fonnat- Disseminated to Sites\03-07 History and Physical Exam.pdf. 8.2.S. Pregnancy Screening and Prenatal/Postnatal Care. All female detainees will be questioned about the date of their last menstrual period, and if they are sexually active. All female detainees over the age of ten shall have a urine test for pregnancy at the time of intake, regardless of history of sexual activity. Females over the age of fifty five (55) need not be tested. Form IHSC-834 (Medical-Psych Alert Form) will be completed on all detainees who are pregnant. A copy of the IHSC-834 will be sent to the ICE. An original will remain in the medical record. The Clinical Director is responsible for assuring that all pregnant females are initially evaluated by an obstetrics specialist. Care may be provided throughout the pre and post-natal period by a member of the IHSC medical staff in consultation with an obstetric specialist. The pregnant patient shall be seen on a monthly basis or as often as recommended by the obstetrics specialist. Pre-natal Flow Sheet IHSC 846 will be utilized. Care shall continue until the detainee is released from ICE custody. 2020-ICLl-00006 4687 Chapter 8, Page 4 January 2014 8.3. Detectionof Abuse and Neglect in Detainees. This section has been archived. The new IHSC policy, 03-01- Abuse and Neglect (Detainee), which is in the new policy format, can be found on the IHSC Global Drive at: Policies and Procedures In New Format- Disseminated to Sites\03-01 Abuse and Neglect (Detainees).pdf; 7/2012- !HSC policy 03-01 Abuse and Neglect (Detainees), is replaced by new !HSC policy 03-01 Sexual or Physical Assault, Abuse and/or Neglect, located on the Global Drive at ..\..\Current DIHS Policy and Procedure Manual\Current DIHS Policy\Policies and Procedures In New Format- Disseminated to Sites\03-01 Assault Abuse and Neglect Final.pdf: 8.4 Detainee Medical Status. The detainee medical status form IHSC-841 is: • A summary of a detainee's medical status • Useful in determining completed and pending health services • Used to track communications with ICE Examples of communication include memos concerning kitchen clearance, letters requesting quick dispositions, letters responding to legal concerns, etc. Copies of communications are not included in the medical record. This form is not used for detainees who will be in the facility for less than forty eight (48) hours. Upon completion of the initial medical screening, the following will be documented: TB screening, RPRs (if required), complete history and physical including assessment of pain, mental health screening and dental screening, and the date, results and initials of the provider performing each function. Information from the IHSC-841 must be also recorded in the progress notes. 8.5. Health Services Request (Sick Call). Each facility shall have a mechanism that provides the detainee with an opportunity to request health care services. The process by which detainees request health services is through Sick Call. Sick Call will be offered during regular working hours Monday through Friday except federal holidays. For weekends and holidays, detainee requests for medical services are assessed by an appropriate provider who determines if the request qualifies as an emergency. All medical emergencies are immediately addressed by the appropriate level provider. The appropriate level provider is determined based on provider protocols. If the request is not determined to be an emergency, an appointment is made for the next regular working day. All detainee requests for health services are reviewed by an appropriate health care provider within 24 hours. The detainee may not necessarily receive the requested services within 24 hours if those services are not indicated. 8.5.1. Mechanisms of Health Services Request. Request for health care services (sick call) may be through the use of a standard sick call form, a verbal request to a medical provider, or by presenting at sick call triage in those facilities that perform this service in the housing units. Local operating procedures will define how each facility administers requests for health services and how privacy and confidentiality are maintained. 8.5.2. Appropriate Level Provider. Requests for medical services shall be evaluated by the appropriate level provider. Registered nurses may evaluate/triage patient requests for same day 2020-ICLl-00006 4688 Chapter 8, Page 5 January 2014 medical services. If the registered nurse determines that the care may be rescheduled for a future date, the case must be discussed with the physician, a nurse practitioner, or physician assistant who will confirm that the treatment or evaluation may be scheduled in the future. 8.5.3. Documentation. Each medical facility will maintain a pennanent record of sick call requests. The detainee name, alien number, date of request, chief complaint and date of service are to be included in the record. This sick call record will have a paper record maintained in a loose-leaf binder and stored at the facility indefinitely. Documentation of health care provided in response to a detainee's request will be recorded in the progress note in the health record. Documentation must clearly indicate the visit was as a result of a sick call request. This shall be accomplished by utilizing a rubber stamp indicating "SICK CALL" on the health record. Entries need to include the date and military time the detainee was seen. 8.5.4. No shows/not seen. An entry in the medical record is required to document all cases where detainees are scheduled for medical services but are not seen by medical staff. Examples: XA detainee does not report for sick call/appointment after being summoned. Documentation must include but is not limited to the date and time(s) the detainee was called and did not respond and the signature of the individual who called for the detainee. A rubber stamp with this information can be used but must be signed as indicated above. . . X Anv., c:.ih1!ftinnlf"Vf"ntin thf" far.il,tv., thRt nrf"VPnt<:.<:.Pf"inu whn rf'tl11P.c:.tMc:.ir.k-r.Rll .., fill thf" ril'!tRinf'f'!<:. or were called for appointment (i.e., lock down). Documentation must include the situation, date, time, and a signature. 8.6. Care of Chronic Conditions. This section has been archived. The new IHSC Chronic Care Policy (03-03- Care of Chronic Conditions), which is in the new policy format, can be found on the IHSC Global Drive at: Policies and Procedures In New Format- Disseminated to Sites\03-03, Care of Chronic Conditions.pd( 8.7. Health Evaluation of Detainees in Segregation. This section has been archived and replaced by IHSC policy 03-06: Health Evaluation of Detainees in Special Management Units. 8.8. Referrals to the IHSC Medical Referral Centers or other SPCs. Detainees requiring services beyond the capacity of the current housing facility but who do not require acute hospitalization services may be transferred to a more appropriate site. These include SPCs, contract medical facilities, or contract detention facilities. Requests for patient transfers to any of the IHSC Medical Referral Centers or other SPCs will be routed through the appropriate Managed Care Coordinator (MCC). The MCC shall compile 2020-ICLl-00006 4689 Chapter 8, Page 6 January 2014 necessarydocumentation,consult with IHSC Medical Director, and make a recommendationto the originating facility. The HSA or their designee will brief the OIC of any potential transfers. The authority to approve transfers rests with the Field Office Director (FOD), ICE Office, or the SPC OIC. See SOP 8.8. 8.9. Referrals to Off-Site Care. Detainees requiring health services that cannot be provided by the current housing facility but are included in the IHSC Medical/Dental Covered Services Package are referred to off-site consultants or health care facilities. All off-site care must be authorized. (Refer to SOP 8.9 Treatment Authorization Request). 8.9.1 Medical Claims. A Treatment Authorization Request (TAR) Form must be completed for all hospitalizations, emergency services and other reimbursable services. In emergency situations where the form cannot be filled out before the service is rendered, it should be completed and forwarded as soon as possible but no later than one business day from the date of service. Without this form, the medical claim may not be paid. 8.9.2. Referrals to Long Term Health Care Facilities. Detainees who have been housed in an offsite health carefacility for more than 15 days will be evaluated (on day 15) for transfer to a SPC with a SSU or community long tenn care facility. When it is determined by the CD or the MCC that a detainee requires medical or mental health care for an extended period of time, the detainee will be referred to a long-term network facility. See Columbia Care Center SOP 8.9.2 8.9.3. Consultation Reports. After the off-site medical services have been completed, the consultant's report will be given to the CD or designee for review and signature. If the recommendations are acceptable, the CD will document any and all pertinent information including physician orders in the health record. At no time is a consultant, on-site or off-site, authorized to write in the IHSC health record. 8.10. Emergency Services. Each medical facility shall maintain an emergency cart containing all necessary medical supplies/equipment to offer urgent services in accordance with the level of care they provide. 8.10.1. Procedure for Ambulatory Facilities. The medical facility that offers only ambulatory care shall have Basic Life Support (BLS) capabilities in accordance with the American Heart Association Guidelines. Mock Code Blues will be performed on a quarterly basis through the Performance Improvement function. 8.10.1.1.Emergency Cart Contents. Emergency carts at medical facilities where only 2020-ICLl-00006 4690 Chapter 8, Page 7 January 2014 ambulatory care is delivered must contain, at a minimum, the items listed on the HSD-51 and HSD-53. The contents of the emergency cart will be checked on a monthly basis and after every use by the designated staff member. Items included on the Urgency Room/Equipment Daily Check List fonn IHSC 53 must be checked daily (including weekends and holidays). IHSC 53s must be kept in a binder for at least three years. 8.10.2.1. Emergency Cart Contents at IHSC Medical Referral Centers. Emergency carts in ambulatory and SSU care medical facilities must contain, at a minimum, the medications and equipment specified by the most current American Heart Association Guidelines. See SOP 8.10.1 Zoll 1600/2000 Semiautomatic External Defibrillator. The contents of the emergency cart will be checked on a monthly basis and after every use by designated staff utilizing the Emergency Cart Contents Check List form IHSC 51. The emergency cart medications will be checked on a monthly basis and after every use by the pharmacy staff, utilizing the Emergency Cart Medication Check List fonn IHSC 52. 8.11. HIV/AIDS. To the extent possible, the accurate diagnosis and medical management of HIV infection among detainees will be promoted. The diagnosis of AIDS is established only by a licensed physician hasect on a mectical history, current clinical evaluation of signs anci symptoms, Rnd lahomtory testing. Routine mass testing for HIV infection will not be conducted. HIV testing will be performed only when clinically indicated, on an individual basis, or when requested by a detainee and deemed necessary by the medical provider. If a provider determines that HIV testing is indicated based on clinical evaluation, the test may be performed only after pre-test counseling is completed The results of the HIV test will be reviewed by the CD or designee. The detainee will receive post test counseling regardless of the results. If a detainee is found to be HIV positive using the ELISA test, they will not be diagnosed with HIV infection until the ELISA test has been confirmed by a Western Blot or a comparable test. If the results of both the ELISA and Western Blot test confirm HIV seropositivity, post-test counseling will be provided. Whenever possible, such counseling should be given by a mental health professional in the native language of the detainee and whenever possible, will also be provided in writing in the native language. Both pre and post-counseling must be documented in the detainee's medical record. Counseling must include, but is not limited to, the following: 2020-ICLl-00006 4691 Chapter 8, Page 8 January 2014 XFacts about the cause and progression of HIV infection XTreatment techniques XEffective measures to prevent transmission of infection to others 8.11.1. Specific, IHSC-approved guidelines for the management of HIV infection are included in the Infectious Diseases Management Clinical Guidelines (most current version can be found on the Division web site). 8.11.2. Precautions. Standard (Universal) precautions are to be used at all times when caring for detainees. It should be assumed that all detainees are infectious for blood-borne pathogens. No additional special precautions are required for the care of HIV-positive detainees. 8.11.3. Staff Risk/Responsibility. Staff will not be excused from carrying out their regular duties and responsibilities with respect to detainees who are suspected or diagnosed as having HlV infection, unless the IHSC staff member is at high risk for infection because of compromised immune status (e.g. HIV infection or immunosuppressive therapy). If a IHSC staff member believes that he or she is at risk, they are responsible for discussing this issue with the supervisor. The employee's concerns will be evaluated by the Clinical Director and HSA who will adjust the individual's work responsibilities to lessen the risk to themselves or others. 8.11.4. Staff with HIV. Any IHSC staff member who is known to be HIV positive shall be managed according to the guidelines developed by the Office of Personnel Management and the Division of Commissioned Personnel. They will: X Be treated with the same considerations as employees who suffer from other serious illnesses XBe accorded all employee rights, such as leave, job restructuring, and flexible scheduling, including the right to strict medical confidentiality XBe expected to fulfill all obligations and responsibilities pursuant to their assignment which can be conducted safely and effectively. and which do not pose a special risk to the individual or to other persons XBe accommodated to the greatest extent possible with respect to daily work activities in response to the consequences of infection, consistent with meeting program goals and satisfying personal health needs. 8.11.5. Education. Each medical facility shall have an on-going education program that effectively communicates to IHSC staff the known facts about HIV infection and preventative measures. The program will address the following about HIV: Xlnfectious agent 2020-ICLl-00006 4692 Chapter 8, Page 9 January 2014 XEffects of infection XModes of transmission XRecommended preventative methods XCurrent materials for review XUse of multi-media teaching aids XMental health aspects Each medical facility will appoint a IHSC resource person responsible for the ongoing dissemination of current HIV infonnation. 8.11.6. Confidentiality. Strict confidentiality procedures shall be followed concerning the health records of detainees with HIV and/or AIDS. Confidentiality with regard to HIV is the same as for any other medical condition. 8.12. Sexually Transmitted Disease Prevention, Treatment, and Control. Providers shall follow the current sexually transmitted disease (STD} prevention, treatment, and control guidelines established by the CDC. All on-site treatment provided to the detainee should be directly administered and supervised on a daily basis and appropriately documented in the health record. Upon identification of a detainee with an STD, the recent sexual partners should be identified, examined, and treated as though infected, to the extent possible. --1:•. •1-.- r1:_; __ 1 n:---•-;1,..1_,av, __ ---··..:-__ . ,v ~n:-~-•:. ........... •-1 ..,,}.. :--1----• uul'•"'•u .. u• .1,..:_ HUJ }'V""'J• u,.., ...,.,.,,_, L'u .. ..,,v, ;•J________ ,....,yvu.>,v,., .. ,..,,...,.,0•1-...,..,,_11_.,.: ,..,.,..,,.,ut,;. 'T'~ XThat any detainee for whom STD treatment is prescribed (including juveniles) receives it and that it is appropriately docwnented XThat all of the appropriate Federal/State/local reporting requirements are met XThat all information regarding appropriate follow-up (including upon release) is provided to the detainee and is documented in the health record 8.12.1. STD Screening. All detainees over the age of 15, regardless of history of sexual activity, will be screened for symptoms of STDs. Detainees younger than 15, who are determined to be sexually active, will also be screened. STD screening will be completed within the first 14 days. RPR/VDRL tests will only be performed when clinically indicated. 8.13. Tuberculosis (TB) Control It is the policy of the IHSC that all lHSC medical facilities implement and monitor a tuberculosis control plan. The IHSC Tuberculosis Control Plan is described in the IHSC Infection Control Plan and includes the following priority areas: 2020-ICLl-00006 4693 Chapter 8, Page IO January 2014 • • • • • • • • • • • • • • • • Symptom screening Tuberculin skin testing (TST) Screening with chest x-ray TB Control Protocols TB Screening Sputum Collection for Individuals with Suspect TB Airborne Infection Isolation (All) Consultation and Specialized Services TB Laboratory Result Monitoring Treatment of Suspected Active TB Communication with Local Health Departments Transportation TB Surveillance TB Referrals and Continuity of Care TB Control Checklist and Risk Assessment Contact investigations for tuberculosis TB control: In order to prevent the spread of Mycobacleriatuberculosis(TB), detainees with suspected or confirmed active TB disease will be immediately placed and remain in airborne infection isolation until no longer considered infectious. Referral to the proper health authorities will be made in accordance with state and local regulations. Treatment: Tuberculosis will be appropriately and effectively evaluated by consultation with the IHSC Medical Director and local Clinical Director, and in coordination with state and local health department TB control programs. Tuberculosis Referrals and Continuity of Care will be arranged in coordination with: • state, or local public health authorities in the jurisdiction where the detainee is being treated • TB referral programs (i.e., Cure TB, TB Net, or the U.S.-Mexico Binational TB Referral and Case Management Program) TB Risk Assessment: All IHSC medical facilities will undertake a TB risk assessment at least annually in accordance with CDC guidelines for the control of tuberculosis in health care settings (see IHSC Infection Control Plan). Education: basis. Continuing education on tuberculosis will be given to the detainees and staff on an ongoing 2020-ICLl-00006 4694 Chapter 8, Page 11 January 2014 The following, policies, procedures and guidelines support the IHSC tuberculosis control program:: • IHSC Infection Control Plan • IHSC Infectious Diseases Management Clinical Guidelines (most current version) • Centers for Disease Control and Prevention and other national guidelines for tuberculosis treatment and control are available at: http://www.cdc.gov/nchstp/tb/pubs/mmwrhtrol/maj__guide.htro 8.14. Hunger Strike. The medical staff ofIHSC shall assure medical management of detainees who either declare that they are on a hunger strike or are observed to be on a hunger strike. A hunger strike is defined as refraining from eating in excess of72 hours. IHSC staff will initially and periodically counsel any detainee who is on a hunger strike as to the adverse effects of a prolonged hunger strike and to promote resumption ofnonnal eating. Hunger strikes in contract facilities will be monitored and tracked through the Managed Care Coordinators. Hunger strikes in SPCs are to be reported to the Executive Officer to the Associate Director for Field Operations. It will be recommended to the ICE that a detainee who is on a hwiger strike be isolated from other detainees for monitoring purposes. Regular meals and fluids of various kinds should be left with the detainee. An initi?.!m~ii:-?.1!md psychi?.tri<:t>"?.h1at!l'.'n wfl! 1:,ei:-0nd1_1<:t':'d ~mdrepeated BSnf;'('t>Ss~.ry. The IHS.C' Huoger Strike Monitoring form (IHSC-839) will be used to monitor the patient on a daily basis. This form will be kept in the detainee's health record. Any medical procedure or treatment to be performed on a detainee who is on a hunger strike will be done only with their informed consent. No medical treatment will be forced upon a detainee. If the detainee refuses treatment he/she will be requested to sign a refusal form. If the detainee's condition deteriorates to the point that care is beyond the scope of management by the IHSC staff and life may be in jeopardy, the Clinical Director will notify ICE and initiate the process for Force Feeding (See Hwiger Strike/Force Feeding SOP 8.14 ). At the conclusion of any hwiger strike, the IHSC staff will provide the detainee continued medical and psychiatric follow-up care as necessary. Discontinuation of hunger strikes in SPCs are to be reported to the Executive Officer to the Field Operations Associate Director. 8.15. Immunizations. Providers, when performing a health assessment, shall determine the immunization status of the detainee. An immwiization schedule will not be initiated for all detainees. The IHSC policy is designed to meet two purposes: XTo prevent outbreaks of commwiicable diseases in a detained population 2020-ICLl-00006 4695 Chapter 8, Page 12 January 2014 XTo provide individual detainee protection in the event of a disease outbreak When it is determined that immunizations will be administered, CDC, American Association of Pediatrics (AAP), and American College of Immunization Practices (ACIP) guidelines must be instituted and the appropriate immunization records be kept as a part of the health record on Standard From 601, Immunization Record. The Clinical Director is responsible for ensuring the following: XThat the appropriate informed consent is obtained prior to immunization and kept as a part of the health record XThat adverse reactions to immunizations are reported utilizing the MEDWATCH Form FDA 3500 XThat all the FederaVState/local reporting requirements are met The following precautions should be kept in mind regarding immunizations: XWhenever possible, live-virus vaccines should be administered on the same day, or should be given at least 30 days apart. XTuberculin testing should be done either on the same day that live-virus vaccines are administered, or no sooner than four to six weeks after immunization. Xlmmunization with live virus vaccines should not, in most circumstances, be performed on persons kr;.v·•.-u.tv be iu.fcctc 65 and volume depletion. 2020-ICLl-00006 4703 Chapter 8, Page 20 January 2014 3. Susceptible detainee contacts should ordinarily not be transferred or moved until the incubation period has lapsed however, if detainees need to be moved from the isolation area then a mask should be worn at all times and the following applies: 8.26 Availability of Health Care in Other Countries. IH SC provides medical recommendations for availability of health care in other countries. IHSC responds to Immigration's request regarding availability of health care for detained and non-detained aliens who may be returning to their country of origin or another country. Requests are sent to the Consultant Services Coordinator in the Clinical Branch (See Availability of Health Care SOP 8.26.). 8.27 Infection Control. Refer to the IHSC Infection Control Plan regarding IHSC' Infection Control Program. 8.28 A via ti on Medicine Program (AMP). The Chief of the Aviation Medicine Program reports directly to the IHSC Medical Director. The IHSC Mental Health Consultant as well as all available Clinical Directors will serve as consultants to the AMP for medical escort concerns. 8.28.l Medicaf Escort. A health care provider may accompany the transport of an alien along with a minimum of b)(?)(E) I DurinQ trnnsnort. the meoie11l escort shall sit as close as nossihle to the alien and th~ b)(l )(E) rth; alien ·has-a medical condition it is preferable that the medical escort sits next to the alien if security is not compromised. If the alien has a psychiatric condition or is potentially combative, the ICE officers shall sit next to the alien assuring a safe environment during transport. In tum the medical escort shall sit as close as possible to the ICE officers escorting the alien. At no time will the medical escort assume security responsibilities for the alien while in the air or on the ground. Prescribed medication can be provided to an alien if they are at immediate risk to cause harm to self or others as outlined in the IBSC Clinical Practice Guidelines and Protocols for Management of Combative Detainees During Transport. Physical restraint, if required, is the responsibility of the ICE officers or other security personnel. Form AMP002 (IHSC Aviation Medicine In-Transit Progress Notes and Medical Summary) may be used to document medical interventions, medication administration, significant and pertinent medical observations and findings during transport. When a medical escort is initiated outside of the IHSC, any medication and/or treatment orders provided should be attached to Form AMP-002 and appropriate documentation made on the fonn. Form AMP - 003 (OTC Medication Administration Record) may be used when administering OTC medications during a chartered flight. Upon completion of the medical escort, the completed AMP-002, and AMP- 003 form should be 0 forwarded to the IHSC Aviation Medicine Program. For more information please refer to SOP 8.28.1 (Medical Escorts). 2020-ICLl-00006 4704 Chapter 8, Page 2 I January2014 8.28.2 MedicationDuring InternationalEscort. Due to the uncertainresponseof many governments toward individuals entering their country with medication/s and related supplies (syringes and needles) in their possession, all personnel performing international medical/psychiatric escort services are provided the following guidance: • Medication is to be administered only as directed by a physician's written orders while en route to deportation destination. • Administration of medication and or treatment performed is to be documented appropriatelyas defined by IHSC policy. • Escorts are not to disembark aircraft at final destination with any medication or supplies (syringes and needles). All unused medication & supplies are to be disposed of on the aircraft, just prior to landing, unless these supplies have been pre-coordinated to be left with the detainee or the medical personnel/family receiving the detainee. 8.29. Risk Management Activities Risk management activities specifically related to medical procedures and patient safety will be defined and describedin national standardoperating procedure. This will include but is not H!!l.itedto ~!i::-vantPatii::-nt Safi::-ty Goals ?.S ii:li::-ntified J:,ythi::-foint C'omm!ss!onon._A_i:i:ri::"",ue: (b)(6); (b)(7)(C) JUNO7 201 7 2020-ICLl-00006 4707 uSDepartment of Home land Securit) US Immigration and Customs Enforcement Krome Sen;ce Pr ocessino Center Specific Post Ord ers Con trol Post I, 2, & 3 Control Post 2 and Control Post 3 • Perform an accurate radio inventory when assuming the post to ensure that all radios are accounted for. This radio inventory will be completed within the first hour of assuming the post. Report discrepancies to the shift supervisor immediately. • Complete a Radio Inventory Sheet by ensuring to call every post and verify: 1. The name of the Officer assigned to the post. 2. The proper radio is assigned to the post. 3. The Serial Numbe r of the radio assigned to the post. 4. Document the findings on the radio inventory sheet. 5. The completed Radio Inventory Sheet, with name and signature, will be submitted to the Shift Captain before the end of your shift. Key Watc her System Procedure (Control Post 3) • Perform an accurate key inventory when assuming the post to ensure that all keys are accounted for. This key inventory will be completed within the first hour of assuming the post. Report discrepancies to the shift supervisor immediately and note key issue on count sheet. • (b)(7)(E) • Procedures for 1sst11ngkeys to statt are as tollows: I. Receive swipe card from staff member. 2. Staff member will advise which key(s) is required for their post. 3. In the event that the staff member has not yet been issued a swipe card, utilize the control emergency swipe card to issue key(s). 4. ln the event the swipe card is inoperable or unavailable, utilize the employees' pin number located in the "Summarized User List Report Binder" to issue key(s). 5. Control Post #3 officer will maintain accountabi lity for issued keys via the emergency swipe card by utilizing the Key Watcher Back-up Logbook. 6. Control Post #3 officer will log in the Key Watcher Back-up Logbook the date, name, location, number of keys, key ring number, time out and time in. 7. Control Post #3 will verify all keys returned by staff are reconciled with the Key Watcher Back-up Logbook in order to ensure that all entries are closed out. 8. Ensure that a Memo is generated to the Security Officer via the shift supervisor identifying swipe cards of staff members that are inoperable or access is denied to nonrestricted key(s). 9. Check and ensure video camera is functional (battery, on/off power button, lens). Notate all results in the logbook. If repairs are needed, immediately notify the supervisor for corrective action. • --- ---11 b)(6); (b)(7)(C) .\fOD OI C conc ur Page J of 8 JUN 'l7 20'7 2020-ICLl -00006 4708 CS Departm ent of Hom eland Sec uri l) US Immi g rati on and Cu stoms Enforcement Krom e Ser.ice Pr ocess ing Ce nt er S pecific Post Orders Co ntr ol P os t 1, 2, & 3 Key Control (Rest ricted K eys) • All keys are issued via the Key Watcher system. • The issuance of restricted keys to a staff member with a swipe card without access to a restricted key must be authorized in writing by a SDDO or higher authority, on a Restricted Key Access Form. • Fill out the form completely and give it to the person requesting the keys so that he/she may get the required signature. 1. Once the authorizing signature is received, the Control Post Officer will sign the form, issue the key(s) using the Transportation SDDO's swipe card and place the form in the box labeled "Restricted Key Forms". 2. The form is valid for that person for the duration of that person's tour of duty. 3. Each time restricted keys are issued to staff, the transaction must also be logged in the key logbook. Procedures du ring coun t • Fifteen minutes prior to count time, the Control Post officer will announce "Attention in the camp, stop all detainee movement and prepare for the count" via camp radio. • At the official count time, Control Post will announce "The camp is closed for the headcount". • Once the count has been initiated, intake and release operations will be suspended until the count has been cleared. • The SDDO will enter the Control Post to mon itor the count. • The Control Post Officer 3 will receive the count from all posts via telephone and count slips. • If the numbers add up correctly, the SDDO will verify the count with the G-22.5 in processing before clearing the count. • The sally port gates will remain closed until the count clears unless otherwise authorized by the SDDO or higher authority. • During an emergency count the outside posts (e.g. Larkin, Hospital details, and hotels) shall be notified by the Control Post Officer I or 2 that an emergency count is being conducted. • The outside posts shall also be notified once the emergency count is cleared. (b)(6) ; -- - ---l •(b)(7)(C) .\~OD 01( concurs: Page ~ of 8 JU~'l 7 2017 2020-ICLl-00006 4709 t:S Depar tm en t of H o meland Secur it) U Immi gration and Cu stoms Enforcement K r ome Se r vice Pr ocess in o Ce nt er Specific P os t Orders Con trol P os t I , 2, & 3 Alarms F ire Alarms: • In the event that a fire alarm is activated: I. Look at the fire alarm panel to see where the fire is. 2. Press the LOCAL SILENCE button to silence the alarm in control. Annou nce, via radio that "we show a fire alarm in _ _ (location ,) all available officers respond. "S top a ll unneces sary r adio traffic at this tim e". 3. Ca ll the area affected via radio and/ or phone to get a status report of the situation. 4. Notify the SDDO on duty of the fire a larm. 5. Issue Emergency key to the closes officer. 6. Announce via radio which officer has the emergency key and that the office r is in route to location. 7. Stand by and wait for further instructions from the Shift Supervisor. 8. Press the ALARM SfLEN CE button to silence the alarm in the affected area, once a superv isor on the scene has verified the alarm, and that supervisor has advised you to do so. 9. DO NOT DIAL 911 for Fire Rescue unless advised to do so by a supervisor , or the fire is obviously a threat to anyone. P anic Alarms: • In the event that a panic alarms is hit by anyone in the courts. I. Announce, via radio that "we have a dur ess alarm in _ _ ( locati on,) all ava ilable office rs respo nd. "Sto p all unnece ssary radio traffic at thi s time ". 2. Call the affected area and acknow ledge the alarm. 3. Notify the Shift Supervisor of the situati on. 4. Upon securing the situation, reset the Alarm panel. FM200 System: Sequence of Operation Fire Suppression Systems Be ll/ First Alarm Ala rm : F ir st activation of a ny smoke d etec to r in a prot ecte d area . System will sound bells in the prote cte d area. Base building fire alarm will activate with a ge nera l alarm ton e. C heck prote cted area for signs of fir e. Sile nce FSCP or reset if needed. Horn/Strobe Second Alarm P r edi sc har ge: U pon mi grat ion of sm ok e from fir st s mok e detec tor to secon d det ecto r in a pr otected a r ea . System will begi n re lease co untdown (30 sec ond s) Hold down abort button in prot ecte d a r ea a nd look for visua l sig ns of lire. Cf lire is detected, and th e agent is need ed, re lease abo r t butt on a nd exit t he ro om. Age n t will discharge soo n after. Silenc e FSCP or reset if nee ded after vis ual inspection. Do no t r elease a bort until system is full y reset. (b)(6) ; \FOD 01( concur~: (b)(7)(C) Page 5 of 8 Date: JUNQ7 2017 2020-ICLl-00006 4710 LS Departm ent of Homeland Securir~ US Immi grati on and Customs Enforc ement Kr ome enice Pr ocessin° Center ~pecific Post Ord ers Contr ol Post 1, 2, & 3 Strobes/Release Release: System releases agent in protected area. The interior and exte rior strobes will flash for the protected area. Do not enter protected area until syste m has been purged and or reset by fire department. Emergency Situations • • • • During an emergency situation staff shall refer to the emergency plans checklist located in the red binder. In the event of an escape, upon the CP officer being notified he or she will immediately notify staff via radio that there is an escape in progress. The CP officer shall include the location of the escape with as much detail as possible, and the number of detainees involved (if known). This will be repeated a minimum of three times over the radio. Upon these actions being taken, the camp will be placed on a LOCK DOWN status. Once the escapee(s) is in custody, the CP officer will announce the status. Only the Camp SDDO or another supervisor of equal or higher rank will have the authority to lift the lock down. In the event of an officer in distress/officer down within the facility, the CP officer will immediately notify staff via radio, utilizing the appropriate code. The CP officer will include the officer's location and any other relevant information. This will be repeated a minimum of 3 times. In the event of a facility LOCK DOWN confirm the presence of an SDDO at the main gate to provide guidance/instruction until the facility is reopened. NOTE: In any emergency situation, the CP officer will make an additional announcement that all radio communication not associated with the escape, distress call, officer down, etc., will cease, (except for another urgent situation). Only supervisors and officers directly involved with the emergency and pertinent activities will continue to utilize the radio. In addition, the CP officer will make exhaustive efforts to ensure that the Camp SDDO and the Shift Captain are notified telephonically and/or receive confirmation of the announcement from both supervisors via radio. (b)(6); ..\S OD O f( concurs: (b)(7)(C) P,ier 6 of 8 Jd~r o1 2011 2020-ICLl-00006 4711 L'S Depa rtm en t of H omela nd ecu ri t} S Immi g ra tion an d C u.sto m En forc ement Kr ome eni ce Pr ocess in O'Ce nt er S pec ific P ost Ord ers Contr ol Post 1, 2. & 3 Chronological Act iviti es: 0200 0400 0500 0530 0545 0600 0700 0745 0800 0830 0900 1020 1100 1130 1150 1300 1400 1530 1630 1645 1800 1900 2000 2100 2230 2300 2330 0030 Camp closes for detainee population count Insulin shots (until completed) Lights on in the detainee dormitories (wake up time) Camp closes for detainee population count Cafeteria workers report to the cafete ria Detainee breakfast begins Televisions turned on Norma l telephone access begins Comme nce clean-up procedure (continues upon return from cafeteria) Medication is issued in IHSC Law Library (0700-1130 / see schedule) Outdoor recreati on begins (until 11:00/see schedu le) Medical Triage & medical appointments Unit inspections begins Weekend/Holiday Visitation (until 1530 / see schedule) Barbershop open (0830-1100 M-F I see schedule) EO IR court sessions begin Detainee lunch begins /Commissary KTU / MHU Barbershop begins (until 1230) Outdoor recrea tion begins ( until 1715/see schedule) Law Library ( 1150-1915/ see schedule) Camp closes for detainee population count Medication is issued in IHSC Barbershop open (After population count -1600 M-F I see schedule) Leisure Library (1400-1445 Fridays / see schedule) Leisure Library (1530-1615 Wedn esdays / see schedule) Detainee dinner begins I Commissary Leisure Library (1645-1720 Mondays / see schedu le) Weekday vis itation (unti l 2200 / see schedule) Religious Services (see sched ule) Medicat ion is issued in IHSC Camp closes for detainee popu lation count (face to photo) Issue razors (until 2250) All razors returned Normal telephone access ends Televisions turned off (Sunday - Thur sday) Lights out in the dormitories (Sunday - Thursday) Televisions turned off / lights out in dormitorie s (Friday - Saturday) ------1 (b)(6); .\rQD 0 1( concur (b)(l )(C) Pa~e ' of 8 Date: JUNO7 20'7._____ 2020-ICLl-00006 4712 L · L>epartment of Homelan d ec urit~ C Im mig rat ion and Cu tom ~ Enforc ement h'.rome enice Pr oce in o Center pcc ific Po st Orders Control Po t I, 2, & 3 Hours : Th e Co ntro l Pos t I Office r will be man ned 24 hours a day, seve n days a wee k. T he Co ntrol Post 2 Office r will be manned 24 hours a day , seve n days a week. The Con tro l Post 3 Offi ce r will be manned24 hours a day, seve n days a week .. Post Closure • 1nthe eve nt that the post is closed due to no Deta inee population, you are to report to your immediate superviso r to assist wit h cam p operat ions. *** T hese post ord ers a re to be used as a guide for th e successful comp letion of your duti es. It is not expected that th ese post ord ers will cover every conceivable situ atio n t hat you ma y b e confro nted wi th while per for min g your assigned duti es. However, you are expected to exer cise good jud gment a nd good sense in the application of th ese or ders. Your duties are not necessaril y limited to th ose described her ein, an d may be amend ed orall y or in wr iting whe n deemed app ropri ate. b)(6); (b)(7)(C) JUNO7 2017 Approved By \ I 01) Q I( conrm Date: ------- b)(6); (b)(7)(C) lh tc: JUNO7 20\7 2020-ICLl-00006 4713 --~ 8 \ j ; I I • L ~ lh:·partntt'lll o f lfomdand , ,1:uri1~ L · Immi gration and Cu,10111, [ nforn :mt'nt Krom e Sen ice Proce~~ino Ccn tt-r ':-111::dfo: l' u~I Unlt :r~ l>c taioee Housing Lnit Building 1-t-\ De k Detainee Hous ing U nit Building 14A Desk Assume Post • Read and sign post orders and General Post Orders. • Receive a thorough briefing from the previous officer. Briefing should include any pertinent informatio n that would affect the Housing Unit. • Make official entry in the logboo k stat ing you have accepted the post, and assume a ll responsibilities that go with the post. Review past entries in the Ho using Unit logbook. • Inventory all eq uipme nt and not ate the results in the logbook. • Receive the keys from the previo us Building 14-A Desk Office r. Check keys and locks for status, accountability and proper ope ration. Report status and accountability of all keys to the Cont rol Room Officer. • Ensure that all Detainee fonns are available. • Prior to the outgoing officer exitin g the Housing Unit, examine the overall cleanliness of the unit. • Inventory cleaning chemicals and make the approp riate entry in the inventory log. • Conduct a security and sanitation check of the area prior to relieving the outgoing office r. • Notate all discrepancies in the logbook and submit the appropriate repair order when applicable . • Ensure that your communication radio is in good working order with a fully charged battery. • Review and maintain organization of detainee bed cards (3x5) and confirm the head count ; ensure that a bed card is present for each detainee in the unit. Dut ies and Responsibiliti es • Maintain care, custody and contro l of detainees hou sed in the Housing Unit. • All detainees will be awakened at 0500 hrs. • All detainee beds ,viii be made neatly and in an orderly fashion no later than 0700 hrs. dai ly. • All dormito ries will be clean and free of trash and debris no later than 0800 hrs. daily. • Dormitories must be maintained in a sanitary manner at all times. • Make frequent but irregular patrol s of the unit. • Ensure that all detainee s are searched upon exiting and returning to the dormitory for any reason. • A visual check will be made o f each detainee's wristband every time they are pat searched upon enter their housing units. This check will verify ; Correct detainee , good physical shape of the wristband ; is it stretched , is the print in good shape, is it faded, and is the plastic clasp sti ll on . • A Detainee with a wristband in poor conditi on or loose wi ll be sent immediatel y to processing for a replacement. • Perform a minimum of five random searche s o f detainees in the unit, and their personal area s, in an effort to maintain the safety and security of the facility (individual shakedow ns). • Do not perform shakedown s after .. lights out'", exce pt in emergency situations or when authorized by a supervi sor. • Log in the contraband logbook the detainee·s name, A#, findings , exact locatio n where cont raband was found, type( s) of co ntraband and )'Our name . 2020-ICLl-00006 4714 ~ Dl•p;lrllllt ·nt o f H u ml'land ' n:urit_\ CS Imm igration and Custo m~ F:nforn ·ment Krome Sen ice Prul"<:Sing C en ltr l ~p ""l"ilil· l' v,t On.l.:r:l>et.iinee H ousing L'nit Build ing 1-L\ Oest.; Duties and Respo nsi bilities - continued • Maintain and update the housing unit bed sheet. Obtain a new 3x5 card from control , if a detainee is moved. • If a detain ee receives a medical pass, document the type of pass ( example : glasses , lower bunk) under the comment section. Fold and place the medical pass behind the detainee's 3x5 card. • Ensure that all doors are functi onal (open and close secu rely). • Ensure that all detainees are offered meal s during the regularly scheduled meal. • Ensure that the established housing unit guidelines are being enforced. • During normal operat ing situat ions, unit doo rs are to remain secured. • Ensure that detainees who are being moved or released from the unit have the followi ng in their possession I towel , all issued uniforms and linen. • Cabinets will be used to store only the chemicals and other small items related to the cleaning of the housing unit and/o r the accountability of the chemicals. • When patrolling , constantly be on a lert for suspicio us activities. Look for contraband and anything out of th e ordinary. Patrols must never become regular and routine. If detainees can a nticipate you r activities, then they can plan prohibited activities accordingly. • At any time if a female enters a housing unit or any area in which a detainee is likely to be showering , perfonning bodily functions or changing clothes the officer is required to annou nce to the detainees " Female on Deck" • Do not vacat e the post unless properly relieved. Note: Officers will conduct and annotate in the logbook a Security , Safety and San itation check every 45 minutes to an hour at irregular times (24 hours a day). To ensure the Officer 's safety , watch calls will be conducted between the hours of 1800 and 0600 every half hour by notifying the control post by telephone or radio. Annotate in the logbook that a watch ca lJwas conducted. Recurring Duties • Rounds are to be conducted throughout the ent ire shift ensuring that beds are made prope rly; common areas and living are clean and neat, etc. • During patrols of the unit, ensure that all exit doors are secured , by depres sing the locking bar. • Note any movement of detainees from the unit in the logbook with the last name, first name, complete alien number, country and destination. • Maintain accountab ility of items issued (i.e. board games , pencils, etc.). Cleaning Supplies and Eq uipment • Clea ning supplies and equ ipment will be inventoried before and after use and logged in on the proper invent ory sheet. • Officers will verify that detainee(s) are volunteer workers prior to issuing any supplies. • Officers will ensure that the proper notation is made on the pay roster fonn once vo lunteer deta inee workers have completed their assigned work. MAY2 8 b)(6) ; \~O]) OI< c,,nr ur, : b)(7) (C IIAI~: 2020-ICLl-00006 4715 l " l>t.>p.lrlllll ' l11 uf l:-fo111da11 1l 'n ·uri1_, t ;s Im migra t ion and Cui.tom~ Enforcement Kr ome Sen ice P r ocessi ng Cente r ~Pl 'l'ifi\: P u ,t Unl l'rs Detainee H ousing t ·nit Building 1-t -\ Dtsk Sanitizing Mattresses • The mattress and bed frame will be wiped down with sanitize wipes once vacated. • Ensure that the detainee worker is wearing gloves when cleaning these items. Television s • Detainees are not allowed to have possession of the TV remote contro l. • Te lev isions will be turned off during official counts, cleaning of housing areas, and when it will interfe re with daily facility operat ions. • Volume of te levision shall be kept at a reasonable leve l, so as not to disturb other detainees or daily fac ility operat ions. t st Shift 3x5 Binder Audit • • • • • The I st Shift Pod Office r is responsible for ensuring on a nightly basis that detainee 3x5 Binder is accu rate. The audit will be documented in their log book. The Officer will ver ify the re are no excess papers or documentation from detainees who are no longer housed in their Pod. The Officer will verify the following for Medical Passe s: l . All medical passes are current and not exp ired. 2. Under the comment section of the 3x5 card the medical pass is documented. 3. The medical pass is stored behind the card. Detainees required to be in a Lower Bunk: 1. Confirm the detainee is in the correct ass igned lower bunk. 2. Ensure the 3x5 card states lower bunk under comments The Officer will verify the detainees are in the assigned bunks and the bunk is documen ted clearly on the 3x5 card. Ha ircuts • Haircuts will be determined by the posted schedule. Rec reation • Recreat ion w ill be determ ined by the posted schedule. Religiou s Services • When adv ised, the housing unit officer will make an announcement for the detainees to prepare for religious services. The announcement will include which religious service is bei ng provided and the officer wi ll log the announceme nt in the log book. Law Library Sched ule • Law Library hours will be determined by the posted schedule . • Detainees must sign-up two hours prior to the housing unit's scheduled library time. De tainee Cafeteria Worke rs • Detainee cafeteria workers sha ll change into the uniforms that correspo nd with the ir classificati on level when they are not working in the cafeteria . Detain ee Living Area • Detainee(s) are responsible for keeping their living area neat and orderly. 2020-ICLl-00006 4716 L-s l>l·partm i:nt o f Hun a ·land :'-l'curil~ VS Immigrati on and C u toms Enfo rcem ent Kr ome erYice Proc essing Cen ter • • • • ~p1:cilil· l' ost OrJl'r~ Detainee Housing L'nit Building l -'A Ot• k Towels and laundry bags are the only items allowed hanging from the beds. No pictures are allowed hanging from the walls or beds. Only authorized amount s of linen and clothing. No washing clothes in the housing units. Officer's Station • The officer's station will be kept clean and neat with no detainees being inside it at any time, for any reason . • Detainee s shall not loiter around the office r's station, take things from it or view any written material that is on or around the area. Tools • Any maintenan ce and/or contract worker entering the housing unit will provide the housing unit officer with a tool inventory list before commencing work in the area. The officer will verify that all tools present are listed on the tool inventory list. • Upon completion of work, the housing unit officer will account for all tools listed on the tool inventory list with the worker before he/she exits the unit Hours: The Bldg. 14A Desk Officer will be manned 24 hours a day, seven days a week. Post Closure • In the event that the post is closed due to no Detainee popu lation, you are to report to your immediate superviso r to ass ist with camp operation s. 2020-ICLl-00006 4717 l ~ lfrparlmtnl 11 1'Ho111da11d~~·curi1~ L'S I mmig rati on and Cu:-tnms Enforcement hr umc 'eryice Pr ocessi ng Ct·ntcr ~pn: ilic l•u~I Unltr, lh •rainee H o using l'nir Buildin~ 1-t.-\ D esk Chronolof{ical Activities: 0200 0400 0500 0530 0545 0600 0700 0745 0800 0830 0900 1020 1100 1130 1150 1300 1400 1530 1630 1645 1800 1900 2000 2100 2230 2300 2330 0030 Camp closes for detainee population count Insulin shots (until completed) Lights on in the det ainee dormitories (wake up time) Camp closes for detainee population count Cafeteria wo rkers report to the cafeteria Detainee breakfast begins Televi sions turned on Normal telephone access begins Commence clean-up procedure (continues upon return from cafeteria) Medication is issued in IHSC Law Library (0700 - 1130/ see schedule) Outdoor recreation begins (until 11 :00/see schedule ) Medical Triage & medical appointments Unit inspect ions begins Weekend/Holiday V isitation (until 1530 / see schedule) Bar bershop open (0830 -1 100 M-F / see schedule) EOIR court sessions begin Detainee lunch begins /Commissary KTU / MHlJ Barbe rsho p begins (until 1230) Outdoor recreation begin s ( unti l 1715/see schedule) Law Library (1150-l 915/ see schedule) Camp closes for detainee population count Medication is issued in IHSC Barber shop open (Afte r population count -1600 M-F / see schedule ) Leisure Library ( 1400- 1445 Frida ys / see schedule ) Leisure Library (1530-1615 Wednesdays / see sched ule) Detainee dinner begins / Commissary Leisure Library (l 645-1720 Mondays / see sched ule) Weekday visitation (until 2200 / see schedule ) Relig ious Serv ices (see schedule) Medication is issued in IHSC Camp closes for detainee population count (face to photo ) Issue razor s (un til 2250) All razors returned Normal telep hone access ends Televisions turned off (Sunday - Thursday) Light s out in the dormitories (Sun day - Thursday) Televisions turned off I lights out in dormitorie s (Friday - Saturday) (b)(6) ; .---------nu ru )(7)(C) 2020-ICLl-00006 4718 l . · D1:p,lrtm t:111 of Humd a nd ~1:curi1 ., l' Immi grat io n and Cu toms E n forc em en t Kr om e Se n ·ice P roce ss in o Ce nt er ~ pn ·ilk l' u::.t Ord er.., f>eta inee Housing l nit Bu ild ing 1-t\ Des k *** These post orders are to be used as a guid e for the successful completion of your duti es. It is not expected that th ese post ord ers will cover every conceivable situation that you may be confronted with while performing your assigned duties. However, you are expected to exercise good judgment and good sense in the application of these orders. Your duties are not necessarily limited to those described herein , and may be amended orally or in writing when deemed appropriate . (b)(6); (b)(7)(C) MAY2 3 2017 Date: _ _ _ ___ Approved B, Assistant Field Director/U C \F O il ( IIC ronrur,: ll.ue: r:>- MA'(I 3 2~ 2020-ICLl-00006 4719 _ :+-~c.ol"ER r co(-. !l ~#1ts1csiv.-l Montgomery County Forensic Services Department 205 Hilbig Road, Conroe, Texas 77301 Phone: 936-538-3791 Fax: 936-538-3794 Release of Decedent and Personal Effects I, _____________ , bearing the relationship of ______ to ___________ _ , acknowledge that I am the legal next of kin and (decede nt's nam e) authorize the Montgomery County Forensic Services Department to release the decedent and his/her personal effects in the possession of the MCFSD to the funeral home or its agent listed below. Name of Decedent:________________ DOB: ____ Name of Funeral Home and/or Crematory: _____________ Signature of next of kin ______________ _ _ Date:_____ Street Address _ Telephone _____ City _____________ State __ _ Zip Code ____ Witness __________________________ _ _ Street Address ______________ City ____________ _ State __ Telephone _____ _ Zip Code ____ _ _ The following define rights of disposition of a body in Texas (Texas Health and Safety Code, 711 .002): (1) the person designated in a written instrument signed by the decedent; (2) the decedent's surviving spouse; (3) any one of the decedent's surviving adult children; (4) either one of the decedent's surviving parents; (5) any one of the decedent's surviving adult siblings; or (6) any adult person in the next degree of kinship in the order named by law to inherit the estate of the decedent 2020-ICLl-00006 4720 8520 Sweetwater Ln. Houston , TX 77037 281-272-5220 Fax 281-272-5225 DATE 9/19/2017 To Whom It May Concern: The following is an itemized list of charges for preparation, documentation, and transportation to Florida. • • • • • Removal from Montgomery County Medical Examiner: $175 Autopsy Embalming:$400 Documentation: $25 Combination Shipping Unit: $100 Deli very to Airport: $ 100 o Total: $800 • Death Certificate s: $20 for first copy, $3 for each additional. o 2 D.C. 's = $23 • Airfare: o United Airlines: IAH to MIA $440.94 o Delta Airlines: IAH to MIA $606.06 We are known shippers with both airlines listed, and can use which ever you prefer . Please feel free to call us with any questions or concerns, Thank you. 2020-ICLl-00006 4721 STATE OFTEXAS CERTIFICATE OFDEATH 1. LEGAL NAME OF□ EC EASED ~nclude AKA'sif any)(Fir~!, Middle, Last) 3.SEX 4. DATE OF8IRTH ' ' ' ' ' '' IFUNDER 1YR m 5.AGE•la5tBlrtllday 7. SOCIAL SECURITY NUMBER .., 6.BIRTHPLACE (City& S!aleorForeign Counby) SPOUSE (lfwffe,givenamepriortofim!mafl'iaga) 8.MARITAL STAitJS ATTJME Of DEATH D Married 9. SURVIVING □ Widowed□ DivorcedD NeverMarrled 0 UnkriOWII 10b.APT NO 10aRESIDENCE STREET AODRESS 10e,STATE 1Cd.COUNTY 2. DATEOFDEATH-ACTUAL QRPRES\IMEO IFUNDER 1 DAY "'~ "'~ I (Ye~rs) STATE FILENUMBER (Maiden) 10c.CITY ORTOWN 10f.ZIPCODE 10g.INSIDE CITYLIMITS? 0 Yes □ No 12.MOTHER'S NAME PRIOR TOFIRST MARRIAGE 11.FATHER'S NAME 13.PLACE OFDEATH (CHECK ONLY ONE) IFDEATH OCCURRED JNA HOSPITAL: [ ER:Outpalienl □ DOA □ Inpatient 14.COUNTYOFDEATH ·I lFOEATHOCCURRED SOMEWHERE OTHER THANA HOSPITAL: 0 Hospice Facility D Nursing Homo 15.CITYJTOWN, ZIP(Ifoutside cityllmlls, giveprecinct no) . 17.INFORMANT'S NAME& RELATIONSHIP TODECEASED 19.METHOD OF'DISPOSITJON D Cremation D Dona~·on 0 Bllial 0 Elllombmenl □ Remo~al FromS13te D Olhar(Sp&cify) D Decedent's Home D Other(Specify) 16.FACILITY NAME (Ifnollnsblulion, giveslrEelad'dress) 18.MAILING ADDRESS OFINFORMANT (Street andNumber, City,Slate,ZipCode) 20.SIGNATURE ANDLICENSE NUMBER OFFUNERAL DIRECTOR ORPERSON 21. ACTINGASSUCH Section 0 UnknOl'ifl BlocK Lot 22.PLACE OFDISPOSITION (Na:ne ofcemetery, cre/lllllory, otherplace}Zl. LOCATION (CilyJTown, andStale) Spare 24.NAME OFFUNERAL FAGrtlTY 25. COMFLETEADORESS OFFUNERAL FACILITY {Stroot andNumber, City,Slate,ZipCode) 26.CERTIFIER (Checl< onlvona): D Certifyirig PhysfclanTotheliestofmyknowledge, deathoccurred duetotflecause(~)and man~ersla:ed. D MedbilElamilerfJustice of \hePeace - Onthebasisofexamina!lon, and/orinvesligation, inmyop:nioo, deall,occurred at lhetime,date,arulplace, andduetothecause(s) and'maim8lslated. 27.SIGNATURE OFCERTIFIER 28,DATE CERTIFIED (Mo/Df.yN1) 29.tlCENSE NUMBER 31.PRINTED NAME, ADDRESS OFCERTIFIER (SkeetandNumber, City,State,ZipCode) 30.TIMEOFDEATH (Actual orpresumed) ~. TITLEOFCERTIAER 33.PART1.ENTER THECHAIN OFEVENTS-OISEASES, INJU.:~IES, ORCOMPI..ICATlOtut pregnant43 days to1year~efore death D Unknown ifpregnant within the!)the stationary guard medical officer. MTCstaffahaDIn no way impedethe detalnee'sheellhcare. The s1ationary guard medlcal officershall rmnalnin 1hen:,om wilhthe detainee at all times whHe the resballrtsareremoved. C. A stationaryguardmadk:alafficar who is issueda firearm shall malntaln possession of the restraint keys at all limes. D. ?lastlcrestraintsshallbe ussd when necessary for a MRI or during an x--ray• Detaineesearches If the delalnee cannotbe &tripsearched,the stationaryguardmedical officer shall Immediatelycommunicate&ud1with the fadlity securitywpervisar. The warden or duty wardenshaDbe Mtifled lmmedla:tsly.In no way shall 6t8ffImpede1hedetalnee'shealth CSR!. 5. Detaineeracmds The stationaryguard medicaloffloaraare respansiblefar aDnea,ssmy paperworll pertainingto Iha transferof the dnlnee(s). Delalnae(s)&tud1 be transferred with a transport orclar. B. Vehlcle security _ The stationary guardmedicalofficerand fac.lfrtysupenrlscrshaOcha every medical transfer vehicle for emnal and lnlemal security issuesbeft,19 any detaineesare loaded onto the vehicle. In additionto routineseard1es, conductedspecifically to sean:h for amtraband and any Itemsthat pose a security risk.,the &tationaryguard madlcal officer ahaD: A. ensure all med'icaltransferveh!cle safety equlpmetttis In place and In working order,such aa lights, ml1TOn., and ether similar equipment. 8. Verify the tntegrttyof all ham and screens over windowsand inspect the partition batweanthe a1Btlonary guard medical officer and dalainee comparbnentsfor security i&SUes. C. Ensure all medial transfer veh!clo doors amess!ble tu detainees are padlocked from the outside. It Is permissibleto place the padlockon the outside of the cage door if a vehlcle Is equippedwith Interiorsecwtty cagas. 0. Ensure the vehiclecontains a fuDycharges fire aidlnguisher. E. Visuallylnapedvehlae tires,Includingthe spareandjack and ensurethe detainee 0oas not have accessto arr, of these tools. F. Ensurethe transml&&lonradlo Is operating properly.In addition ta the vehicleradio a facility cell phoneshall be Issuedto the stationaiy guartl medical officers. e!!!!!!!!!!!!!!!!~!!!!!!!!!!!!!!!!!!!!!!!!!!!!ll!!!!!!!!!!!!~~!!!!!!!!!!!!!!!!!!!!!~~~~~!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!~ statloniuy Guard MedicalOfficerPost OrderDated S/1/15 Reviewed 7•15-1s 2020-ICLl-00006 4725 (b )(6) ; (b)(7 )(C) 7. Free-world ambulance A .-1. (b)(7)(E) B. C. B. Emergencval!Uatlonaand proced1.D98 Toa ltationBI)' guardmadlcalofficer&haa maintainccntactwith the faa'l!tysupervisor during an emergencysituation.Once the stationaryguard medical officerhas departed the facility,1:ransportallon shall not be lntenuptad unl8ss one ¢ the fo~owing circumstances OCQ.11S; • A A publlt:medical emergancyoa:ura whlcl! would requ!rathe vehicleto be stepped or red'IJ'lldedto a mareapproptlatahealth care facility. A senior medical attendant shall decidewhen1Dstep or redirect.. B. A dlshui:,anceerupts which requires the stationary guard medical cfficer lD give verbal commands kl c:eue the disturbancelmtnedlatety. Dependingon the aeriou!.NIS6of Iha disturbanceIt may be necessary ttl divert 1Dthe nearest MT'C faclll1yor requestassistance from a law enforcementagency C. In the avant of a mechanicalbrealakM1'1 on the ~. the sea.irity af the detainees in ----------------11mn~rusinlhllll1181'i1rba1ir1:tmiurtt,r.ff,e,;ilalil:mairY"o-uarn-rned'rcat-officentran---1alla the fonowingsteps: • • • • • • Immediately contacttheir supervtsorand the nearestMTCfaclllty via radio or 0811 phone Contact local lawenfurcooient for assistance . The Btationary guard medical officer shall make an effort1DIdentifythe problemwith the vehicle If p01&1"ble, the vehide sha&be movedolfthe roadway and placedIn a pos]11on ttat shouldallowfor adeqUBte1111rvelDsnce Toe medlcalvehicle6tlall be plaoecl In the shade, if possible,dllrlng hot wea1her If fl ii. delelmlnedthe publictransfervehiclecannot be repaired on the scene and anolharvehlde is dispatdled to transfer the detainees, the followl119 steps shall be taken: o The cagee oo the medical vehlde shall only bs openedwhen adequatesecurity has arrived o The reOefwhlde shaObe parked as dose as possibleto the disabled vehlcle to :edlte the process o l(b)(7)(E) lmedlcalofficershaJIescort the detalneeifromvefi• u:,vehicleand o If available,lccallaw enfotalment shall be requested at the scene. Slaflonary Guam Medical OfficerPost Order Da1ed511/15Reviewed7-15-16 2020-ICLl-00006 4726 (b)(6); (b)(7)(C) D. In the event a MTC medicallransfer vehicle become&Involvedln an accident,the fc!lowlng steps shall be taken: • • • • The pubUcstationa1)' gua,d medltaf ofticershall immediately determine if there are anyinjuries to anyparties Involved Thu slatioflmy guard medicalofficer shafta>ntad the facility supervlsor as soon • possible and ob1alnfurther Instructions The lllationaryguard madlcalofficer shall cxmtad the nearestMTC fac:illty andfor local law enfDrcementagencyand advise them of the <uation If the medical transfer vahlae I&still operable, and there are Injuries,It maybe nec::essa,y to proceed tc the nearest MTC faclllty or melf!cal facllilJ • • • • E. . In the event the mecflcaltransfer vehicle Is dlsabled and there are injt.trles requiringtrvatmem, medicalstaff'may have to admlnl6tertreatment to detainees on the vehicle. Toe securttycage shall only be opened whan adequB1a seanity has arrived. In the event there are no raporlBd Injuries,all occupants on Ihamedical transfarvahlcle shall be offered a medlcalexam at the n98l'8St MTC facility. A stationaryguard medlad officer shall ccmplste the necessary workels a,mpensation fonna. Doc:wnantatlonshall be completedfor all occupants on the medical transfer vehlcle·and.emedical reportshall be requested from the medical depal1menlbldicatingwhich Individualswerechecked, traatad, ar refused treaimant Inthe event It becomesnecessaryto evaaJate the vehicle dueto a fira,or other al:mllBrincident,the statlona,yguard madlcal officer shall posltlan themselvesin a manner allowingfull view of the veh!cle and the areato whlch detaineeswere mamlned. stationaryguard m&dlcalofficer shaR 1115trud detaineesto exit the medlcallransfar vehicle, proceed to a designates area and assumea sitling positionuntil aaalstancearrivea. Thestattonary;uard medical0ffit:ershaDoblalnthe foDowlnglnfOffllatlonwhen a medlcal transferwhlcle is InvolvedIn an accident • Data and time of accident • Loc:alicn • Make, modal and VIN # of transfer vehlcle • Oesatpllon of other vehlcte,make, model, color, license nwnber,VIN # • Name,address and telephone number of other driver • Othercl1vel's lnsunw:e lnforme:fion • Copy of Investigatingofficer's llilport • Name and contactphone numberofln\/8Stlgalingofficer and department repreaented. 9. Security procedures A. Armedstationaryguard medlcalofficers shall maintaina safe distance, approximately25 feet from aOdetainees.The use of elevators IB 1heonly exception. WhOeIn an elevator, the anned statlonaiy guard medicalofficer shall be positioned so the weapon Is not aocesslbleto the detainee. If the use of an elevator Is necessary,the stationaryguard medical officershall • Search the elevatorprlor to use • Request lndMdualsof the general publicto take an altemata elevatorto minimizethe changefor a hoslagesituationand • Request hospital security escort If posslbl9. a (b)(6); (b)(7)(C) ~!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!~~~~~~~~~!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!-! stationary Guard MedlculQfficerPost'Onfer Dated 5/t/15 Ravlswed7-15-18 Initial 2020-ICLl-00006 4727 a. Responslbilili8$ at a PublicMedicalFacility a detainee Is admittedto a publ\c:medical facilityfor an extendedperiod af time, the &tatlonaryguard medicalofficer shall • Ensure the detaineeremainswithin rangeerr sight and 80t.lndof the When • • • • stalicnaJy guard medical officer If armed,neverenter a roomwhere a detainee is present Restrictthe detainee to the assigned n:iomunlessmedicalstaffdeemsIt necessaryto movethe detaineeto a spaclaltyarea Maintaina dallylo; of activitiesto inch.IdeYisltsby physicians,nurses, roomatterutams,and any other re!evant 'Information and In an eventthe detaineehas SU'lJl!IY,the stetionBI')'euard mstlical afficer shaTIremain'Withthe detaineeduting the procedUre or watt outside1he surgeryroom,unlessthe public med'icalfacility policy requiresotherwise. A securitysuparvlsorshaDbe nc11fied if the stationaryguard medical officer ls not anawedto remalnwiththe dBlalneeduringany procedure. 10. Under no circumstance shan the stationaryguard medical officer leave a detainee UDQeCUred tnany an,a at any ttme during a medical transport, The stationary guard medical Dfficer ~hallbe prpperty rullpyed ortorto leavingthe duty pos:l 11. Toe stationaryguard medicalofficer shaOmaintainpossessionaf MTC issuedpn,perty. 12. MTC Issuedfirearms A. In the event the armeds1atlonaryguard medicalofficerIs issued morethan one ftreann,the stathmary guard medlcal tJffitershall coordinatewith hospital seamty s1affand seaJJ'& the extra ft.rearm In the transfervehicle. B. If It becomesnec:easaryfor the stationarygullldmed"n::a1 officer to .l8leaae a MTC III lu a la..,euforcementoffic:eilhe stationmy-gtmrdmec:Bc:al officer shall lmmed"cately, or as soonas possible,contactthe securitysupervisorto make arrangementsto have the MTC lsauedfireannsecuredwith an appropriate ------------~-------,lssuecHireaJ MTCsupervisor. 13. 14. Use of ccmmunicationequipment A. AHtransfervehlciesare equippedwith radiosor a cell phone fer communication purposes. • The stationaryguard medicalofficer shall not make or permit unauthorized transmissionor unnecessary chatter overthe radio • Radio or calt phone communicationshall be In English using mmmon tannlnology • Underno ciraJmatancesshall the radioor ceUphone be usedto wam other d~ of law enfcn:ement personnelwho maybe enforcingtraffic laws B. stationaryguardmedk:alofficersshall keepin contacthourty along their route advisingthe facll1tyof their estimatedtime of lllTival C. Pn:>fessionaf C01Jrtesy shall bs used while on Iha radio D. Issued cell phonesare for official use 0/lly. other duties and responslb!lllles A The stationaryguard medicalofficer &haDImmediatelynotify a securllysupervisor -------------------~·-R,ff!Qblems.aRISG----------------------B. The stationaryguardmedicalofficer shall performany other duties assigned by a supervisor. Sla1lonaryGuard MedlcalOfficer Post Order DalBd 511/15Revlewad 7-16-1B b)(6); (b)(7)(C) Initial 2020-ICLl-00006 4728 l(b)(6); (b)(7)(C) From: Sent : To : 19 Sen 201710·23·01 -0400 f .... ___,l b-)(6 _ )_ ; (b - )-(7-)(C _ )________________ Cc: RE: Transportation request - Funeral Remains Subject: (b)(6); (b)(7)(C) Good morning. When I reached out to ICEAIR,it was merely an inquiry, nothing solid, only researching options, not a request . After further research, it may be better to go commercia l as the funeral home coordinates and obtains all needed certificates as well as facilitatin the transfer of the individual to the family, basically a funeral home to funeral home transfer. AFOD (b)(5 ); (b)(?)(C) 1sthe Main POChere and is working with the Mexican Consulate locally in reaching out tot e ami y to coordinate. There is nothing confirmed yet. We will work closely with Miami, specifically AOIC)~;)~(rr., r coordination {POCto POC). I hope this helps, sorry for the confusion. (b)(6); (b)(7)(C) From: l, Subject : Detainee Death Review - Huy Chi TRAN Good afternoon, The ICE Office of Professional Responsibility, External Reviews and Analysis Unit, has completed the Detainee Death Review for Huy-Chi TRAN. TRAN, who was in U.S. ICEcustody at the Eloy Detention Center in Eloy, Arizona (AZ), was pronounced dead on June 12, 2018, at Banner Casa Grande Medica l Center in Casa Grande, AZ. TRAN's cause of death was sudden cardiac death due to coronary artery disease. The memorandum announcing completion of the review, the final report, and the exhibits can be found HERE. 2020-ICLl-00006 4736 If you have any questions or wish to further discuss t he findings, please contact me. rb )(6); (b)(7)(C) (Acting) Unit Chief External Reviews and Analysis Unit Office of Professional Responsibility Immigration and Customs Enforcement roJ202-732 J;_lrcJ202-42 \~/\~/;,,_, 2020-ICLl-00006 4737 (b)(6); (b)(?)(C) From: Sent : To: Subject: 8 Jul 2019 11:58:50 +0000 !(b)(6): (b)(?)(C) ~~--~---~ (b)(6); (b)(?)(C) l~-----~MD ! RE: Detainee Death Review - Huy Chi TRAN lease remove the following names from your distribution list: I ,CCHP Deputy Assistant Director Clinical Services IHSCMedical Director 500 12 th Street, SW Washington, DC 20536 Desk: 202 -73 b)(6); Cell: 202-515 b)(?)(C) (b)(5); (b)(?)(C) dhs. ov IHSC: One Team , One Mission ... Leading the Way in Immigration Health Care. ____ kb)(6); (b)(7)(C) ,...._ ___, From:1 Sent : Fridav Julv 5 2019 4:09 PM (b)(6); (b)(?)(C) Subject: Detainee Death Review - Huy Chi TRAN 2020-ICLl-00006 4738 Good afternoon, The ICE Office of Professional Responsibility, External Reviews and Analysis Unit, has completed the Detainee Death Review for Huy-Chi TRAN. TRAN, who was in U.S. ICEcustody at the Eloy Detention Center in Eloy, Arizona (AZ), was pronounced dead on June 12, 2018, at Banner Casa Grande Medical Center in Casa Grande, AZ. TRAN's cause of death was sudden card iac death due to coronary artery disease. The memorandum announcing completion of the review, the final report, and the exhibits can be found HERE. If you have any questions or wish to further discuss the findings, please contact me. i 2020-ICLl-00006 4739 From: Sent : To : Subject: un :04:40 +0000 I l(b)(6); (b)(7)(C) RE: Eloy DDR Travel Estimates Hi there, Cost is $1851.60 Doc number is DOC510143 r b)(6); (b)(7)(C) Management & Program Analyst ICE/OPR/ERAU (b)(6); 950 L'Enfant Plaza SW; (b)(7)(C) Washin gton DC 20536 202-732_ (b)(5) (desk) 202 -253 - (b)(?) (cell) l(b)(6); (b)(7)(C) From~..... ______ _. ;:fc~\~~1;6: :::JS;:182:•e°' Su Jee : t oy rave sl:1maes (b)(6); (b)(7)(C) Can you all please send me your travel estimates for the Eloy DOR trip, including the DOC number? Also , please ensure you are using the ERAU UP code . (b)(6); (b)(7)(C) let me know if you need any help with yours. Thanks! l(b)(6); (b)(7)(C) Section Chief External Reviews and Analysis Unit Office of Professional Responsibility Immigration and Customs Enforcement Desk: 202 - 73 t b)(6); ~- [ell: 202 -423 /~\/ ~\(C) 2020-ICLl-00006 4740 l(b)(6); (b)(7)(C) From : Sen t: To : Cc: Sub ject: Thank 14 Jun 2019 13:41:18 +0000 l(b)(6); (b)(7)(C) RE: TRAN DOR (b)(6); (b)(7)(C) Have a good weekend! Sent with BlackBeITy Wo rk (www.blackberry.com) F r orrfb)(6); (b)(7)(C) Date: Friday, Jun 14, 2019, 9:19 AM Subject : TRAN DDR Good morning all, ow has the TRAN DORfor review . I sent it to her electronically. can you please log it on the spreadsheet please. Have a great weekend everyone! fb )(6); {b )(7)(C) I 2020-ICLl-00006 4741 l(b)(6); (b)(?)(C) From: Sent : To : 3 Aue 2018 18·26·23 +oooo Cc: Subject: Correction: Huy Chi TRAN DOR- Preliminary Findings Please see correction below - the detainee received his medications on May 30, 2018, not May 20, 2018. Apologies for any confusion. Thanks (b)(6); (b)(?)(C) Subject: Huy Chi TRAN DOR- Preliminary Findings Good afternoon, On July 17-19, 2018, ERAUconduct ed an onsite review for the death of detainee Huy Chi TRAN who was detained at the Eloy detention facility in Eloy, AZ, and who died at the Banner Casa Grande Medical Center in Casa Grande, AZ, on June 12, 2018 . During the review, ERAUidentified the following significant preliminary findings, which were briefed to EROand facility personnel. The final report will include a comprehensive discussion of all findings . • Although a provider ordered the medications Haldol and Fluoxetine for TRAN on May 28, 2018, his Medication Administration Record (MAR) indicates he did not receive his first doses ofthese medications unti l May 30, 2018 . Additionally, on June 5, 2018, the date of TRAN's medical emergency, medical staff erroneously administered Fluoxetine t o him twice. See, ICE PBNDS 2011, revised 2016, Medical Care, Section (U} (4), which states, "All prescribed medications and medically necessary treatments shall be provided to the detainees on schedule and without interruption, absent exigent circumstances." • A security officer assigned to check on TRAN every 15 minutes while he was detained in the Special Management Unit (SMU) on Mental Health Observation (MHO), did not check TRAN for approximately 24 minutes on June 5, 2018. During this extended period without a security check, TRAN experienced a medical emergency which resulted in his t ransport to the hospital where he died seven days later . Further, the officer in question falsely logged a security check at the appropriate 15 mi nute interval. See, ICE PBNDS2011, revised 2016, Special Management Units, Section (VJ (M), Close Supervision, which states, "Detainees in SMU shall be personally observed and logged at least every 30 minutes on an irregular schedule. For cases tha t warrant increased observation, the SMU personnel shall personally observe detainees accordingly." Please let me know if you have any questions or concerns . 2020-ICLl-00006 4742 Thank ou, b)(6); b}(7)(C) (b)(6); (b)(?)(C) it Chief ice o ro essional Responsibil ity External Reviews and Analy sis Unit Offic e - (202) 732- (b}(6}; Mobile - (202) 90 (b)(?)(C) 2020-ICLl-00006 4743 From: f b)(6); (b)(7)(C) Sent : 19 Jun 2019 20:06 :54 +0000 To : Subject: Attachments : Latest edits; thanks, l(b)(6); (b)(7)(C ) I Cover memo TRAN Draft AD Memo (OPR)_(DAD review and comments).doc b)(6); b)(7)(C) ssociate Director ICE Office o 'Pro essional Responsibility (202) 732- (b)(6); 2020-ICLl-00006 4744 Office of Professio11a/Re sponsibility U.S. Dcpnrtrnc11t of Hom eland Security 950 L • Enfant Plaza SW Washington. DC 20536 U.S. Immigration and Customs Enforcement b)(5) ; (b)(7)( E) MEMORANDUM FOR: Nathalie Asher Executive Associate Director Offic e of Enforcement and Remova l Operations THROUGH: l(b)(6); (b)(7)(C) Associate D1rector FROM: SUBJECT: Investigativ e Findings for the Death of ICE detainee Huy Chi TRAN (A#037949945) (JlCMS - ,, '' ,, ,, ,,'' " "" :: The U.S. Imm igration and Customs Enforcement (ICE) Office of Professional Responsibility (OPR), External Reviews and Analysis Unit (ERAU), has completed its investigation into the death ofICE detainee Huy Chi TRAN. _TRAN died on June 12, 2018, while in ICE custody at the Banner Casa Grande Medica l Center (BCGMC), in Casa Grande , Arizona (AZ). _The Pinal County Medical Examiner documented TRAN's cause of death as sudden cardiac death I due to coronary artery disease. 2 On June 25 , 1984, the former U.S. Immigration and Natura lization Services (INS) ~~)1sttted IR AN iota rbe I !oiled States io Sao Fraocisco California as ao immicrtaot £i " :: i 1 Sudden cardiac death is a sudden, unexpected death caused by loss of heart function. Coronary artery disease occurs when plaque grows within the walls of the coronary arties until the blood flow to the hea,t ' s musc le is limited. >ERA U was unab le to dete rmine the disposi tion for approximate ly 17 ofTRAN's arresl~ and/or offenses. 2020-ICLl-00006 4745 . f "_j July 2017, TRAN was arrested and/or convicted of various criminal offenses. 3 An immigration judge ordered TRAN removed to Vietnam three times before the ICE Office of Enforcement and Remova l Operations (ERO) Phoenix determined there was no significant likelihood of removal in the reasonably foreseeable future; therefore, ERO released him on an order of supervision (OSUP) on January l 0, 2005. On July 17, 2017 a 287(g) officer lodged a detain er against TRAN while he was in Arizona Department of Corrections (ADOC) custody. On May 25, 2018, ADOC released TRAN into ERO Phoenix custody. On the same date , ERO Phoenix booked TRAN into the Tucson INS Hold Room in Tucson, AZ and then later that day, the Florence Staging Facility (FSF) in Florence, AZ. On May 28, 2018, ERO Phoenix transferred TRAN from FSF to the Eloy Detention Center (EDC) in Eloy, AZ, to pursue his removal to Viemam. 2 "" :: "" :: " :: "" :: (b)(5); (b)(7)(E) On May 25 , 2018, upon admission to FSF, a Licensed Vocational Nurse (LVN) conducted a 111edical pre-screen and docum ented TRAN arrived with the medications haloperidol and fluoxetine, F~ b_)(_5)_________________ the LVN determined TRAN had a se nsitive medical condition needi ng imm ed iate medical care in accordance w ith IHSC policy. 4 On May 26, 2018, a Registered Nurse (RN) perfor med TRAN's medical and mental health intake sc ree nin g, during wh ich TRAN acknowledged receiving treatm ent for dep ress ion for the past 20 years . He also denied current suicidal ideations , homicidal thoughts , and hallucinations. Based on the , / ~ 1,___ _// (b)(5) '-rr-r.....-,.,.... ,, ,'' ' _,___ '' _ -:::-=-="""'""" .,..,-,c-:::--:::-::-:r-::icc-::~ :c::-::-r=:r-rr:-=- -r-T,.......'1<'T""c:r::-::-:-::-T con ucte -nT"T ..-r,--=-::=:-:=-r:::-,--,:-,::-::,-ri=-r:c,~ s men a ea o ow -up an ocume n e t mt eme •::::: current hallucinations but had hallucinate d in the past. The LCSW documented TRAN's appearance as bizarre , poorly groome d, affec t flat ,6 and that he exh ibited letharg ic psychomotor activ ity.7 Th e LCSW diag nosed TRAN with schizop hren ia, 8 unspecified, and noted TRAN would continue his medica tions as prescribed. On May 28, 20 18, FSF transferre d TRAN to EDC. Upon arrival to EDC, an ERO Deportation Officer (DO ) assigned to ED C intake that day, noted that TRA N arrived soaking wet and sweat ing profusely. The DO alerte d a Supervisory Detention and Deportation Officer (SDDO ) who confirmed that the air conditioning was working proper ly. The SDDO acco mp an ied TRAN to the front of the medica l pre-sc ree n line, and the RN immediate ly conducted TRAN 's medical pre-screen. The RN did not note profuse swea ting as described by ERO staff in either pre-screen or intake screening . The RN recorded TRAN's intake assessment as abnomrn l du e to his mental hea lth issues and referred him to a mental health provider. Later that day, the same RN con ducted TRAN 's abbreviated intake med ical screen ing. A Case Manager (CM) co mpleted TRAN's initial custo dy classification and appropriately classifi ed him as high; howeve r, the CM signed for both the classification officer and supervisor and did not seek supervisory approval. "" " !! " . :. : :. ii" " I I ! ! i ,, I On this same date , a Nurse Practitione r (NP) performed TRAN's physical examination 9 I 4 See THSC Policy 03-08, Section 4-3(a), dated January 19, 20 15. AIMS assess the occu rrence of tardive dyskinesia (TD), a side effect of taking antipsychotic medication. Initial AIMS results may serve as a baseline for future monitoring or may prompt ordering of medication to address symptoms of the disorder. A score of zero indicates no occurrence of TD observed . The refore, due to TRAN being on antipsychotic drugs, the RN conducted the AIMS assessment . 6 Flat affect is a lack of emot ional expressiveness. 7 Psychomotor activity are ski lls where movement and thinking are combined . This includes balance and coordination . 8 Schizophrenia is a serious menta l disorder in wh ich a person interprets reality abnormally, to include hallucinations, delusions, and extremely disordered thinking and behavior . 9 This exam is the initial health assessment of patients with chron ic conditions , conducted by a provider. 5 The 2 2020-ICLl-00006 4746 (b)(5) ; (b)(7)(E) On May 30, 2018, medica l staff administered TRAN his first doses of haloperidol and tluoxetine, two days after he reported taking his last dose. On June 4, 2018, a psychiatrist assessed TRAN , diagnosing him with schizoph renia and an anxiety disorder. The psychiatrist continued TRAN on the same medication but ,, ,, ,' , ,' ' '............. haloperidol and tluoxetine for the first time since arriving to EDC . eQ uring the EDC special needs meeting a Unit Manager followed-up on a menta l health referral for TRAN she submitted to medical the previous day. At 12:31 p.m. , a psychologist assessed TRAN and noted he was extremely slow moving , lethargic, exhibited rigid movements with occasional hand tremors, and was sweating on his forehead. The psychologist placed TRAN on menta l health observation (MHO) from June 5 to June 7, 2018, with nursing checks twice daily and security welfare checks every r~~~~- l(b_\S_(s_) _j_n_11_te_s_ A_o_ R_N_ si_a_o_e_d _o_ff_ o_o _I_R_ A_l:,_T'_s_ro_ e_d_i_c_a)_ c_l_e_at_a_o_c_e_£_o _c _l\_4 H ... _ O_·_b_o_u_,e_,_,e_c_ b_ et__ The officer assigned to observe TRAN while in MHO documented that he checked the detainee at 3:09 p.m., 3:23 p.m., 3:38 p.m., 3:52 p.m., and 4:06 p.m. Video surveillance , i )(S) ... l_l emerge ncy. At 4: 16 p.m., additiona l officers responded and started cardiopulmonary resuscitation (CPR). Medica l staff arrived two minutes later and assisted with rescue breaths, applied ~(b)(5) 11 Extrap yramida l symptoms are drug-induced movement disorders which include acute and tardive symptoms. 12 Cogentin is the brand name for benztropine, a dmg used to treat symptoms of Parkinson's disease and the side effects of other drugs. 3 2020-ICLl-00006 4747 / ,/:, automated external defibrillator (AED) pads and perfonned other lifesaving efforts. It was later determined that medical staff applied the AED pads incorrectly, as they were only partially adhered. Officers performed CPR for 17 minut es until Emergency Medical Services (EMS) arrived at 4:33 p.m. and took over life-saving efforts. At 4:53 p.m., EMS transported TRAN to BCGMC and at 5:15 p.m., BCGMC initiated patient care. Over the next seven days, doctors performed a series of tests to determine brain function and TRAN's capacity to breathe on his own. On June 12, 2018, BCGMC medical staff confirmed TRAN could not breathe on his own and pronounced brain death at 9:20 a.m. and cardiac death at 2:20 p.m. On July 17, 2018, the Chief Medical Examiner of Pinal County signed the Forensic Examination Report and documented the cause of death as coronary artery disease. ERAU reviewed the medical care EDC provided TRAN, as well as the facility's efforts to ensure that he was safe and secure while detained at the facility. ERAU found EDC failed to comply with the following requirements of the ICE Performance Based National Detention Standards (PBNDS) 2011 (as revised in 2016) : 1. ICE PBNDS 201 1, Medical Care, Section (Il)(20), which states, "Prescriptions and medications shall be ordered, dispensed and administered in a timely manner and as prescribed by a licensed health care professional. This shall be cond ucted in a manner that seeks to preserve the privacy and personal health information of detainees ." Although the NP prescribed fluoxetine and haloperidol at intake , TRAN did not receive his first dose for two days. 2. ICE PBNDS 2011 , Medical Care, Section (V)(AA)(4) , which states, "Prior to the administration of psychotropic medications, a separate documented informed consent , that includes a description of the medication's side effects shall be obtained." FSF and EDC medical staff did not obtain a signed consent form from TRAN for psychotropic medication starting on May 26 and May 28, 2018. When TRAN finally signed a consent form on June 4, 2018, side effects were not listed. 3. ICE PBNDS 2011 , Custody Classification Syste m, Section (V)(A)( 4), which states, "Each detainee's classification shall be reviewed and approved by a first-line supervisor or classification supervisor." A supervisor did not approve the classification rating assigned to TRAN on May 28, 2018. 4. ICE PBNDS 2011 , Special Management Units, sect ion (V)(M), which states, "Close Supervision Detainees in SMU shall be personally observed and logged at least every 30 minutes on an irregular schedule. For cases that warrant increased observation, the SMU personnel shall personally observe detainees accordingly ." Per the psycho logist's order, and following placement in MHO , CoreCivic officers were to conduct welfare checks on TRAN every 15 minutes. Surveillance footage evidence showed the CoreCivic officer on duty issued TRAN linens at 3:00 p.m. but did not look into TRAN's cell again until 3:51 p .m. _During the 51-minute period , 4 2020-ICLl-00006 4748 b)(5) b)(5) survei llance .ll 5. ICE PBNDS 2011, Special Management Units, Section (V)(P), which states, "Detainees must be evaluated by a medical professio na l prior to placement in an SMU ( or when that is infeasible, as soon as possible and no later than within 24 hours of placeme nt). The assess ment shou ld include a review of whether the detainee has been previously diagnos ed as having a mental illness." The RN assig ned to eval uate TRAN for placement in SMU did not conduct a face-to-face assessment. ERAU also noted severa l areas of concern, which are detai led in the attached report. If you have any questions lease contact me or have a member of your staff contact ERA U Acting Unit Chi e b)(6); (b)(?)(C) at (202) 7f~/\~/;c, I Attachment cc : Matthew A lbence ( (b)(6); (b)(7)(C) 13 This rrae Jo hnson 1- -------------~ "" "" " ::" : ! _____________________________________________________ _/! officer resigned prior to ERAU's completion of this review (i.e. the week of July 17, 2018). 5 2020-ICLl-00006 4749 l(b)(6); (b)(?)(C) From: Sent : To : 14 Jun 2018 15:06:06 +0000 r b)(6); (b)(?)(C) Cc: Subject: 1 Eloy death (b)(6); (b)(?)(C) I know we 1 re all still waiting on some details, but I wanted to let you know we're tentatively planning to conduct our onsite for this week 1 s death at Eloy the week of July 16. b)(6); b)(?)(C) 2020-ICLl-00006 4750 rb)(6); (b)(7)(C) From : Sent : 13 Jul 2018 13:52:23 +0000 To : l(b)(6); (b)(7)(C) Subject: Attachments : I FW: TRAN Preliminary Time line Huy Chi TRAN DOR Preliminary Timeline _ MT.docx l(b)(6); (b)(7)(C) Management & Program Analyst ICE/OPR/ERAU 950 L'Enfant Plaza s~ (b)(6); (b)(7)(C) Washin C 20536 202-73 202-25 (desk) (cell) I b)(6); (b)(7)(C) From : , 2018 10:07 PM Sent : Tf b)(6); SubJect: I RAN Preliminary I 1meline (b)(6); Hello / h \ /7 1/rl b)(7)(E); (b)(5) Regards, l(b)(6); (b)(7)(C) Inspections and Compliance Specialist ICE IQPR IERAU 950 L'Enfant Plaza SW Washington, DC 20536 {202) 732 (b)(6); desk) (202) 43 cell) ~;<7>< 2020-ICLl-00006 4751 Eloy Detention Center 1705 E Hanna Rd Eloy, AZ 85131 Onsite: July 17 - 19, 2018 Huy Chi TRAN DDR Preliminary Timeline JICMS #:l(b)(6); (b)(?)(C); I Facility Information • TRAN arrived at the Eloy Detention Center (EDC)on 05/25/2018 Facility owner: CoreCivic • Name of Security Company: CoreCivic • • • • • • • Name of healthcare compa~y· ICEHealthServiceCorr (IHSC) Facility Medica l Coordinato( )(B); (b)(?)(C) _ Applicable standards: PBND-= 5~2~0~1 ~1 ------~ Facility Type : DIGSA Classifications: High, Medium, Low Total number of detainees on day of death o Males: 889 o Females: 470 o Total: 1359 Detainee Information Huy Chi TRAN (A#: 037949945) • Citizenship: Vietnam • • • • • Date of birth: 08/07/1970 Age at death: 47 Deceased date : 06/12/2018 Place of death: Banner Casa Grande Medica l Center Autopsy date: 06/14/2017 Background/Criminal History On June 25, 1984 , the former U.S. Immigration and Natural izat ion Service (INS) admitted TRAN into the United States at San Francisco, CA, as a P-53 immigrant, child of alien classified as P-51 / P-56, brother or sister of U.S. citizen . On October 25, 2000, the Superior Court of Arizona, County of Mar icopa , convicted TRAN of two counts of aggravated assault, and sentenced him to three and a half years of incarceration and three years of probation with credit for 210 days of t ime served . On November 9, 2000 , ERO Phoenix encountered TRAN at the Arizona Department of Corrections (ADOC), Alhambra Reception Center (ARC) in Phoenix, AZ, and lodged an Immigration Detainer- Not ice of Action, Form 1-247, with the facility . On March 29, 2003, the ADOC transferred TRAN to ERO Phoenix custody. On the same date, ERO Phoenix served TRAN a Notice to Appear, Form 1-862,charging removability pursuant to Section 237(a)(2)(A)(iii) of the Immigration and Nationality Act (INA), as amended, as an alien at any time after admission, convicted of an aggravated felony as defined in Section 101(a)(43)(F) of the INA, a crime of violence for which the term of imp risonment ordered is at least one year. 2020-ICLl-00006 4752 Eloy Detention Center 1705 E Hanna Rd Eloy, AZ 85131 Onsite: July 17 - 19, 2018 On M ay 15, 200 3, an immigration judge (IJ) found all TRAN's applications for relief to be abandoned and ordered him removed to Vietnam. On June 16, 2003 , TRAN filed an appeal with the Board of Immigration Appeals (BIA). On October 31, 2003, the BIA remanded the case to the IJ for further proceedings. On Decembe r 10, 2003 , the IJ found all TRAN's applications for relief to be abandoned and again ordered him removed to Vietnam. TRAN reserved his right to appeal. On January 8, 2004, TRAN filed an appeal with the BIA. On June 14, 2004 , the BIA sustained TRAN's appeal and remanded the case back t o the IJ for a decision . On September 21, 2004 , the IJ denied all TRAN's applications for relief and ordered him removed to Vietnam. TRAN waived his right to appeal. On January 10, 2005 , EROPhoenix determined that no significant like lihood of removal in the reasonably foreseeable future existed and released TRAN from custody on an Order of Supervision (OSUP). TRAN reported as required four times between January 27, 2005, to Apri l 20, 2005. On July 8, 2005 , EROPhoenix sent TRAN a call-in letter, Form G-56 ordering him to present himself at their office on July 28, 2005 . On July 28, 2005 , TRAN fai led to appear at EROPhoenix as ordered. TRAN's case was then referred to the Fugitive Operations Team for location and arrest with no result. On February 2, 2006 , the Chandler, AZ Police Department (CPD) arrested TRAN for disorderly conduct and crimina l damage. CPD released TRAN while his charges were pending, EROPhoenix did not encounter TRAN after his release. TRAN failed to appear for court, and the court issued a bench warrant for his arrest. On August 15, 2006 , CPD arrested TRAN for shoplifting. On the same date, CPDcited TRAN and released him to EROPhoenix custody. On August 18, 2006 , EROPhoenix released TRAN under his original OSUP issued on January 10, 2005, to complete his criminal proceedings. There is no record of TRAN reporting to EROPhoenix after this date. On April 8, 2009 , the Superior Court of Arizona, County of Maricopa, convicted TRAN for the offense of aggravated assault, a domestic violence offense, and sentenced him to five years of incarcerat ion with credit for 224 days of time served. On April 13, 2009 , EROPhoenix encountered TRAN at the ARC and lodged a Notice of ActionImmigration Detainer , Form l-247A. 2020-ICLl-00006 4753 Eloy Detent ion Center 1705 E Hanna Rd Eloy, AZ 85131 (b)(5); (b)(7)(E) Onsite: July 17 - 19, 2018 On August 14, 2013, ADOC transferred TRAN to ERO Phoenix custody. EROPhoenix released TRAN from custody under his origina l OSUP issued on January 10, 2005 because there was stil l no significant likelihood of removal. TRAN did not appear at ERO Phoenix for his first scheduled appointment on February 12, 2014 . On January 21, 2017 , CPD arrested TRAN for disorderly conduct and domestic vio lence. On t he same date , ERO Phoenix encountered TRAN at the Maricopa Sheriff's Office (MCSO) Jail and lodged a Notice of Act ion-Imm igration Detainer, Form l-247A. TRAN remained in MCSO custody pending his crim inal proceedings. On July 10, 2017 , the Superior Court of Ar izona, Maricopa County, convicted TRAN for the offense of disorde rly conduct, a domestic violence offense, and sentenced TRAN to one and a half years of incarcerat ion with credit for 117 days of time served. On July 12, 2017, a 287(g) Designated Immigrat ion Officer encountered TRAN at the ARC, and lodged a Not ice of Act ion - Immigration Detainer, Form l-247A. On May 25, 2018, ADOC released TRAN to EROPhoenix custody. EROPhoenix served TRAN a Notice of Revocation of Release w ith the int ention of reviewing TRAN's lik elihood of removal. TRAN was booked iota t bo I I ICSOM III IS Hald Paarn aod htor an the same date EROPhoen ix transferred him to t he , ·--------------~ '''' '' '' '' '' ''' ''' '' '' '' I' '' '' '' '' ,'' '' ,'' ''' '' I' ' ' ,'' '' ' ' '' '' :' 1' : / : On May 28, 2018 , ERO Phoenix transferred TRAN to the Eloy Detent ion Center (EDC) in Eloy, AZ, to pursue remov al to Vietnam. In Custody at Eloy Detention Center (EDC) On Ma 28 2018 TRAN entered EDC.At 7:37 am a prescreen exam was completed by Registered Nurse (b)(6); (b)(7)(C) . During this exam, TRAN affirmed he had a menta l illness and was current ly taking medications. As such, (b)(6); ged TRAN as PRl-1. /h\/7\ /C:\ ! At 9:54 AM Nurse Practit ioner (N*b )(6); (b)(7)(C) completed his intake screen ing. During th is exam, Tran reported a 17-year history of schizophrenia and an anxiety disorder. He also confirmed he was taking HaIdol, Smg, and Fluoxetine, 20 mg. He denied suicidal ideations or harming himse l1 b)(6); noted the abnorma l findings in b~r !i:Xamas both schizophrenia, unspecified, and anxiety disorder, unspecifiecKb)(6); (b)(7)(C)lalle~~~~c: ~o discuss prescribing med ication for two weeks until TRAN's psych evaluation could occur . As of result of this exam, TRAN was ref erred to a medical provide r. At 10:45 a.m., a physician (MD) reviewed t f b)(S) evaluation on June 4, 2018. ~-------------------~ On May 30, 2018, M r. TRAN received his first dose of haloperidol and fluoxet ine. [Investigator's note: The May EDCMAR did not show Mr. TRAN had received his medications on May 28 and 29, 2018.] 2020-ICLl-00006 4754 ,/ / : / / i : i i Eloy Detent ion Center 1705 E Hanna Rd Eloy, AZ 85131 (b)(5); (b)(7)(E) Onsite: July 17 - 19, 2018 On June 1, 2018, a follow -up on TRAN's mental health cond ition was conducted by Licensed Clinical Social Worker (LCSW*b)(6) ; (b)(7)(C) j. No notes were provided for this encounter so it is possible th is was simply a rem inde r for the provider? The APP received and reviewed Mr. TRAN's laboratory results, which for the most part came back normal. On June 4, 2018 , at 12:30 p.m (b)(B); (b)(?)(C) histo ry of schizophrenia and t li~e'"'m=e..,.,.., 1c"a"'1 ' ,o"'" ,..ns,,.....,. .,,...,,.,,. e ro="' u"'"' g~ RAN's psychological evaluation due to his with him from the AZ Department of Cor rections. Tran confi rmed expe riencing some depression. Tran stated he began hearing voices when he was 20 years old but only started taking medication two years ago. According to the provider, TRAN had prev iously to ld the nurs ing staff (not noted in the ECW) he had been taking medications for the past five years . TRAN denied currently hear ing voices or exper ienci ng ha llucinations; however, he confirmed he had experienced both in the past but that it had been at least a year. The prov ider started TRAN on Haloperido l (tablet) 5 mg fo r 30 days and Fluoxet ine (capsu le) 20 mg for 30 days. Follow -up was recommended in four weeks for a Cogentin (benztropine Mesylate) tr ial. TRAN was advised to return to sick call if his symptoms worsened pr ior to his next appointment. ." ; !: !u " :' :: ;n On June 5, 2018, at 10:32 a.m ., the MD sent a telephone encounter to the med ical records personne l to request a comp lete health reco rd from Corizon Health - ADOC Arizona State Prison Comp lex (ASPC) Tucson - Manzanita. ; ;; '" ::: iU ::: ::: ::: At 10:35 a.m., the MD sent a telephone encounter to the medical records personne l request ing Mr. TRAN's Southwest Network - San Tan Clinic, Chand ler, AZ, medica l records. At 12:3oJb )(B); (b)(?)(C) I a Docto r of Psychology (PsyD), saw TRAN for a mental healt h follow -up assessment. The provider noted the patient presented as depressed and apathetic, as we ll as extr eme ly slow mov ing, lethargic and exhibited hand tremors. The provider commented that, contrary to his init ial :: : ,, ' :: ,, '': ,, :: : :; ,, ': :: ': ,, :: : intake screening on f b)(5) Halluc inat ions (AVH).... , _T_R_A_N_ d_e_n-ie_d_ p-as_t_a_n_d_c_u_r-re_n_t_A_V_H_s_. -A-g-ai_n_, _ TR _A _N _ d_e_n-ie_d_t_h_o_u_g-ht_s_o""' f,... s_e_,, lf--h- a_r_ m_, ---.- ; plan, and intent. The provider placed TRAN on Medical Housing Observation (MHO ) w ith mental healt h l nursing checksl(b)(5) schedu led for two to th ree days. At 1:35 p.m. MST, P \~!\~! ;r, / / Follow -up with the menta l_hea lth provider was _____ / : ::'•/ signed a prior ity Special Needs Form for Tran to be moved to the 0000 0 Mental Health Unit for MHO. 0000 Senior Correctional Officer !(b)~~L . bcorted TRAN to B600 (cel l B606) for mental health observat ion checks every 15 m inutes and provided (b)(6); l h \n,,r with the detainee's med ical paperwork. / : *Note, ~RA~ received an extra dose of med ication that day "due to lack of clar ity in how the medication _/ change occurred." (confirm date is June 5) Emergency Event Tran was in Hold Room Gl149 from 0945 to 1155 (15 minute check log). The Confinement Record states he was placed into administ rative segregation at 1335 - was in D-103. Ended up in B-606. On June 5, 2018 , the first time logged in the Watch Log for observing TRAN was 1500 2020-ICLl-00006 4755 I .,..... i Eloy Detention Center 1705 E Hanna Rd Eloy, AZ 85131 Onsite: July 17 - 19, 2018 b)(6); {b)(?)(C) 18, at 16:15 (MST) a medical emergency was called in B-600 by Correctional Officer (CO) I According t~~~~m~C) he was taking a food tray to the detainee in 8-606 when he noticed he was not responding, he then entered TRAN's cell to see if he would respond an b)(5 ); sted to constant watch over cell B-605 told him he should call medica d~~1}~1b lsaid whil ~~~~~~r, was co_nducting feedings and wen t t o give TRAN his mean and noticed TRAN was not responding and t hen nte red the cell, called the detainee's name, an ~~~~~ old~ e needed to call a medical emerge~ hift Superviso ~lb)(5); (b)(?)(C) stated that while CPRwas being performed he aske ~~~~~~~r 1 at had occurred I and was told that he was asking TRAN if he was going to eat. As the detainee did not respond, looked in to his cel l and observed TRAN lying t here. Love to check on TRAN. hen recounted t ~~(~ ~(er, f~~~~~rJ that he then told lntered TRAN's ce ~~l~~~k~, Upon arrival, Assistant Shift Supervisor (A S/s!(b)(5); (b)(l )(C) noted the detainee was face down and unresponsive and "had snot coming out of his nose." AS TRAN was lying face dow[ rbe icbJIWEl 6 chest com ression ~b)( ); (b)(7)(C) bll ed TRAN onto his side then to his back and l~/~~1~ ~, lbegan ~ dministered brea;hs between com' ressions and CO sisted in erform ing chest compressions in alternating with b)(5), very 4 sets of chest compression (b)(5); (b)(?)(C) tatement says Correctional Counselor (b)(6); (b)(?)(C) as standing by to (b)(5), (b)(7)(C) assist with the chest compression rotation). Once medical arrived three minutes later at 16:18, CO fb)(6); (b)(7)(C) r as relieved from admin istering breaths, CO'sfb)(6); (b)(7)(C) tontinued performing chest compressions. l(b)(6); (b)(7)(C) [A S/~ to sto~ rewrding the emergency response to b)( ); 6 6 l(b){ ); (b)(?){C) lwas also direc t ed by ~~~~~lee) escort the ambulance to B-60 b)(7)(C) gate for the ambulance]. I As PA jted TRAN would continue his medications as prescribed. On May 28, 2018, FSF transferred TRAN to EDC. Upon arrival to EDC, an ERO Deportation Officer (DO) assigned to EDC Intake that day, noted that TRAN arrived soaking wet and sweating profusely. The DO alerted a Supervisory Detention and Deportation Officer (SDDO) who confirmed that the air conditioning was working properly. The SDDO accompanied TRAN to the front of the medical pre -screen line, and the RN immediately conducted TRAN's medical pre-screen. The RN did not note profuse sweating as described by ERO staff in either pre-screen or intake screening. The RN recorded TRAN' s intake assessment as abnormal due to his mental health issues and referred him to a mental health provider. Later that day, the same RN conducted TRAN's abbreviated intake medical screening. A Case Manager (CM) comp leted TRAN's initial custody classification and appropriately classified him as high; however , the CM signed for both the classification officer and supervisor and did not seek supervisory approval. On this same date, a Nurse Practitioner (NP) performed TRAN's physical examination 9 and documented on TRAN's reported mental health history and his lack of lower teeth and other upper teeth with no dental prothesis. The NP conducted an AIMS assessment 4 See IHSC Policy 03-08, Section 4-3(a), dated January 19, 2015. The AIMS assess the occurrence oftardive dyskinesia (TD), a side effect of taking antipsychotic medication. Initial AIMS results may serve as a baseline for future monitoring or may prompt ordering of medication to address symptoms of the disorder. A score of zero indicates no occurrence ofTD observed. Therefore , due to TRAN being on antipsychotic drugs, the RN conducted the AlMS assessment. 6 Flat affect is a lack of emotional expressiveness. 7 Psychomotor activity are skills where movement and thinking are combined. This includes balance and coordination. 8 Schizophrenia is a serious mental disorder in which a person interprets reality abnormally, to include hallucinations, delusions, and extremely disordered thinking and behavior. 9 This exam is the initial health assessment of patients with chronic conditions , conducted by a provider. 5 2 2020-ICLl-00006 4772 JICMS !(b)(6); (b)(7)(C); Detainee Death Review - Huy Chi TRAN and noted a score of zero. The NP continued TRAN on the same medication regimen until a mental health provider could assess him. On May 30, 2018, medical staff administered TRAN his first doses of haloperidol and fluoxetine, two days after he reported talcing his last dose. On June 4, 2018, a psychiatrist assessed TRAN, diagnosing him with schizophrenia and an anxiety disorder. The psychiatrist continued TRAN on the same medication but submitted an order to the pharmacy to change the administration times from morning to noon for fluoxetine and evening for haloperidol. The psychiatrist documented an AIMS score of three and that TRAN was exhibiting extrapyramidal symptoms (EPS), 10 which he noted Cogentin 11 could address. However, the psychiatrist did not write the Cogentin order, which he later stated was an oversight. Furthermore, on this date, TRAN signed a consent form for the haloperidol and fluoxetine for the first time since arriving to EDC . On June 5, 2018, TRAN received morning doses of fluoxetine and haloperidol. Although the psychiatrist submitted an order to change the time of TRAN's medication the day prior, the pharmacy received the change request after it had closed; therefore, the pharmacy did not process the new medication orders until they opened that morning, which was after morning pill call. At noon pill call, TRAN received a second dose of fluoxetine. During the EDC special needs meeting a Unit Manager followed-up on a mental health referral for TRAN she submitted to medical the previous day. At 12:31 p.m. , a psychologist assessed TRAN and noted he was extremely slow moving, lethargic , exhibited rigid movements with occasional hand tremors, and was sweating on his forehead. The psychologist placed TRAN on mental health observation (MHO) from June 5 to June 7, 2018, with nursing checks twice daily and security welfare checks every 1S minutes. An RN signed off on TRAN's medical clearance for MHO. At 2:49 p.m., an officer escorted TRAN to the Bravo 600 unit in MHO. At 3:00 p.m., the officer issued linens to TRAN in his cell. The officer assigned to observe TRAN while in MHO documented that he checked the detainee at 3:09 p.m., 3:23 p.m., 3:38 p.m., 3:52 p .m., and 4:06 p.m. Video surveillance, however, does not support the first three welfare checks documented. At 3:51 p.m., per video surveillance footage, the officer first observed TRAN as he looked into his cell. Then at 4:13 p.m. the officer noticed TRAN was unresponsive, and at 4:15 p.m., the officer called a medical emergency. At 4: 16 p.m., additional officers responded and started cardiopulmonary resuscitation (CPR). Medical staff arrived two minutes later and assisted with rescue breaths, applied automated external defibrillator (AED) pads and performed other lifesaving efforts. It 10 Extrapyramidal symptoms are drug-induced movement disorders which include acute and tardive symptoms. 11 Cogentin is the brand name for benztropine , a drug used to treat symptoms of Parkinson's disease and the side effects of other drugs. 3 2020-ICLl-00006 4773 JICMS(b)(6); (b)(7)(C) ; DetaineeDeath Review - Huy Cbi TRAN /h\/7\/ F \ was later determined that medical staff applied the AED pads incorrectly, as they were only partially adhered. Medical staff performed CPR for 17 minutes until Emergency Medical Services (EMS) arrived at 4:33 p.m. and took over life-saving efforts. At 4:53 p.m., EMS transported TRAN to BCGMC and at 5:15 p.m., BCGMC initiated patient care. Over the next seven days, doctors performed a series of tests to determine brain function and TRAN's capacity to breathe on his own. On June 12, 2018, BCGMC medical staff confirmed TRAN could not breathe on his own and pronounced brain death at 9:20 a.m. and cardiac death at 2:20 p.m. On July 17, 2018, the Chief Medical Exam iner of Pinal County signed the Forensic Examination Report and documented the cause of death as coronary artery disease. ERAU reviewed the medical care EDC provided TRAN, as well as the facility's efforts to ensure that he was safe and secure while detained at the facility. ERAU found EDC failed to comply with the following requirements of the ICE Performance Based National Detention Standards (PBNDS) 2011: I. ICE PBNDS 201 1, Medical Care, Section (II)(20), which states, "Prescriptions and medications shall be ordered, dispensed and administered in a timely manner and as prescribed by a licensed health care professional. This shall be conducted in a manner that seeks to preserve the privacy and personal health information of detainees." Although the EDC NP prescribed fluoxetine and haloperidol at intake on May 28, 2018, TRAN did not receive his first dose for two days, May 30, 2018. 2. ICE PBNDS 2011, Medical Care, Section (V)(AA)(4), which states, "Prior to the administration of psychotropic medications, a separate documented informed consent, that includes a description of the medication's side effects shall be obtained." FSF and EDC medical staff did not obtain a signed consent form from TRAN for psychotropic medication prior to administration on May 26 and May 30, 2018, respectively. When TRAN finally signed a consent form on June 4, 2018 at EDC, side effects were not listed. 3. ICE PBNDS 2011, Custody Classification System, Section (V)(A)(4), which states, "Each detainee's classificat ion shall be reviewed and approved by a first-line supervisor or classification supervisor." A supervisor did not approve the classification rating assigned to TRAN on May 28, 2018. 4. ICE PBNDS 2011, Special Management Units, section (V)(M), which states, "Close Supervision Detainees in SMU shall be personally observed and logged at least every 30 minutes on an irregular schedule. For cases that warrant increased observation, the SMU personnel shall personally observe detainees accordingly." Per the psychologist ' s order, and following placement in MHO, CoreCivic officers were to conduct welfare checks on TRAN every 15 minutes. Surveillance footage evidence showed the CoreCivic officer on duty issued TRAN linens at 3 :00 p.m. but 4 2020-ICLl-00006 4774 Detainee Death Review - Huy Chi TRAN JICMS(b)(6); (b)(7)(C); /h\/ 7 \/ ~ \ did not look into TRAN's cell again until 3:51 p.m. During the 5 1-minute period, the officer documented three welfare checks, none of which were supported by video surveillance. 12 ERAU also noted several areas of concern, which are detailed in the attached report. If you have any questions lease contact me or have a member of your staff contact ERAU Acting Unit Chie b)(5); (b)(?)(C) at (202) 73 (b)(5); / h \f 7 \/r'\ Attachment cc: Matthew Albence Tae Johnson (b)(6); (b)(7)(C) 12 This officer resigned prio r to ERAU's completion of this review (i.e. the week of July 17, 2018). 5 2020-ICLl-00006 4775 DETAINEE DEATH REVIEW - Huy Chi TRAN JICMS b)(6); (b)(?)(C) ; (b)(?)(E) SYNOPSIS On June 12, 2018, Huy Chi TRAN , a forty-seven-year-old citizen of Vietnam, died while in the custody of U.S. Immigration and Customs Enforcement (ICE) at Bann er Casa Grande Medical Center (BCGMC) in Casa Grande, Arizona (AZ). The Pin al County Medi cal Examiner document ed TRAN' s cause of death as sudden cardiac death 1 due to coronary artery disease. 2 TRAN was detain ed at Eloy Detention Center (EDC), 3 in Eloy, AZ, from May 28, 2018, until his death. EDC is owned and operated by CoreCivi c, formerly Correction s Corporation of America (CCA), under a Dedi cated Intergovernmental Service Agreement (DIGSA). EDC is required to comply with the ICE Perform ance Based National Detention Standards (PBNDS) 2011, as revised in 2016. Medical care at EDC is provided by the ICE Health Service Corps (IHSC), with support from InGenesis contractors. At the time of TRAN's death, EDC housed approximately 889 male and 470 female detainees for periods in excess of 72 hours. DETAILS OF REVIEW From July 17 to 19, 2018, ICE Office of Professional Responsibility (OPR), External Reviews and Analysis Unit (ERAU) staff visited EDC to review the circumstances surroundin g TRAN' s death. ERAU was assisted in its review by contract subject matter experts (SME s) in correctional healthcare and security who are employ ed by Creative Corrections, a national management and consulting fam. 4 As part of its review, ERAU reviewed immi gration, medical , and detention record s pert aining to TRAN , in addition to conducting in-person interviews of individuals employed by CoreCivic, IHSC , InGenesis, and the local field office of ICE 's Offic e of Enforcement and Removal Operations (ERO). During the review, ERAU took note of any deficiencies observed in the detention standards as they relate to the care and custody of the decea sed detainee and documented those deficiencies herein for information al purpo ses only. Their inclusion in this report should not be construed in any way as indicating the deficiencies contribut ed to the detainee's death. ERAU determined the following timelin e of even ts, from the time TRAN entered ICE custody, throu gh his detention at EDC, and eventual death at BCGMC. 1 Sudden cardiac death is a sudden, unexpected death caused by loss of heart function. See Exhibit I: Pinal County Forensic Examination Report, dated July 17, 2018; According to the America n Heart Association (AHA), coronary artery disease occurs when plaque grows within the walls of the coronary arteries um.ii the blood flow to the heart' s muscle is limited. 3 Eloy Detention Center (EDC) is also known as Eloy Federal Contract Facility (EFCF). 4 See Exhibit 2: Creative Corrections Healthcare and Security Compliance Analysis. 2 1 2020-ICLl-00006 4776 DETAINEE DEATH REVIEW - Huy Chi TRAN JICMSl (b)(6); (b)(?)(C); (b)(?)(E) I IMMIGRATION AND CRIMINAL HISTORY 5 On June 25, 1984, the former U.S. Immigration and Naturalization Service (INS) admitted TRAN into the United States in San Francisco, California, as an immigrant (i.e. child of an immigrant who is the brother or sister of a U.S. citizen). 6 Betwee n June 6, 1994 and October 25, 2000, the Superior Court of Arizona, Maricopa County , convicted TRAN for multiple climes, detailed in Table 1 of this report. On November 9, 2000, INS Phoenix encount ered TRAN at the Arizona Department of Corrections (AD OC), Arizona State Prison Complex (ASPC) Alhambra Reception Center (ARC) in Phoenix , AZ and lodged an Immi gration Detainer -Notice of Action (Form 1-247) with the facility. 7 On March 25, 2003, a 287(g) officer encountered TRAN at ARC and issued a Warrant for Arrest of Alien/Notice to Appear (Form 1-200).8 On March 29, 2003, the ADOC transferred TRAN to ERO Phoeni x's custody. On the same date, ERO Pho enix served TRAN a Notice to Appear (Form 1-862), charging remov ability pursuant to Section 237(a)(2)(A)(iii) of the Immigration and Nationality Act (INA) , as amended, as an alien at any time after admission , convicted of an aggravated felony as defined in Section 101(a)(43)(F) of the INA, a crime of violence for which the term of imprisonment ordered was at least one year. 9 On May 15, 2003, an immi gration jud ge (IJ) found aJI of TRAN' s application s for relief to be abandoned and ordered him removed to Vietnam. On the same date, TRAN 's undated Application for Asylum and for Withholdin g of Remov al (Form 1-589) was marked as received. 10 On June 16, 2003, TRAN filed an appeal with the Board of Immigration Appeals (BIA). 11 On Octob er 31, 2003, the BIA remanded the case to the U for furth er proceedin gs. 12 On December 10, 2003, the U found all TRAN ' s applications for relief to be abandoned and again ordered him removed to Vietnam. 13 TRAN reserved his right to appeal. 5 The listed char ges are those for which ERAU was ab le to determin e a dispos ition from TRAN 's records. ERAU was unable to determ ine a dispos ition for approximately 17 of TRAN' s other arrests and/or offenses, dating from Octo ber 1995 to April 2007. 6 See DHS Form 1-213, Record of Deportable/Inadmi ssible Alien, dated July 17, 2017. 7 See INS Form 1-247 , Im migration Deta iner- Notice of Action, dated Nov ember 9, 2000. 8 See INS Form 1-200, Warrant for Arrest of Alien, dated March 25, 2003. 9 See INS Form 1-862, Notice to Appear, dated March 29, 2003. 10 S ee United States Department of Justice (DOJ) Executive Office for Immi gra tion Review (EOIR ) Immi gration Court: Order of Th e Immigration Judge, dated May 15, 2003 ; see also INS Form 1-589 , Application for Asy lum and for Withholding of Removal , received on May 15, 2003. 11 See BIA Inquiry System Case Appeal summar y, marked as filed on June 16, 2003. 12 See DOJ EOlR Decision of the Boa rd of Immigration Appeals, dated Octobe r 31, 2003. 13 See EOIR U.S. lmrni gration Court, Eloy, Arizona, Decision and Order of the Immigration Cou1t, dated Decem ber 10, 2003. 2 2020-ICLl-00006 4777 DETAINEE DEATH REVIEW - Huy Chi TRAN JI CMS l(b)(6); (b)(?)(C); (b)(?)(E) L On January 8, 2004, TRAN filed an appeal with the BIA . 14 On June 14, 2004, the BIA sustained TRAN ' s appea l and remanded the case back to the U for a decision. 15 On September 2 1, 2004, the IJ denied TRAN 's reque sts for asylum, withholding ofremoval, and deferral of removal, and ordered him removed to Vietnam . TRAN waived his right to appeal. 16 On January 10, 2005 , ERO Phoenix determined that no significant likelihood of remova l in the reasonably foreseeab le future existed and released TRAN from custody on an Order of Supervision (OSUP). TRAN reported to ERO as required four times between January 27, 2005 and April 20, 2005 . 17 On July 8, 2005, ERO Phoeni x sent TRAN a Call-In Letter (Form G-56), ordering him to present himself at their office on July 28, 2005 . 18 On July 28, 2005, TRAN failed to appear at ERO Phoenix as ordered; therefo re, his case was referred to the ERO Fugitive Operations Team for location and arrest, with no result. 19 On August 15, 2006, Chandler Police Department in Chandler, AZ arrested TRAN for shoplifting. On August 18, 2006 , Chandler Police Department relea sed TRAN into ERO Phoenix custody. ERO Phoenix relea sed TRAN under the original OSUP issued on Januar y 10, 2005, to comp lete his crimina l proceedin gs. 20 Between May 11, 2007 and April 8, 2009, the Superior Court of Arizona, Maricopa County, convicted TR AN for multiple crimes, detailed in Table 2 of this report. On August 27, 2008, ERO Phoenix encountered TRAN at the Marico pa County Jail and lodged a Notice of Act ion-Immigrat ion Detainer (Form I-247A) .21 On April 13, 2009 , ERO Phoenix encountered TRAN at the ASPC ARC and lodged a Form I247A. 22 On August 14, 2013, ADOC transferred TRAN to ERO Phoeni x's custody. ERO Phoenix released TRAN from custody under his original OSUP issued on January 10, 2005 , as there was 14 See BIA Inquiry System Case Appeal summary, marked as filed on January 8, 2004 . See EOIR Decision of the Board oflmmigration Appeals, dated June 14, 2004. 16 See INS Form I-205, Warrant of Removal/Deportation , dated September 21, 2004; see also Form I-294, Warning to Alien Ordered Removed or Deported, dated September 21, 2004. 17 See INS Form I-220B , Order of Supervision, dated January 10, 2005 and INS Order of Supervision Addendum, dated January 10, 2005; see also ICE Significant Incident Report, dated June 14, 2018. 18 S ee ICE Significant Incident Report, dated June 14, 2018 . 19 S ee ICE Order of Supervision Appointment, Failed to Appear stamp, dated July 28, 2005; see also ICE Significant Incident Report, dated June 14, 2018. 20 There is no record of TRAN reporting to ERO Phoenix after this date. 21 See DHS Form 1-247 A, Immigration Detainer - Notice of Action, dated August 27, 2008. 22 See DHS Form l-247A, Immigration Detainer - Notice of Action, dated April 13, 2009. There is no documentation regarding TRAN 's transfer from the Maricopa County Jail to ASPC ARC. 15 3 2020-ICLl-00006 4778 DETAINEE DEATH REVIEW - Huy Chi TRAN JICMS ~b)(6); (b)(7)(C); b)/7)/ E) no significant likelihood of remova l. TRAN did not appear at ERO Pho enix for his first scheduled appo intment on February 12, 2014, or any subsequent scheduled meeting.23 On March 16, 2015, Chandler Police Department arrested TRAN for Crimina l Dam age. On August 14, 2015, the Superior Court of Arizona, Mari copa County, sentenced TRAN to 120 days' incarceration and 3 years' probation. On Januar y 21, 2017 , Chand ler Police Departm ent arrested TRAN for Disorderly Conduct and Criminal Damage. Also, on this date, ERO Phoenix encountered TRAN at the Mari copa County Sheriffs Office (MSCO) Jail and lodged a Form 1-247A. TRAN remained in MCSO custody pending crimina l pro ceeding s. On July 10, 2017, the Superior Court of Arizona, Maricopa County, sentenced TRAN to one year and six month s in jail with a credit of 171 days, time served. On July 17, 20 17, a 287(g) Designated Immigration Officer encountered TRAN at the ASPC ARC and lodged a Form I247 A. 24 On May 25 , 2018, A.DOC relea sed TRAN to ERO Phoenix' s custody. ERO Phoenix served TRAN a Notice of Revocation of Release with the intention of reviewing TRAN' s likelihoo d of removal. 25 ERO Pho enix booked TRAN into the TUCSON INS Hold Room in Tucson, AZ, then, later that day, transferred him to the Florence Staging Faci lity (FSF) in Florence, AZ.26 On May 28, 20 18, ERO Phoenix transferred TRAN to EDC in Eloy, AZ, to pursue his removal to Vietn am.27 23 See ICE Form 1-220B, Order of Supervision, dated August 14, 2013; see also ICE ENFORCE Alien Removal Module (EARM) system. 24 See DHS Form 1-247 A, Immigration Detainer - Notice of Action, dated July 17, 2017. 25 See ICE Tucson Field Office Notice of Revocation of Release, dated May 25, 2018; see also EARM system, Detention History, dated May 25, 2018. 26 See EARM system, Detention History, dated May 25, 2018. 21 See EARM system, Detention History, dated May 28, 2018. 4 2020-ICLl-00006 4779 DETAINEE DEATH REVIEW - Huy Chi TRAN JICMS e )(6); (b}(7)(C); (b)(7)(E) L NARRATIVE On May 25, 2018 , at app · 7:22 p.m., upon TRAN 's arrival at FSF , Licensed Vocational Nurse (LVN) (b)(5); (b)(?)(C) conducted a medical pre-screening and documented the following: 28 • • • • • TRAN spoke English fluently. TRAN' s appearance, behavior, and breathing were normal. TRAN' s state of consciousness was alert and there were no noticeabl e restrictions or difficultie s of movement. TRAN arrived with halop eridol 29 (5 mg) and fluoxetine 30 (20 mg) , both pre scribed for morning dosing and self-do sed at the gate. 3 1 TRAN' s pre-screening assessment was normal and his pre-screening disposition identified him as having time sensitive medical conditions needing immediate care, pursuant to IHSC policy. 32 b)(6); (b)(7)(C) On May 26, 2018 , at 4:48 a.m., Registered Nurse (RN intake screening 33 and documented the following: • • • • • igned off on TRAN ' s TRAN' s vital signs (VS) were within norma l limits.34 TRAN acknowledged receiving treatment for depression for the past 20 years but denied suicidal and homicidal thought s or a history of experiencing hallucination s. TRAN denied the use of drugs, alcohol, and tobacco. TRAN denied dental issues. TRAN's tuberculosis (TB) screening was negative.35 See eClinicalWorks (eCW) Pre-Screen by L )~() ~(ir , dated May 25, 2018 . ERAU approximated timing of medical events as best as poss ible. Medical times catalogued within the report are prioritized based on the time medica l staff indicated a round time, VS, or electronically signed their note. 29 Halope ridol, a generic for Hald ol, is an antipsych ot ic med ication used to treat certa in types of mental diso rders such as schizophre nia. 30 Fluox etine, a generic for Prozac, is a selec tive seroto nin reuptake inhibitor that treats depressio n, obsessive compuls ive disorder, and panic disorders. 31 Due to the short amount of time TRAN was ho used at the TUCSON INS Hold Room and the lack of med ical documentation prov ided, ERAU was unable to confirm if he rece ived any medications prior to May 26, 2018. 32 See IHSC Policy 03-08 , Section 4-3 (a), dated January 19, 20 15. Priority one detainees (PRl-1 ) are those identified with time-sensitive med ical condit ions needing immediate care, includin g but not limited to uncon sciou sness, altered level of consciousness, severely intoxicated or under the influence of drugs, medica lly or mentally unstable , suicidal/homic idal, an (b)(6) (b.)(7)(C) ntagious. 33 See eCW Initial Intake Assessment by ' dated May 26, 2018. 34 Normal temperature is 98.6; normal range for pulse is 60 to 100 beats per minute ; normal range for respirations is 12 to 20 breath s per minute; and, normal blood pressure is 120/80 or less. 35 TB is a potentially serious infectious bacterial disease that mainly affects the lungs. Symptoms of active TB include persistent co ughing, co ughing up blood, chest pain, unintentional weight loss, fatigue, fever, night swea ts, chills and loss of appetite. 28 5 2020-ICLl-00006 4780 JICMS fb)(6);(b)(7)(C);(b)(7)(E) I DETAINEE DEATH REVIEW - Huy Chi TRAN (b)(6); (b)(7)(C) ...._ _____ _. conducted an Abnorma l Invo luntary Movement Sca le (AIMS) 36 and noted a sco re of zero. (b)(5); (b)(?)(C) docu mented TRAN's intake screenin........,.........,~ """"-' ......... ........, eferred him to a medical . . (b)(6) ; (b)(7)(C) . provider and (b)(6); (b)(?)(C) duled a physical exam ..______ _. rece ived an order per IHSC Commandl:,L.I-----~ ~, Phy sician 's Assistant (PA), to continue TRAN 's medication s for b)(6) ; (b)(7)(C) . three days . .______ _,schedul ed TRAN for a mental hea lth appointment for Ma y 29, 2018, and medically clear ed TRAN for custody. . d c1· . 1 s . 1 k csn l(b)(6);(b)(?)(C) At 2 :46 p.m., L 1cense 1mca ocia Wor er (L \"l~--------~ TRAN' s mental health follow-up assessme nt 39 and docum ented the following: • • • Is1.gne d o ff on TRAN reported a history of depression and treatm en t over the last 20 years. TRAN stated that before takin g his medications, he heard voices and saw thin gs other people did not but deni ed any current hallu cination s. TRAN' s appeara nc e was bizarre, he was poorl y groomed, his affec t flat ,40 and he exhibited lethargic psychomotor activity. 41 I. . . . . (b)(6) ; (b)(7)(C) .._ ________ __,diagno sed TRAN wit h schizophr enia ,42 unspe cified, and noted that TRAN would continue to take medications as rescribe d.43 TRAN received his medications as prescribed whil e at FSF. 44 LCS b)(5 ); (b)(?)(C) ted a follow-up with TRAN on Jun e 2, 2018 .45 l On May 28, 2018 , at 8: 14 a.m.,j<....IC....>!ent s occurred: • At 1:08 a.m., ED ~) \~t., documented that per BCGMC , TRAN's condition remained unchanged. 205 His pupil s were fixed and dilated, he had no pain response, and exhibited no signs of waking. TRAN ' s most recent VS were a heart rate of 93 bpm, bp of 120/67, venti lator setting respiratory rate of 24, a venti lator oxygen saturation of 94 percent and a body temperature of 97.7 degrees Fahre nheit. BCGMC staff's treatment goal was to continu e monitorin g his neurological status. • At 12: 12 p.m. , TRA N's sister arrived and departed at 1:33 p.m. • At 5:00 p.m., TRAN's pare nts arrived and his sister later returned . The last visitor left at 10:40 p.m. On June 11, 2018 , the followin events occ urred: • At 6:31 a.m., EDC R ~i!~iir., ocumented that per BCGMC , TRAN 's condi tion 206 remained unchan ged. TRAN remained on dialy sis and medical staff plann ed to perform a CT scan to determin e if any brain changes had occurred from the base line scan completed on June 5, 2018. TRAN's VS were within normal limits, except for an increased heart rate of 103 bpm and an elevated bp of 160/ 110. • At 9:00 a.m., medic al staff conducted a test to determine if TRAN could breathe on his own; it was determin ed he could not. • At 9:25 a.m., a family member an-ived, and other s continued to aITive throu ghout the day. • At 9:55 a.m., BCGMC doctor s informed TRAN's sister that there was little chance he would survive. ~~t . . , • At 10:2 1 a.m., EDC RN ,..,rn;,,_., (b)(7)(C) document ed that per BCGMC , TRAN s condition remained unchanged .207 BCGMC staff orde red a CT scan. TRAN's VS remained within normal limits, except for an elevated blood pressure of 154/106. • At 11:15 a.m., a BCGMC doctor spoke with TRAN 's family members about the possib ilit y of orga n donation if there was no brain funct ion after test ing. • At 11:55 a.m., BCGMC staff conducted an echocard iogram .208 • At 2:55 p.m., BCGMC staff conducted a neural X-ray. 209 • At 4:42 p.m., BCGMC staff started TRAN's dialy sis, which ended at 7:08 p.m. June 12, 2018, Day of Death b)(6); (b)(7)(C) • At 1:42 a.m., EDC R documented that per BCGMC , TRAN's condition remained unchanged, ,....,..,_--..,.,..1-n~normal limits and MRI results were pendin g. 2 10 b)(6); (b)(7)(C) See eCW Hospital Upd ate, b, d June 10, 2018. 206 See eCW Hospita l Upd ate, b, ted June 11, 2018. 207 See eCW Hospital Upd ate, b, dated Jun e 11, 2018. 208 An echocardiogram is a test using ultrasound to make pictures of the heart. 209 A neural X-ray refer s to a particular kind of brain X-ray used to determine proof of brain death. 2 10 See eCW H ospital Updatekb)(6); dated June 11, 2018. 205 I. 23 2020-ICLl-00006 4798 DETAINEE DEATH REVIEW - Huy Chi TRAN • • ncMs[ b)(6); (b)(?)(C); (b)(?)(E) L . j(b)(6); (b)(?)(C) I A t 8:43 a .m ., Corr ec tion a l Off ,___ ~___ __,teco rd e d BCGMC sta ff co ndu c te d a tes t to d e te rmin e if TRA N sho we d a n brain ac ti vi ty . 2 11 =cb~)c= =)-------~ 6)~;(~b)=c7~)(c A t 11:42 a .m ., BCGMC (b)(5), (b)(?)(C) tifi e d Offi ce 1 1Cb)(6); (b)(?)(C) ------...,,..,..,.,,,..---,.-----' !pronoun ce d TRA N br a in dea d 212 at 9:20 a .m . 213 Off ice r ,~/\~/;,.., tat e d thi s 214 _ was th e fir s t he hear d of TRAN' s de a th. • l(b)(6); (b)(?)(C) I . . At 11:43 a .m ., Offi ce r l(b)(6);,... F a ile d Shift Sup e rv1sor ~-----~I notif y h im th a t althou g h m e di ca l s ta ff h ad pronoun ce d TRAN d ecease d a t 9:20 a .m ., th ey ju st inform e d him of th e n ew s . 5); (b)(?)(C) ~ • At 2 :00 p .m ., Offi ce r s fbl(5); (b)(?)(C) l·e li e ve d Offi c er slCb)C 6 1Cb)(); (b)(?)(C) ~t 2:30 p .m. , th e Pin a l C o unt y M e di ca l Ex amin e r a rriv e d to take • TRAN' s fin ge rprint s . • A t 2:40 p. m ., BCGMC hi s ca rdi ac d ea th . 216 m e di cal s ta ff remo ve d TRAN fr om li fe support and pron o u nc ed • (b)(6); (b)(?)(C) . At 3:43 p .m. , BCGM ~--~ c ompl e te d a Bann er Health A Z Hum a n R e m a m s R el ease for m a nd do c um e nt e d th e d i ag no sis as ano x ic e nce pha lo p ath y, 217 ac ut e res piratory failur e , 218 and ac ut e re nal failm e . 219 Additionall y, ICb)(6) ;_ I (fir st n a me unknown ) , a re pr ese nt a tiv e from the M e di ca l Ex a miner 's offi c e , s ig n e d for c us to d y of TRAN' s b o d y. 220 A t 3:55 p .m. 221 , EDC RN fbl(5 ); (b)(?)(C) b c um e nt e d th a t p e r BCGMC , m e di ca l s taff • c ondu c te d a n EEG at 7:29 a.m. th a t s how e d no brain a c ti vit . 222 BCGMC s taff c onfirm ed th ese findin gs throu g h a pn e ic tes tin g. 223 ~/\ ~t-, urth er docu me nt ed a BCGMC do ctor d e clar e d TRAN bra in de ad a t 9:20 a.m. a nd th a t TRAN ' s famil y m e mb er s we r e notifi e d o f hi s pa ss in g a nd we re e xpe c te d to a rriv e at th e ho spit a l tha t a ft e rnoon . · nn e d to di sco ntinu e th e ve ntil a tor a t th a t tim e . (b)(6); (b)(?)(C) d h h . l . h TRAN's r ema m . s. A t 3 :59 p. m .,______ ~ art e t e o sp 1ta w it • (b)(6); ERAU telephonic interview with 0 ffic (b)(?)(C) uly 18, 2018. 2 12 Brain death is irreversib le brain damage causing the end to independen t breathing. 213 S~b)(6); (b)(?)(C) ki dent Stateme nt, dated June 12, 20 l 8. 214 ERAU telephon ic interv iew with Office rKb)(6); ~uly 18, 2018. 215 Both 0ff icersl(b)(6); (b)(?)(C) lubmitted inc ident statements on June 12, 20 18; however, the times they prov ide in theiJ statements are not consistent with entries in the hosp ital log they kept. Within this report, entries made in the hospi tal log are used . 216 See Exhibit I: Pinal County Fore nsic Examination Repo rt, dated July l 7, 2018 . Cardiac death is when the heart stops beating. 217 Anox ic encep halopathy is a condition where brain tissue is deprived of oxygen and there is a global loss of brain function. 218 Acute respiratory failure occ urs when fluid builds up in the air sacs in the lungs. When this happens, the lungs cannot release oxyge n into the blood. 219 Acute renal failure occ urs when the kidneys suddenly lose the ability to eliminate excess salts, fluids, and waste mater ial from the blood. See Banner Health AZ Human Remains Release Form, da ted June 12, 2018. 220 See Banner Health AZ Human Rema ins Release Form, dated June 12, 2018. 22 1 Although the note is marked that it was entered at 3:55 p.m., this may indicate the time the RN signed the note a~d not the actua l time the hosp ital pr1~l~;1t'.ntr mation as TR AN was taken off the ventilator at 2:40 p.m. 22 - See eCW Telephone Encounter, by \bl{~),,.. dated June 12, 2018 . 223 Apneic testing is an essen tial component in the clinical determina tion of brain death. The main objective of apnea testing is to prove the absence of respiratory control system reflexes in the brainstem when intense physiolog ic stimulation to breathe takes place . 211 24 2020-ICLl-00006 4799 DETAINEE DEATH REVIEW - Huy Chi TRAN JICMS l(b)(6);(b)(7)(C);(b)(7)(E) L Post Death Events On June 13, 2018 , Pho enix Field Office Director (FOD) Enrique Lucero signed a letter to TRAN ' s family offering hi s condolences for their loss. 224 On June 19, 2018 , the Con sulate General of Vietnam in San Francisco wrote that TRAN's family receiv ed his body and conducted his burial. They requested ICE clarify the cause of death and share other information related to TRAN ' s death. 225 (b)(6); The Facilit Inve stigator signed the Incident Investigation Report she began at Ward (b)(7)(C) (b)(B); (b)(?)(C) reque st on June 5, 20 18.226 On June 20, 2018 , EDC staff mailed TRAN' s property and fund s to his father in Me sa, AZ and on June 21, 2018, the package was received and signed for. 227 On July 6, 2018 , the State of Arizona Certification of Vital Record issued a Certificate of Death documentin g TRAN' s immediat e cau se of death as pending invest igation. 228 b)(6); On July 17, 2018 , Chief Medical Examiner b)(?)(C) D, signed the completed forensic examination report, stating the cause of death was coronary artery disease. 229 MEDICAL CARE AND SECURITY REVIEW ERAU reviewed the medical care EDC provided TRAN , as well as the facility's effort s to ensur e that he was safe and sec ure while detain ed at the facility. ERAU found deficiencies in EDC's compliance with certain requirements of the ICE PBNDS 2011 (as revi sed in 2016). 1. ICE PBNDS 2011 , Medical Care, Section (II)(20) , which states, "Prescriptions and medication s shall be ordered, dispen sed and administered in a timely manner and as prescribed by a licen sed health care profe ssional. Thi s shall be conducted in a manner that seeks to preserve the privacy and personal health information of detainees." • (b)(6); (b)(7)(C) Although the.__ ___ _.prescribed TRAN fluox etine and halop eridol at intak e on May 28 , 2018, TRAN did not receive his first dose of either medi cation until May 30, 2018. If TRAN received a dose from the in (b)(B) (b)(?)(C) edical staff did not documen t the administration of the medications. ' nded her employment with EDC prior to the site visit; therefo re, ERAU could not discuss this issue wi1(b)(6); (b)(7)(C) to determine whether the break in medication was determined acceptable. I 224 See Written correspondence from Phoeni x FOD Enrique M. Lucero , dated June 13, 2018. ERAU notes EDC was unable to confirm a follow-up response to the Vietnam Consulat e. 226 See CoreCivic Incident Investigation Report, dated June 19, 2018. 227 See U.S. Postal Service Certified Mail Receipt. 228 See Exhibit 8: State of Arizona Certification of Vital Record : Certificate of Death , dated July 6, 2018. 229 See Exhibit 1: Pinal County Forensic Examin ation Report , dated July 17, 2018. 225 25 2020-ICLl-00006 4800 DETAINEE DEATH REVIEW - Huy Chi TRAN JICMS (b)(6); (b)(7)(C) ; fh\/7\/ r::.\ 2. ICE PBNDS 20 11, Medical Care, Section (V)(AA)(4), which states, "Prior to the administration of psychotropic medication s, a separate documented informed conse nt, that includes a description of the medication's side effects shall be obtained." • Medical staff did not obtain a signed consent form from TRAN at FSF for psychotropic medications started on May 26, 2018. • Medical staff did not obtain a signed consent form from TRAN at EDC for psychotropic medications started on May 30, 2018 until June 4, 20 18. The signed consent form documents the psychiatrist discussed the side effects with TRAN but does not list any side effects. The side effects were, however, listed in the psychiatrist's encounter note. 3. ICE PBNDS 2011, Custody Classification System, Section (V)(A)(4) , which states, "Each detainee's classification shall be reviewed and approved by a first-line supervisor or class ification supervisor." • A supervisor did not approve the classification rating assigned to TRAN on May 28, 2018. 4. ICE PBNDS 2011, Special Management Units, Section (V)(M), which states, "Close Supervision Detainees in SMU shall be personally observed and logged at least every 30 minutes on an irregular schedule. For cases that warrant increased observation, the SMU personnel shall personally observe detainees accord ingly." • Per the psycho logist's order, due to placement on MHO, CoreCivic officers were to conduct welfare checks on TRAN every 15 minutes. Surveillance footage evidence showed the CoreCivic officer on duty issued TRAN linens at 3:00 p.m. but did not look into TRAN' s cell again until 3:51 p.m. During the 5 1-minute period , the officer documented three welfare checks, none of which were supported by video surveillance. AREAS OF CONCERN ERAU noted the following generalized concerns regarding TRAN's medical care: b)(6); (b)(7)(C) • • • Because the pharmacy did not receiv ',-----..--~ orders to change the administration times of TRAN ' s medication during p arrnacy ours, the pharmacy did not process his orders until the next day, after TRAN already received his once-daily dose of fluoxetine. As a result, he received twice the prescribed daily dose of fluoxetine. Idid not order Cogentin to treat TRAN's EPS symptoms as intended. He stated that his failure to order Cogentin was an overs ight. l(b)( 5 ); (b)(?)(C) EDC medical staff did not take TRAN's VS during his mental health appointm ents on June 4, 2018 and June 5, 20 18. Although policy did not require VS, Creative Corrections advised they are a key factor in the early detection of life-threatening conditions. 26 2020-ICLl-00006 4801 DETAINEE DEATH REVIEW - Huy Chi TRAN • n cMs [b)(6); (b)(?)(C) ; (b)(?)( E) L CoreCivi c staff obse rved TRAN unresponsive in his SMU cell within approx imate ly three hour s after the psycho logist ordered his assignment to MHO. Th e segregation med ical clearance comp leted bylCbl(6); (b)(?)(C) pn sisted only of a medical recor d review. Per H(b)(5); (b)(?)(C) medi)<.MJ. ....................... """"'""..., s deta inees in-person before medica lly clearin g 5 them for segregation. A blCl; (b)(?)(C) id not cond uct an in-person assessment , she did not ob tain TRAN' s VS nor did she conduc t an assessment of his physica l condition. I • Durin g the med ical emergency response, the medical team leader did not place the ABD pads in the proper position and did not dry TRAN ' s skin before attempting placemen t after noticing his skin was moist. The pad s did not adhere, rendering the AED ineffective in analyz ing heart activity . BRAU cannot determine whethe r the pad s did not adhere beca use they had expired or becau se TRAN was per spirin g. T he eme rgency bag inventory did not list AED pad expiration date s, nor did it include a second set of pad s. Thorough inventories of emergency bag contents, to include review of AED pad expirat ion date s and a seco nd set of pad s, helps to ensu re necessa ry equ ipment is available and operab le durin g medical emergency events. b)(6); (b)(?)(C) • ---~-~ph ysical exa mination entry included do cumentation that TRAN had no ower teet and was missing other upper teeth, but she did not order a special diet to assure TRAN's nutritional intake was adeq uate. BRAU noted the following concerns related to safe ty and security: ~;)~\re:, • After Offic called the medical emergency, the first security responders arrived within an estimated three minute s. They stood at the cell but did not enter to render aid. Despit{bl(?)(E) ~ and one correctio nal counselor being present, one respondin g officer stated they did not enter out of concern for their safe ty. !Cb)(6); land another male officer arrive d on scene shortly thereafter and entered the cell, followed by the initial respo nders. Followin th e eme rgency response \~)\~\ ,, clarified to the respondin g office rs that when (b)(?)(E) are present, regardl ess of the gender of the detainee or responders, they s ou enter t e cell. • For the first 46 seconds of the medical emergency recording, the handh eld camera lens cover wou ld not fully open. Fo llowing the medical emer genc (~/(~/;/"', sent the handheld camera out for repair of the slide action that jammed to co1Tectthe identifi ed malfunction. • (b)(6); (b)(6) (b)(?)(C) When Capta i1(b)(?)(C) -rived on site, he asked Offi c ' to stop recording the medica l emer ency , prior to EMS arriving , as he believed it was a HIP AA violation. Capta· _bl~~);·-· correct ly viewed the recording of CPR as a HIP AA violation, as Creative Correct ions advised that HIP AA does not apply to those in custody of the Federa l Governm ent. 27 2020-ICLl-00006 4802 DETAINEE DEATH REVIEW - Huy Chi TRAN JICMSfb )(6) ;(b)(7)(C) ; (b)(7)( E) L TABLE ONE Offense Disorderly Conduct Shopliftin_g Shoplifting Disorderly Conduct Disorderly Conduct Driving with Licen se Suspended; Failure to Appear/Failure to Pay Conviction Date June 6, 1994 December 5, 1996 December 4, 1996 Au_gust22, 1997 Apri l 30, 1999 Sentence 12 months of probation Fined $320.00 Fined $300.00 Three years of probation Three years of probation November 18, 1999 18 days incarceration October 25, 2000 3 years, 6 month s incarceration (credit 210days' time served) Aggravated Assault Aggravated Assault Three years of probation TABLE TWO Offense Conviction Date Disorderly Conduct Sentence 120 days incarceration May 11, 2007 Criminal Damage One year of probation Shopliftin_g Criminal Damag e (Two Counts) May 11, 2007 November 10, 2008 Aggravated Assault April 8, 2009 One year of probation 90 days incarceration Five years' incarceration (credit 224-days' time served) 28 2020-ICLl-00006 4803 DETAINEE DEATH REVIEW - Huy Chi TRAN JICMSI CblC5 l: CblC7 lCCl; iiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiii(,C _:, b )(:.._ ?):.:_: ( E:.:_ ) ___ _J L EXHIBITS 1. Pinal County Forensic Examination Report, dated July 17, 2018. 2. 3. 4. 5. Creative Con-ections Healthcare and Security Compliance Analysis. Initial Custody Classification Fo1m 18-1B, dated May 28, 2018. EDC Medical Administration Record (MAR) for Huy Chi Tran , dated May 20 18. Immigration Health Services Corp Consent Form for Psychotropic Medications for Adults, dated June 4, 2018. 6. Confinement Record Form, dated June 5, 2018. 7. Confinement Watch Log, dated June 5, 2018. 8. State of Arizona Certification of Vital Record: Certificate of Death , dated July 6, 2018. 29 2020-ICLl-00006 4804 18-303 Huy-Chi Tran f\ ~~ PINAL COUNTY WIDE OPP.:,;'OJ>PORTU 'ITV FORENSIC EXAMINATION REPORT HUY-CHI TRAN PINAL COUNTY ME CASE #18-303 CASA GRANDE POLICE DEPARTMENT CASE #18-00036663 Pinal County JUL17 2018 Medical Examiner (b)(6); (b)(7)(C) Page 1 of 9 2020-ICLl-00006 4805 18-303 Huy-Chi Tran Report of Examination ME Case number : Agency , number : Decedent: Date of birth: Date of death : Date of examination : Time of examination : Invest igator: Forensic Technician : Present at examination : Cause of Death : Manner of Death : 18-303 CGPD , 18-00036663 Huy-Chi Tran August 7 , 1970 June 12, 2018 June 14, 2018 1000 hours (b)(6); (b)(7)(C) Chief C ll..e i~~ li ~c..!.!.l r.\a:.J c) L...J-b)(_6)_; <_b)_ (7)_(C-') ICE Coronary artery dis,ease Natural (b)(6); (b)(7)(C) July 17, 2018 Date Signed xammer b)(6); (b)(7)(C) Page 2 of 9 2020-ICLl -00006 4806 18-303 Huy-Chi Tran REPORTED CIRCUMSTANCES OF DEATH The decedent was a 47-year-old unmarried Asian male who was an inmate at a prison in Eloy, Arizona. On June 5, 2018 , he was found unresponsive in his sing le-man cell. Resuscitative efforts were initiated on scene , and the decedent was transported to Banner Casa Grande Medical Center. He was placed on life support in the Intensive Care Unit. When there was no response to treatme nt, those measures were removed. Brain death was pronounced at 0920 hours on June 12, 2018. He was then taken off of the ventilator , and cardiac death was pronounced at 1440 hours on June 12, 2018. Past Medical/Social History According to Banner Health Medical records The decedent was reportedly found unconscious in his cell , and had been down for an unknown period of time . He received chest compressions for 10 minutes before EMS arrival. He was found to be in PEA , and received two rounds of epinephrine. A heartbeat subsequently returned and he was transported to Banner Casa Grande Medical Center. After admission he was diagnosed with clostridium difficile in the stool. He was declared brain dead . His condition continued to decline until death was pronounced on June 12, 2018 . A. Acute kidney injury, likely due to severe hemodynamic acute tubular necrosis from cardiac arrest 8 . Anoxic brain injury C. Cardiogenic shock D. Acute respiratory failure E. Schizophrenia a. Haloperidol b. Fluoxetine F. Metabolic acidosis/respiratory alkalos is G. Possible clostridium difficile infection H. Leukocytos is I. Thrombocytopenia , possibly antibiotic related J. Gastrointestinal bleeding K. Status post cardiac arrest , on hypothermia protocol L. Acute renal and hepatic failure M. CT of the brain on June 5, 2018 a. No intracerebral arterial or venous activity N. Subsequently declared brain dead , initial CT of head negative for trauma 0. Initial urine drug screen unremarkable P. CT of head in June 5, 2018 a. No acute intracranial abnormality identified b. Findings suggestive of chronic sinusitis b)(6); (b)(7)(C) Page 3 of' 2020-ICLl-00006 4807 18-303 Huy-Chi Tran c. Presumed ente ric tube nasopharynx appears coiled at the level of t he According to the medical records from Banner Casa Grande Medical Center "This 47-year-old male was seen for evaluation 4B and nonresponsive. Medical staff responded to medical emergency call at 14:15 hours. Patient has no pulse and is not breathing, no reaction noted with sternal rub. Oxygen saturation was 48% at room air. Ambulance bagging with oxygen at 15 Um was initiated while CPR was being done. Patient's shirt was cut in the middle of and AED pads were applied. Nursing staff attempted to obtain the patient's blood pressure but was unable to get a reading. Blood glucose was checked with a glucose which shows 280 mg/dL. Peripheral intravenous catheter insertion was attempted twice without success. Oxygen saturation reading was between 48% to 93% with peripheral pulse ranging from 50-115 during CPR. Provided examined oral cavity for up structuring and was returned. CPR lasted 17 minutes before the paramedics arrived. AED shocked the patient multiple times during the resuscitation but without a shockable rhythm. EMS assume resuscitation on 1633 hrs. IV was started via intravenous route. Patient was given Narcan and epinephrine. Cardiac monitor showed sinus rhythm. Patient was transferred to the ambulance en route to Banner Casa Grande Medical Center." INITIAL EXTERNAL EXAMINATION The body is received in a zippe red body pouch secured by evidence seal number 00002659. CLOTHING AND PERSONAL EFFECTS All property is documented on the property sheet that is sepa rate in the file . EVIDENCE OF MEDICAL INTERVENTION There is an endotracheal tube present in the mouth. There is an orogastric tub e present in the mouth . There is a centra l line present on the right neck. There is a central line present on the left neck. There is an ova l shaped compressio n pad present on the midline chest. There are two defibrillator pads present on the front of the chest. There are multiple EKG leads present on the front of the chest. There is a foley catheter in place. There is a pulse oximeter probe affixed to the right index finger . There are multip le needle puncture marks present on the left antecubita l fossa . There is a needle puncture mark present on the right antecubita l fossa . b)(6); (b)(?)(C) Page 4 of 9 2020-ICLl-00006 4808 18-303 Huy-Chi Tran EVIDENCE OF TRAUMA There are bluish contusions on the midline lower chest from cardiopulmonary resuscitation. There are bilateral anterior rib fractures. There is a vertical fracture of the lower sternum with intercostal muscle contusion . There are mild infiltrative hemorrhages in the mediastinum. These injuries, having been once described , will not be repeated. SCARS, TATTOOS , AND OTHER IDENTI FYING BODY FEATURES There are no significant scars or tattoos identified. GENERAL EXTERNAL EXAMINATIO N The body is cold to touch, subsequent to refrigeration . developed . Posterior red-purple lividity is partially fixed. Rigor mortis is fully The body is that of a normally developed Asian male, measuring 68 inches in length and weighing 192 pounds. The general appearance is compatible with the reported age of 47 years. Scalp hair is black . The irises are brown, and there is no jaundice or lesions of sclera or conjunctivae. The nose is unremarkable. There is facial hair of a beard and mustache . The ears are unremarkable. The mouth is unremarkable. Teeth are natural. The neck is unremarkable. There are no palpable axillary , cervical, abdominal , or inguinal masses. The chest and back are symmetrical and unremarkable. Body hair is normal in amount and distribution of an average male adult. The abdomen is mildly protuberant. The external genitalia , anus, and perineum are unremarkable. The extremities are symmetrical , without significant clubbing, edema, or deformity. Fingernails are intact. INTERNAL EXAMINAT ION The body is opened by a standard Y-shaped thoracoabdominal mc1s1on . All viscera occupy their appropriate anatomic relationships. Subcutaneous adipose tissue ranges up to 3 cm in thickness over the abdominal wall. Serous surfaces are smooth and glistening throughout. There are no adhesions or significant free fluid accumulations in the body cavities. CARDIOVASCULAR SYSTEM The pericardium is unremarkable. The heart weighs 490 grams. The heart occupies its usual mediastinal site, and has a smooth epicardial surface. The external configuration is not remarkable. All major vessels arise in their appropriate anatomic relationships. The coronary ostia are normally placed and b)(6); (b)(?)(C) Page 5 of 9 2020-ICLl-00006 4809 18-303 Huy-Chi Tran are patent. The coronary arteries arise normally, are distributed in a right dominant pattern, and contain severe atherosclerotic changes, with stenosis ranging from 30% in the proximal right coronary artery, 20% in the distal right coronary artery, 75% in the left circumflex artery, 30% in the left anterior descending coronary artery, and 50% in the left main coronary artery. The atria and ventricles are of normal caliber, and are free of gross anomalies and thrombi. The myocardium is red-brown and firm , with focal red areas in the upper part of the interventricular septum measuring 1 x 0.5 x 2.5 cm. The dark red area is close to the atrial ventricular valve. A histologic section from this area is obtained. This is consistent with acute myocardial ischemia. The rest of the myocardium is grossly unremarkable. The ventricular thicknesses are as follows: left ventricle 1.2 cm, interventricular septum 1.1 cm, right ventricle 0.2 cm, with 0.7 cm epicardial fatty tissue present. The endocardium is unremarkable. The cardiac valve circumferences are appropriate for the caliber of the cardiac chambers. The cardiac valves have thin, pliable leaflets that are free of fusion, vegetations, or significant fenestrations . The aorta is of normal caliber, with all major arterial branches arising in their appropriate anatomic relationship. The intimal surfaces contain mild atherosclerotic changes in the abdominal aorta, without aneurysm formation or dissection. No systemic venous abnormalities or thrombi are present. RESPIRATORY SYSTEM The upper airway, larynx, and trachea are patent, with no evidence of edema, ulceration, or obstruction . There is a small amount of gastric contents present in the trachea. The right lung weighs 640 grams and the left lung weighs 630 grams. The pleural surfaces are smooth and glistening . The parenchyma is well expanded . Sectioning reveals pink to red-purple tissue with no areas of induration, consolidation, hemorrhage, or gross scarring. The bronchi and pulmonary vessels are patent and of normal caliber. DIGESTIVE SYSTEM The tongue is unremarkable. The oropharynx is grossly normal and unobstructed. The esophagus is of normal caliber, with a smooth, gray-white mucosal lining. The gastroesophageal junction is well defined. The stomach has intact mucosal surfaces. The lumen contains 900 ml of brown fluid with a large amount of partially digested food. There are multifocal mucosal hemorrhages in the gastric lumen. There is no evidence of bleeding in the gastric lumen. There are no areas of mucosal ulceration, erosion , or scarring. The small and large intestines are not remarkable. The appendix is present in the right lower quadrant and is unremarkable. The tan-gray , lobular pancreas has no focal abnormalities . The pancreatic ducts are patent and of normal caliber. b)(6); (b)(7)(C) Page 6 of! 2020-ICLl-00006 4810 18-303 Huy-Chi Tran HEPATOBILIARY SYSTEM The 2190 gram liver has a smooth capsule, covering red-brown parenchyma with focal mottled appearance. The liver tissue appears to be friable. The cut surfaces show no diffuse or focal abnormalities. The intrahepatic and extrahepatic biliary ducts are unremarkable. The gallbladder contains viscid olive green bile, and is free of calculi. The gallbladder mucosa is grossly normal. GENITOURINARY SYSTEM The right kidney weighs 200 grams and the left kidney weighs 230 grams. The kidneys are similar in shape, with intact capsules covering smooth, red-brown parenchyma. The capsules strip with ease. The cut surfaces show poorly defined corticomedullary junctions . The calyces, pelves, and ureters are unremarkable. The renal vessels are patent and of normal caliber. The urinary bladder contains no urine. There is approximately 20 ml of dark yellow urine in the foley catheter bag. The mucosal surfaces are flat and pinktan. The prostate gland appears to be slightly enlarged with multiple nodules. RETICULOENDOTHELIAL SYSTEM The 170 gram spleen has an intact, smooth, and glistening capsule covering dark purple, moderately soft parenchyma. Regional lymph nodes have their usual distributio n and appearance. ENDOCRINE SYSTEM The thyroid and adrenal glands are grossly not remarkable. NECK The cervical spine, hyoid bone, and thyroid cartilage are intact and unremarkable. An anterior layer by layer neck dissection reveals focal hemorrhages on the surface of the left omohyoid muscle measuring 2 x 0.2 cm and on the left sternohyoid muscle surface measuring 1 x 0.2 cm. These hemorrhages appear to be superficial and do not involve the muscular parenchyma. There is no other hemorrhage in the strap muscles or soft tissues of the neck. MUSCULOSKELETALSYS TEM The bony framework , supporting musculature, and soft tissues are grossly normal. (b)(6); (b)(7)(C) Page 7 o 2020-ICLl-00006 4811 18-303 Huy-Chi Tran NERVOUS SYSTEM The scalp is reflected in the usual fashion . There are no contusions , lacerations, or abrasions of the scalp or subscalpular structures. There are no skull fractures . The pituitary gland is unremarkable. The cerebral vessels are intact, with no malformation , aneurysm, thrombos is, or significant atherosclerotic narrowing. The cranial nerves are grossly normal. The dura and dural sinuses are unremarkable except for a thrombus in the superior sagittal sinus. There are no epidural , subdural , or subarachnoid hemorrhages . The brain weighs 1470 grams. The leptomeninges are thin and clear. The cerebral hemispheres are symmetrical , extremely soft, and disintegrate upon removal from the cranial cavity . The external landmarks for the superior cerebral surfaces are unremarkable with normal convolutional patterns, however the gyri appear to be edematous, with narrowing of the sulci. There are no uncal, subfalcial, transtentorial , or tonsillar herniations. Multiple sections of cerebrum, cerebellum, and brain stem reveal poorly defined gray-white borders and the brain tissue is extremely soft, consistent with anoxic encephalopathy . The ventricular system is symmetrical and compressed . TOXICOLOGY SPECIMENS Samples of the following are collected and some submitted for toxicological testing. • • • • • Vitreous fluid . Blood. Urine. Heart tissue. Admission specimens The toxicology report is separate in the file. MICROSCOPIC EXAMINATION Multiple microscopic sections are reviewed. Apart from information listed below, histology findings correspond to the gross diagnoses and provide no further information. Cassettes: Heart: Multiple focal myocardial ischemia and necrosis with mild neutrophil infiltrates. Lungs: Multiple microscopic foci and pneumonia ; focal atelectasis ; marked increase of macrophages . (b)(6); (b)(7)(C) Page 8 of 9 2020-ICLl-00006 4812 18-303 Huy-Chi Tran FINAL SUMMARY Based on the forensic examination findings and investigative history as available to me, it is my opinion that Huy-Chi Tran , a 47-year-old Asian male, died as a result of coronary artery disease. The manner of death is natural. As with all death investigations , opinions expressed herein are amenable to change should new, reliable, and pertinent information come to light. The Pinal County Medical Examiner's Office is required by statute (A.R.S. § 11-594(A) (2) and (4)) to certify the cause and manner of death following completion of the death investigation of each case over which it assumes jurisdiction , and to promptly execute a death certificate, on a form provided by the state registrar of vital statistics, indicating the cause and manner of death. The form provided by the state registrar of vital statistics includes five manners of death: homicide, suicide, accident, natural, and undetermined . The determination of manner of death is a forensic determination by the pathologist predicated upon the totality of all then-known forensic evidence and other circumstances surrounding the cause of death; it is not a legal determination of criminal or civil responsibility of any person(s) for the death. The significant findings below may not be a complete list of the decedent's medical history. Significant findings I. Sudden cardiac death due to coronary artery disease a. Cardiopulmonary arrest , status post resuscitation b. Myocardial ischemia and necrosis c. Multiple organ failure i. Multiple microscopic foci of pneumonia ii. Myocardial ischemia and necrosis iii. Acute renal failure iv. Anoxic brain injury v. Cardiogenic shock vi. Acute respiratory failure vii. Metabolic acidosis viii. Possible clostridium difficile infection ix. Thrombocytopenia x. History of gastrointestinal bleeding xi. Hepatic failure xii. CT of the brain revealed no acute intracranial hemorrhage xiii. Anoxic encephalopathy 11. Schizophrenia Ill. Toxicology negative IV. No evidence of trauma b)(6); b)(7)(C) Page 9 of 9 I 2020-ICLl-00006 4813 ◄ AXIS Web : www .axisforto x.com Phone: (317) 759-4TOX FORENSIC T OXICOLOGY Laboratory Case Number : 3149324 Subject's Name: Client Account : 14185 / PCME01 Agency Case #: Physician: TRAN, HUYCHI 18-303 Date of Death : 06/12/2018 Pinal County AZ Med Exam Offic Report To: Test Reason: Other ATTN: Pinal County Investigator: ,~/hb)(6); \/7 \/f:\ 570 W. Adamsville Road Date Received: 06/18/2018 Florence, AZ 85132 Date Reported: 06/26/2018 I FX: 520-866-7296 Laboratory Specimen No: 40728713 _ Container(s): 01 :RTB Blood ,ILIAC Analyte Name Date Collected: Test(s): Res ult A MPHETAM INES Negative BARBITURATES Negative BENZOD IAZEPINES Negative CANNABINOIDS Negative COCAINE/METABOLITES Negative FENTANYL Negative METHADONE/M ET ABO LITE Negative OPIATES Negative OXYCODONE/METABOLITE Negative PHENCYC LIDINE Negative PROPOXYP HENE/MET ABO LITE Negative ALCOHOL Negative Methanol Negative Ethanol Negative Acetone Negative lsopropanol Negative ANALGESICS Negative BUPRENORPHINE Negative STIMULANTS Negative TRAMADOUMETABOLITE Negative Specimens 70530 Conce ntr ati on will be kept f•>r 06/14/2018 10:30 two Drugs of Abuse Panel , Blood Therapeutic Range Units year from the date Loe roceived. The Specimen identified by the Laboratory Specimen Number has been handled and analyzed in accordance with all applicable requirements . I Laboratory Director (b)(6); (b)(7)(C) l. . Ph.D., F-ABFT TRAN, HUYCHI Laboratory Case #:3149324 Print DatefTime:06/26/2018, 10:02 ~C ~ as ..:... e.:....-,R =e.,,, v-ie_w_e_r______ t _,,, b)(6); (b)(7)(C) Page: 1 of 1 This individual may not have perfo rmed any of the analytical work . 2020-ICLl -00006 4814 DETAINEE DEATH REVIEW: Huy Chi TRAN, A037949945 Healthcare and Security Compliance Analysis Eloy Federal Contract Facility Eloy, Arizona As requested by the ICE Office of Professional Responsibility (OPR), External Review s and Analysis Unit (ERAU), Creative Corrections participated in a review of the death of detainee Huy Chi TRAN while in the custody of the Eloy Federa l Contract Facility in Eloy, Arizona. A site visit was conducted Jul 17-19 20 18 by ERAU staff * b)(6); (b)(7)(C) IMana gement and Program Analyst and team leader, b)(5); (b)(?)(C) spection and Compliance Specialist, and Creative CoITections contract personnel (b)(6); (b)(7)(C) ecurity Subject Matter Expert and J b)(5); (b)(?)(C) IRN, Healthcare Subject Matter Expert. Contractor participation was requested to assess compliance with the ICE Performance Based Nationa l Detention Standards (PBNDS ) 2011, revised 2016, governing medical care and security operations . .,__..._..,.__,,..<::..UJL.U..L......,,__..., collaborative effort on the part of the SMEs who particip ated in the site visit and ._ ____ ....,Program Manager for the OPR/ERAU contract. Included in this report is a case synopsis, description of the facility and its healthcare services, a naintive summary of events, and conclusions. The information and findings herein are based on analysis of detainee TRAN's medical record and detention file; tour of the medical clinic, housing unit, and intake area; interviews of staff; and review of policies, video surveillance footage, and available incident related documentation. SYNOPSIS Huy Chi TRAN, 47 years old, was admitted to the Florence Special Processing Center on May 25, 2018 and was transfe1Tedto the Eloy Federal Contract Facility three days later, on May 28, 2018. He reported a long term history of schizophrenia and depression for which treated with psychiatric medications. A medical provid er examined TRAN the day he was admitted and after consultation with a psychiatrist, ordered the medications which a1Tivedwith TRAN , Haldol and fluoxetine, pending psychiatric review. The medications were started the second day after they were ordered. Pursuant to referrals from the provider and the intake nurse, the facility psychiatrist evaluated TRAN on June 4, 2018. The psychiatrist continued the medications, changing the administration times from morning to later in the day, and documented his intent to order Cogentin on a trial basis to address observed side effects of Ha.Idol. The Cogentin was not ordered; the orders changing administration times for Haldol and fluoxetine were not processed until the next day, June 5, 20 18. As a result of the delay, TRAN received two doses of fluoxetine within four hours. Determination of whether he was given two doses of Haldol is not possible due to ambiguous entries on the medication administration record. DETAIN EE DEATH REVIEW: Huy Chi TRAN Page 1 Healthcare and Secur ity Comp liance Ana lysis August , 2018 l_C 'r e:ali1t ,e i::11rii111eti 1111 :s 2020-ICLl-00006 4815 The same day , June 5, 2018, a psychologi st directed detainee TRAN's placement in the special management unit for mental health observatio n. The psycholo gist's eva luation resulted from a referral by security staff following observation that the detainee appeared lethargic and generally non-responsive to communications. Approx imately 75 minutes after TRAN was placed in segregat ion, he was found unresponsiv e in his cell and medical emergency was called. Prior to the medica l emergency, the officer documented but did not conduct monitoring rounds every 15 minutes as ordered by the psychologist. Response to the emergency call by security and medical personnel was swift, although there was a brief delay while the first three secur ity responder s, all wome n, waited for male responder s before entering the cell. Cardiopulmonary resuscitation was initiated by officers and 911 was called immediately. Officers continued chest compressions after medical staff arrived and performed life-sav ing efforts until paramed ics took over care. TRAN was taken by ambu lance to the local hospital and was admitted to the inten sive care unit. He remained on life support for one week, durin g which he was visited by family. Death was pronounced at 9:20 a.m. on June 12, 2018 . The autopsy report cites cardiac arrest as the cause of death. FACILITY DESCRIPTION The Eloy Federa l Contract Facility has been owned and operated by CoreC ivic, formerly Correction s Corporat ion of America , since 1994. The facility is a dedicated Intergovernme ntal Service Agreement facility housing both male and female ICE detainees. The capacity is 1500. The population on the date of detainee TRAN 's death was 1359, including 889 male s and 470 female s. The facility has a double fence with razor wire on top and between the fences. The interior fence is equipped with stun technology to deter escapes. Staff and visitors enter from the main lobby , first placing their belonging s through an x-ray machine , then passi ng through a metal detector. All persons entering the sec ure section of the faci lity must display a staff or visitor identification badge. Video surveillance cameras positioned throughout the facility monitor and record events. The direct superv ision model of detainee supervisio n is in place in genera l population housing units. Meals are served to general population detainees in a centra l dinin g hall. The control center is located off the main entrance and is staffed at all times bj(b)(7)(El ~- 1~ ~b _l<7_H_El__ ~ handles radio traffic, the logbook and the shift report. The other officer contro ls door s and monitor s cameras . Durin g an emerge ncy, the officer is able to access video from the closest camera in the area . DETAIN EE DEATH REVIEW: Huy Chi TRAN Page 2 Healthcare and Secur ity Comp liance Ana lysis August , 2018 l_C 'r e:ali1t ,e i::11rii111eti11 11:s 2020-ICLl-00006 4816 On each shift, a team of officers is designated to serve on the Emergency Response Team (ERT). As defined in CoreCivic Policy and Procedure 9- 16, Emergency Response Team, the ERT is comprised of five members who respond to emergency calls with a specific piece of equipment such as a handheld video camera, fire extinguisher and cardiopulmonary resuscitation (CPR) valve. The ERT responded when medical emergency was called for detainee TRAN . HEALTHCARE SERVICES Eloy Federal Contract Facility received accreditation by the National Commi ssion on Correctional Health Care (NCCHC) in March 2015 and was audited for reaccreditation on May 31 and June 1, 2018. The health services department is staffed 24 hours a day, seven days a week by ICE Health Services Corp (IHSC) and contractor InGenesis Medical Staffing . The staffing plan authorizes 79 total positions, ten of which are commissione d officers of the U.S. Public Health Service. They include the Health Services Admini strator (HSA), two assistant HSAs, one advanced practice provider 1, a nurse manag er, two pharmacists, program manager, registered dental hygienist, and registered nurse (RN). There are two General Schedule (GS) for Federal Pay physician posit ions, one of which is the designated Clinical Director (CD). According to the HSA, the CD position has been vacant for four years. Until the position is filled, IHSC regional and headquart ers physician s share responsibility for clinical oversight. InGenesis positions include a staff physician, psychiatrist, 2 1 RNs, an administrative assistant, seven advanced practice practitioners, five behavioral health professionals, one dentist, one dental assistant, 12 licensed practical nurses (LPN), six medical record s technician s, two pharmacy technician s, and a radiology technician. Part time contract positions include one pharmacist and one psychiatrist; as needed positions include four RNs and two LPNs. The HSA reported that in addition to the CD position, the GS staff physician position was vacant at the time of the site visit. The reviewer confirmed the credentials of healthcare staff were current and primary source verified. Training records for all medical and security personnel involved in the emergency respon se include docum entation of cardio pulmonary resuscitation training in the past year. The facility uses IHSC's e-Clinical Work s (eCW) electronic medical record system. The reviewer notes that times the encounters were actually conducted are not available; therefore, medical encounter times identified in this report reflect system-generated time stamps documenting when associated vital signs were taken or providers electronically signed their notes. DETENTION SUMMARY Per the Telmate Report of telephone calls, detainee TRAN attempted seven phone calls during his detention , two of which were completed. Both completed calls were placed on May 29, 2018 and 1 Advanced practice providers i nclude nurse practitioners and physician assistants. DETAIN EE DEATH REVIEW: Huy Chi TRAN Page 3 Healthcare and Secur ity Comp liance Analysis August , 2018 l_C 'r e:ali1t ,e i::11rii111eti11 11:s 2020-ICLl-00006 4817 lasted seven and five minute s respectively. The calls were conducted in a language believed to be Vietname se. Detain ee TRAN had no visits. There was no docum entation he filed any requests or grievances, and no record of any disciplinary report s. Detain ee TRAN was classified high custody by ERO. Although he qualifi ed for medium custody based on the CoreCivic classification syste m, his rating was overridd en to high based on the ratin g applied by ERO. TRAN was first assigned to a top bunk on an upper tier in a general population unit ; then, within approximate ly six hour s, he was moved to a lower bunk on the bottom tier because he had difficulty climbing to the top bunk. On the eighth day of his detention at EFCF, TRAN was transferred to the special management unit for mental health observat ion. He was in the special management unit for approximate ly 75 minute s before medical emergency was called. SUMMARY OF EVENTS Florence Service Processing Center (FSPC) Friday_, May 25, 2018 ~b-)(6~);-(b-)(= ?)~ (C-) ---~ A medi cal pre-screen docum ented b~---~--~t es detainee TRAN 's time of arriva l at the staging facility was 7:22 p.m. He was med1ca y c eare d for travel/tran sfer, with instruction to the recei ving facility to follow up with his menta l health diagnosis and treatment. Saturday Mav 26 2018 5 ); (b)(?)(C) . ake screen, notmg . d etam . ee TRAN h ad b een A t 4 :48 a ~------~ comp lete d th e mt treated for depression for the past 20 years. He denied any suicidal history or current thought s of self-harm . Vital signs entered at 4:46 a.m. were as follows: temperature 98.4, pul se 69, respirat ions 16, and blood pressure 109/75 , all within norma l limits. He height was five feett, four inches and he weighed 177.3 pound s. He was referred to the medical provider and medically cleared for custody. t )( IRN I l (b)(6); (b)(?)(C) A mental health note completed by ~--------~L CSW at 2:46 p.m. documents detainee TRAN was refen-ed to her by medical staff. He reported a history of depression for the past 20 years but denied any pa st suicide attempts. He was not exhibiting any sign s of a serious mental disorder or conditi on, and he denied auditory or visual hallucination s. Follow up appointment was scheduled for June 2, 2018 . Eloy Federal Contract Facility Monday, May 28, 2018 Video surveillance foota ge from the north intake rear sallyport shows detainee TRAN exited a van with three other detainees at 9:26 a.m. At 9:28 a.m., Supe rvisory Deportation and Detention DETAIN EE DEATH REVIEW: Huy Chi TRAN Page 4 Healthcare and Secur ity Comp liance Ana lysis August , 2018 l_C 'r e:ali1t ,e i::11rii111eti 1111 :s 2020-ICLl-00006 4818 I· . . )(5 ); (b)(7)(C) . . Off 1.cer SDDO fo ~r----~ 1ssee n po mtmg to d"rrect TRAN to enter the h a11way. 0 n mterv1ew, SDD _b)(~);___ ·ecalled he direct ed TRAN to the hallway becau se the detainee was "sweat ing profuse ly" and he wanted the nur se to see him first for medical pre- screen ing . SDDd\~ /\~/;,~, said that when he asked TRAN if he was alright, he did not respond. He commented that a lot of detainee s do not respond to quest ions because they are upset whe n they arriv e. Other than l,µ::,L~,J.J,!,,l,>.!.,-,-.t...o. AN "seemed fine " to _ b)(6/;"' . Durin g interview of ICE Deportation Officer ~----h e confirmed SDDO ~/(~/;"' oved detaine e TRAN to the head of the line so he wou ld be the first to see the nurse. He recalled TRAN was swea ting so much that he asked another detainee if the air conditioning was workin g in the van. The detain ee stated it was . Offidb )(6); I sa id that he asked TRAN if he was okay but receiv ed no response. He comme nted the detain ee looked like he "was somewhere else." I (b)(6); (b)(7)(C) I RN j._ ______ _,was assigned to intake this date. On the video, she is seen speakin g with detainee TRAN at 9:28 a.m. and at 9:30 a.m. , he signed some paperwork and entered the Intak e area. Over the course of the next hour, TRAN was pat searche d, walked throu gh a medical detector, was given a property box , shower ed, changed into a faci lity uniform , and was placed in a holdin g cell with three other detai nees . Onc e in the cell, he ate a sack meal. The EFCF Receiving and Discharge Log document s the time of his booking was 9:45 a.m. (b)(6); (b)(7)(C) At 10:10 a.m. ~,.,,...,..,...,............,.,......,,..-,i. gned a pr e-scree ning note documentin g TRAN was alert and his behavior and b ea 1 g w orma l, but his appearance was anxious . The note also docume nts he spoke Englis h fluently, that a medi cal transfer summ ary accompa nied him from another facility, and that he was taking medications for current health probl ems. The pre-screening dispo sition was priority one. Note : The video doe s not show any interact ion betwee n TRAN and medical personnel between 9:28 a.m. and 10:30 a.m. when he left the holding cell, oste · dica l . . . (b)(6); (b)(7)(C) mtake screen mg (see below). Ther efore, the revi ewers conclu b)(6) (b)(7)(C) prescreenin g note docum ents her interact ion with TRAN at 9:28 a.m. · made no referenc e to the profu se swea ting observ ed by SDDO j(b)(6); Ind Offic b)(5); (b)(7)(c) (b)( 6); 7)(C) was prepared at FSPC on the day TRAN was The tran sfer summary referenced by RN (b)( tran sferred and admitt ed to EFCF. The summary documents a diagnosis of schizophr enia and that he arrived at FSF with haloper idol 2 5 milligrams (mg) to be taken once daily and fluoxetin e 3 20 mg, also to be taken once daily. The summary includes the note, "Please follow up at receiving facility medication attach ed." (b)( 6); (b)(7)(C) , documents TRAN 's statem ent, "I have been treated for depressio n for pa st years . e enied suicida l or homicida l thoughts or history of hallu cinations. He stated he had arr ived with haloperido l and fluoxet ine, both prescr ibed for morning dosing. He denied a history of attempting to harm him self or others or of being a victim 2 3 Haloperidol, common ly known by the trade name Haldo l, is an anti psychot ic medication. Fluoxetine tr eats depression and anxiety . DETAIN EE DEATH REVIEW: Huy Chi TRAN Page 5 Healthcare and Secu rity Comp liance Ana lysis Augus t , 2018 l_C •r e:ali1t ,e i::11rii 111et i 1111 :s 2020-ICLl-00006 4819 of physical or sexual assa ult. He deni ed smokin g or having eve r used alco hol or illicit drugs. Th e screen for symptoms of tuberculosis was negative , and he denied any dental problems. V ital signs entered at 4:46 a.m., were all within normal limits, as follow s: temperature 98.4, pul se 69, respiration s 16, blood pressure 109/75, and oxygen saturation 96. He denied pain, and he was found to be absent of adverse side effects related to use of the two psychotropi c medications. The exam ination noted norm al phy sical and emotional charact eri stics, with no disabilities, no disorgan ization of thoughts or behaviors, no agitation, and no baniers to communication . Th e skin assessment showed no abnorma lities. The intake assessme nt was abnormal, he was referred to a medical provid er for a comp lex physical exam ination, and he was medically cleared for custody. At 10:30 a.m. , TRAN is seen on video exiting the holding cell to see the nurse, pre sumably for intake screening. I 5 Note: fbH >; (b)(l)(C) entered an abbreviated intake screening in eCW , exp laining durin g interview that she did not comp lete a full screenin g because TRA N was screened at FSF two days earlier. Vitals signs entered at 10:43 a.m. were all within normal limits, as follows : temperatur e 98.8, pulse 92, respirat ions 18, blood pressure 120/78, and oxygen saturation 95. His height was 64 inches; his weight was 176.4 pound s. He denied · · · ion tested at 20/70 in the left eye, 6 20/ 100 in the right eye, and 20/70 4 in both eyes . b)( ); (b)(l)(C) did not document whether TRAN was wearing corrective lenses or whethe r he was asked if he wore them in the past. Note: Capta itj(b)(5); (b)(l )(C) ksA, stated durin g interview that detainees who are found to have vision deficits are either referred to optometry or are give n a commi ssary form for purchase of read ing glasses in a designated strength. A copy of the form is then filed in the medical record. Neither an opto metry referral nor a commi ssary form were located in TRAN ' s record. In her screening note, i~ii ~irci described detaine e TRAN as appropriat e in behavior, in no acute distress, well developed, and well-nourished. He reported taking Haldol and fluoxetine for depression for a period of five years , and that he last took medications the previous afternoon. He denied hallucination s, anx iety, and depression. No symptoms of tuberculosis infection were obse rved and a purified protein derivative skin test was planted . The test was read as negative two days later. The assessme nt finding was "abn ormal intake screening , refene d to medical provider." In the Notes section of her intake screening entry ,ICb)(6); (b)(l )(C) !wrote that telephon e encount ers were sent to a provider and mental health for furth er eva luation. The telephone encounte rs, prov ided to reviewe rs on site, were sent td(b)(5); (b)(l)(C) ~ and Cb _)C6 _)_;(b _)_C_)7(C _)____ ____, psychiatrist. l.... 4 20/20 vision is considered no rmal, based on being able t o see an object at 20 feet away. If vision is not 20/20, corrective lenses may be necessary. DETAIN EE DEATH REVIEW: Huy Chi TRAN Page 6 Healthcare and Secur ity Comp liance Ana lysis August , 2018 l_C 'r e:ali1t ,e i::11rii111eti 1111 :s 2020-ICLl-00006 4820 (b)(6); (b)(7)(C) Note: As discussed below, TRAN was examined b l(b)(6);(b)(7)(C)h aluated TRAN on Jun e 4, 2018. ~---~ later the same day; Dr. Patient education brochures were provided and the detainee said he understood the teaching and instruction. TRAN signed a consent for general treatment. (b)(6); During interview, (b)(7)(C) explained that detainee s who arrive with medications or with mental health issues are a priority and TRAN met both criteria. She stated her first impression was that he was okay but then noted he did not seem to fit in with the other detain ees. She did not know if it was because they were Spani sh speaking and TRAN spoke English, or if TRAN was simply anxious. The video shows TRAN returned to the holding cell at 10:39 a.m. He exited the holding cell at 10:48 a.m . and reported to the Intake desk where his property was inventor ied and documents were signed. Intake Officerl · · ng 35 seconds later. Per Investigator ~\ }~\rr:, report, the bag contained linens. Office (b)(7) (C) formed her that when he brought TRAN his bedding , the detainee did not say a word an seeme to be shaking a little. Over the course of the next 51 minutes, video shows Offic ~~~~ ~~;,,.. , the vicinity or walking past detainee TRAN' s cell on five occasions, never lookin g in to confirm the detainee's welfare. At 3:15 p.m. , he marked clipboards at three nearby cells but does not look in any of the three. After marking the clipboards, he passed TRAN' s cell at 3:17 p.m. without stoppin g. At 3:27 p.m. , Officer /(b)(6); ~~t the clipboard by TRAN 's cell but does not look in. At 3:45 p.m. , the video h \/ 7 \/r\ 6)· shows 1c ,~_,~, :~, lacing an orange card on TRAN' s cell door to indicate he~~.,. medical observation stat us but again, he does not look in the cell. At 3:47 p.m., (b)( ) · · (b)~~! ;r, laced an 6 orange card on the cell door next to TRAN 's, 605, and spoke to Officer 1h\f7\1r.,-~)(~)._ wh~ assigned to constant watch vigil for the detainee assigned to the cell. At 3:51 p.m. Officer~ is seen on video l · ·nto TRAN's cell and marking the clipboard. He then stood at the door b )( ) (b)( )(;) g in. Offi c ~~(~~l~r1 hen moved from cell 605 to look in TRAN's cell, after which Officer 6 7 ' pened then closed the door to the cell. He did not enter. Offi c ~\~~ !~ ,,..left the east side at 3:55 p.m. He returned at 4:04 p.m . and after delivering a meal tray to another cell opened the i~...,,,,.........,.als in TRAN's and another detainee 's cells. At 4:06 ·t·· (b)(5> d d Ott· (b)(G) k . . ·cte watc h an d p lace d Of p.m. , 1c rh,m rr., an e ice (b)(7)(C) ac me (b)(6) he detamee on smc1 a meal tray ~ 's food port . er Office (bl(7) (Cl moved away to deliver...,_........ ..,t10another cell, Offi cer ~ears to look in TRAN's cell. At 4:08 p.m. when Office assed the sack meal to the detainee on suicide watch, TRAN's tray remained on the foo porta . Officer ~~l~~\cc) DETAINEE DEATH REVIEW: Huy Chi TRAN Healthcare and Secur ity Comp liance Ana lysis August, 2018 2020-ICLl-00006 4833 Page 19 b)(6); hen looked again into TRAN 's cell. At 4:11 p.m. , Office b)(7)(C)delivered a meal to another .. On his way back to the officer 's station, he stopp ed (b)(6) 's cell briefly before moving on, but does not look in. A minute later, 4:12 p.m. , Offic (blm<~> ;c epor ted that when she arrive d, she passed Office (~)(~J,c ho was exitin g the area. He pointe to cell 606 and said, "Thi s is the cell." She called out to TRAN three times from the doorway but he did not respond. ~\~~\,c:, Note : EFDC Policy, Segregation/Re strictive Hou sing Unit Man ageme nt, 10- 100, section 10-100.4, (E)(2)(c) states, "St aff members equal to the number of inmate s/residents assig ned to the cell will be present pr ior to opening any occupied cell door. " ~ (b)(6 );(b)(7)(C) Per the video foota ge, Lieutenant~ arrived 22 seconds later and 5 6 en tered the cell. Officer b)( ); (b)(?)(C) nJ(b)( );(b)(?)(C) tallowed. Lieutena nt ~)~~t,, confirme d that when he arrived on th e unit (b)(6);(b)(7) (C) re stand ing outside 5 the cell. He said that when he and Office b)( ); entered TRA N's cell, he was laying on his stomach with his face in the pillow. Lieuten ant ~!}~!:r-\ ported that when he rolled the detainee onto his right side, TRAN was "cold to the touch and stiff." He recalled that a yellow/reddish discharge was coming from the detain ee' s nose and that the deta inee was not breathin g. He stated on inter view that he instructed security staff to begin CPR, later instructing that they rotate DETAINEE DEATH REVIEW: Huy Chi TRAN Healthcare and Secur ity Com pli ance Ana lys is August , 2018 2020-ICLl-00006 4834 Page 20 /~\ i~\i performance of ches t comp· · s afte r every four series to avo id fatigue. Offi cer onducted the first round. Lieutenant ~()~(i said that after directing initiation of CPR, he immed iately radioed Central Control to direct calling 911. The video shows he stepped out of the cell at 4: 17 p.m. and spoke into his radio, presumably to direct the 911 call. Note: Although the Central Control lo g documents the call was not made until 4:21 p.m., the Eloy Fire District Prehospi tal Care Report documents a unit was dispatched at 4: 19 p.m., sugges ting the call was made quickly after Lieutenant )~\/~\icl irection. The Central Control log details other events with times inconsistent wit v1 eo evidence. Because the officers in Control were not in a position to directly witness events, the reviewe r concludes the entries were made as information was reported and do not reflect the times events occmTed. For that reason , Central Control log entries are not included in the below recounting of events unless not documented elsewhere. I 6 Th e video shows RJ!