B16rRJBUfftJill Office ofEnforcement and Removal Operations ICE Health Service Corps U.S. Department of Homeland Stturity S00 12th Sttcct, SW Washington, D.C. 20S36 U.S, Immigration MEMORANDUM FOR: THROUGH: FROM: September 11, 2018 and Customs Enforcement .... , _);(_ b)_ (7_ ) (C_ )_ b)(6);(b)(7 ) ( ) (b)_ (6 ______ C r Assistant Director _ _ -------� � ICE Health Service Corps - - - - fb)(6); (b)(7 ) (C) fb) (6) ; (b) (7 )(C ) �l ---------------� Deputy Assistant Director of Clinical Services/Medical Director ICE Health Service Corps __.I b 6 b 7 C l(b)(6 ) ; (b)(7 )(C ) I ( ) ( ); ( )( )( ) Chief of Staff l ICE Health Service Corps �------------� Physician, Medical Asset Support Team ICE Health Service Corps r PJ1)(6); (b) (7)(C ) I b )(6); (b)(7}(C ) Assistant to the Assistant Directo! ICE Health Service Corps = ========--.,,.. b.,..,. �) ;::::;:(b)(::::;:7:::;: -, )(6 )( C:;:;:) fb)(6 ); (b)(7 )(C ) I Investigations Unit Chief ICE Health Service Corps '(/ fb)(6);(b)(7 ) (C ) 11 1 Senior Investigator/Fact Fin er ICE Health Service Corps b)(6); (b)(7 ) ( ) rb)(6 );(b)(7 )(C ) Investigator ICE Health Service Corps ����--------l(b)(6) ; (b) (7)(C ) (b )(6); (b) (7)(C ) or man contains pre-decisional om o toms Enforcement, ICE C (b) (6); (b)(7 )(C ) l not release without prior PR:EE>oa&.rf»IM,lfi>&UBEiJMTf-lIM.J.8&R:.4TW-E .�{)Ce,SS ,"-iJR: JN+EIWAb /JlSCV��ON()NJ.YlN()T€OR D1ST,/UR(,/'J:JQ,N Mortality Review - Roger RAYSON, lEL,'-B£R,f 'ffJ'E PR0CFJ:J& F0Rl1WE/fMfE. F>lSCUB&fQ1l 0i\'lf/ ,W:Jr.f.f>R f;Jl&'FRJBIJT.'Q.1r Mortality Review - Roger RAYSONJb)(B); (b)(?)(C) Page4 of33 The following is a summary of health care delivery/program weaknesses found during this review: 1. Continuity of Care. Mr. RAYSON did not receive access to appropriate and timely continuity of care in accordance with Performance-Based National Detention Standards (PBNDS) 2011 and IHSC policies. • The LDF Health Services Administrator (HSA) and Clinical Director (CD) received notification of Mr. RAYSON's pending release and intake into ICE custody five weeks in advance. Although indicated, the HSA and/or CD did not request additional medical infonnation from the BOP to determine ifLDF could support Mr. RAYSON's medical needs. They informed Enforcement and Removal Operations (ERO) that Mr. RAYSON was medically cleared for admission into LDF. • Obtaining additional medical infonnation from BOP in advance would have shown the need to expedite Mr. RAYSON's deportation so he could resume treatment for his cancer. • The HSA and/or CD did not infonn LDF health care staff of Mr. RAYSON's pending transfer to LDF. • Upon admission to the MHU, timely medical orders were not given to continue Mr. RAYSON's pain medications and diabetic diet. • A January 30, 2017 order to obtain additional medical records from the BOP was not implemented. 2. Medication management. LDF staff did not prescribe and administer medications to Mr. RAYSON in accordance with PBNDS 2011 standards, IHSC policies, and DEA regulations. • Controlled substance pain medications were administered to Mr. RAYSON without appropriate orders from a medical provider. • Nursing stafffrequently administered as needed (PRN) medications without noting in the medical record the subjective and/or objective findings to support administration of the medication. • Nursing stafffrequently did not document timely monitoring of Mr. RAYSON's response to PRN medications. • Medical providers gave verbal orders for medications in non-emergent circumstances, while they were present in the facility. • An order for a PRN narcotic pain medication was incorrectly transcribed on the medication administration record (MAR) and administered as a regularly scheduled medication. Enforcement, ICE {W:EB£C.'SK»,.',tVE>El.'fJEIMT.W-E P:R0CEG& fi.f}iiJ.,&q:ERJ�4l. JJ..'SCUSS.�M ONLYlNO'l'li'-QR. f>.'STRf8f:ff1YJ,V Mortality Review - Roger RAYSON, fb)(6); (b)(7)(C) Page 5 of33 3. Access to an appropriate level health care provider. Mr. RAYSON did not receive timely and appropriate referral to an appropriate level health care provider in accordance with PBNDS 2011 standards. • • • • • • • An advanced practice provider (APP) attempted to consult with the CD by telephone, but the CD was unavailable and the CD's voice mailbox was full. The APP did not attempt to notify the HSA of the CD's unavailability to receive instructions for an alternate CD to consult with. A registered nurse (RN) noted that Mr. RAYSON had abnonnal vital signs (VS), but did not recheck them and/or consult a medical provider as indicated. Mr. RAYSON required skilled nursing care; discharge from the MHU to GP/SMU was inappropriate. APPs infonned the CD that they did not feel comfortable caring for Mr. RAYSON due to the complexity of his medical care. LDF did not have a staff physician and the CD did not assume primary responsibility for Mr. RA YSON's medical management. When an LDF psychologist infonned the HSA, CD, APP, and visiting IHSC Associate Medical Director (AMD) that Mr. RAYSON was "looking bad and should not be housed in SMU," a medical provider did not evaluate Mr. RAYSON and he remained in SMU. APPs repeatedly recommended transferring Mr. RAYSON to a hospital, but the CD persisted in recommending caring for Mr. RAYSON at LDF. Mr. RAYSON'scondition warranted transfer to a higher level ofcare. Nursing staff regularly reported about Mr. RA YSON's deteriorating health status. In response to these reports, LDF clinic administration (HSA, AHSA, and CD) focused their efforts on communicating to ERO the need to deport Mr. RAYSON as soon as possible. However, LDF clinic administration did not ensure Mr. RAYSON received an appropriate level of care while detained. 4. Access to appropriate medical care. Mr. RAYSON did not receive timely and appropriate access to medical care accordance with PBNDS 2011 standards. • On one occasion, Mr. RAYSON remained in moderate to severe pain for over seven hours until a physician prescribed narcotic pain medication. • Mr. RAYSON required skilled nursing care; discharge from the MHU to GP/SMU was inappropriate. • CD review of Mr. RA YSON's abnormal urinalysis results was delayed four days. The CD did not develop an appropriate treatment plan in response to these results. • The CD stated that he evaluated Mr. RAYSON numerous times while he was in the MHU, but he did not document these encounters in the medical record. For 1c1a contains pre-decisional and/or deliberative process in mandatory disclosure under the Freedo . Do not release without prior , m1grat1on and_Cu.sloms Enforcement, ICE Health Service Corps. �f»!Al:,,(f>S.'-BERA.1'.'J'E.'2J.1.Q� ,q;;� '�1.1:'.Ell>',fb f>l&GUSSlQN QNL¥/,¥0T,'+JR BISTil:/81:ffffhY Mortality R eview - Roger RA YSON,fb)(6); (b)(7)(C) Page6 of33 • A physician did not examine or observe Mr. RAYSON after he was discharged from the MHU. • The CD's care and treatment plan throughout Mr. RAYSON's LDF detention, as evidenced by the medical record, appears as if the CD deliberated Mr. RAYSON' s care from afar without examining the patient when indicated and as requested by theAPPs. • An APP evaluated Mr. RAYSON in SMU but did not document this encounter. • An LDF psychologist informed the CD and an APP that Mr. RAYSON "was looking bad" and should not be housed in SMU. A medical provider did not examine Mr. RAYSON. • APPs repeatedly recommended transferring Mr. RAYSON to a hospital, but the CD persisted in managing Mr. RAYSON at LDF. Mr. RAYSON's condition warranted transfer to a higher level of care. 5. Access to appropriate nursing care. Mr. RAYSON did not receive timely and appropriate access to nursing care accordance with PBNDS 2011 standards and IHSC policies. • Nursing staff did not develop a nursing plan of care for Mr. RAYSON during his MHU admission. • While Mr. RAYSON was admitted to MHU. nursing staff did not routinely document Mr. RAYSON' s ability to engage in activities of daily Iiving. • Some nursing staff reported they were unable to provide skilled nursing care in the MHU because the beds could not be elevated to a level where nursing staff could perform care safely, and they could not elevate the head or foot of the bed to improve patient comfort. • An RN noted tllat Mr. RAYSON had abnonnal VS but did not recheck them and/or consult a medical provider as indicated. • Nursing staff did not document taking VS every two hours as ordered by a medical provider. • There were several instances of nursing staff failing to administer PRN medication for pain and/or nausea when indicated. For example, while housed in the MHU, on one occasion Mr. RAYSON did not receive medication to relieve his severe pain and nausea with vomiting for over nine hours; on another occasion he waited over eight hours. • Nursing staff did not immediately notify a medical provider about Mr. RAYSON's abnonnal urinalysis results. • Generally, when nursing staff administered PRN pain medications or anti-nausea medications, they did not document Mr. RAYSON's symptoms that warranted administering these medications. In addition, they did not reevaluate Mr. RAYSON within an hour to determine if the medication relieved his symptoms. • Nursing staff observed Mr. RAYSON's deteriorating status while in the SMU and reported it verbally during shift reports; however, they did not routinely document these observations in his medical record. o ma ins pre-decisional · · release without prior P·REB£€.'fJK»l:,fb'E>E£}BE/.l,fTU'E ,P-RQ(]F,El; ,"GR. JH:rERll.41, fJJSC.USSlO.V €»ll¥/iWJ'l'F9R B1'&'FRJSLIT!01II Mortality Review - Roger RAYSON, fbl(6); (b>(?)(C) Page 7 of33 6. Access to appropriate mental health care. Mr. RAYSON did not receive timely and appropriate access to mental health care in accordance with PBNDS 2011 standards and IHSC policies. • During Mr. RAYSON's health assessment and physical examination, an APP noted Mr. RAYSON was depressed. The APP did not refer Mr. RAYSON to mental health for evaluation. 7. Patient advocacy. LDF health care staff did not advocate in a timely and appropriate manner for Mr. RAYSON to receive necessary and appropriate health care in accordance with PBNDS 2011 standards and their licensed health care professional duty of care. • Nursing staff and/or the APP did not take steps to advocate for Mr. RAYSON, so an order for PRN narcotic pain medication was written in a timely manner. Mr. RAYSON remained in severe pain for over eight hours until the order was written. • An RN medically cleared Mr. RAYSON for SMU even though he observed Mr. RAYSON "looked like he needed to be in a hospital." The RN did not take steps to advocate for a more appropriate placement. • LDF health care administrators frequently advocated for Mr. RAYSON's rapid deportation; however, they did not take steps to ensure he received appropriate care while in detention. • Although Mr. RAYSON was on the Significant Detainee 1llness (SDI) list and staff reported his condition was deteriorating in SMU, the LDF HSAs did not visit Mr. RAYSON. • LDF administrators did not take proactive steps to identify community resources to support the medical needs of patients at LDF. • LDF administrators did not take proactive steps to transfer Mr. RAYSON to a detention facility with community resources that could meet Mr. RAYSON's needs. • When the IHSC Medical Director/Acting Assistant Director (AD) requested a headquarters (HQ) level review of Mr. RAYSON's medical care, the review relied on summaries and reports created by LDF staff. The designated HQ reviewer did not conduct an independent review of Mr. RAYSON's medical records. 8. Special monitoring unit. Mr. RAYSON did not recejve appropriate access to SMU health care monitoring in accordance with PBNDS 201 I standards and IHSC policies. or mandato · ocument contains pre-decisional Enforcement, ICE · · · lease without prior .DffEl:JECHHOiV,fb'B£MlJER:iff.W-E PR.0eE.i5 F0R .WTERJl,H, l,>,'&CUB&'ON 0Nll'/NOf'F9fl l).'SfRf-Br,n:JQ..1/ Mortality Review - Roger RAYSON,ICb)C5); (b)(?)(C) Page 8 of33 • An RN medically cleared Mr. RAYSON for placement into SMU without consulting a medical provider, even though the RN believed this placement was medically contraindicated. • The documented observations of Mr. RAYSON' s health status during most of the SMU nursing rounds were inconsistent with their verbal reports of his deteriorating status. Recommendations • Forward these findings to the IHSC Deputy Assistant Director (DAD) of Health Care Compliance (HCC). • The IHSC DAD of HCC will share these findings through appropriate communication channels to ICE, the LDF administrator and health authority for review and to create a corrective action plan (CAP). • The respective IHSC HCC Unit and ICE will ensure the CAP is implemented and sustained. Mortality Review Detailed Report: On March 13, 2017, lHSC received notification of the death of ICE detainee Roger RAYSON, A206 839 071. Mr. RAYSON, a 47-year-old Jamaican male, was in ICE custody from January 28, 2017, to March 13, 2017, and assigned to LDF, Jena, LA, on the date of his death. The Assistant Director for IHSC requested a mortality review to learn from Mr. RAYSON's death by reviewing the care provided and the circumstances leading up to his death. The goal of the mortality review is to detennine the appropriateness of clinical care; ascertain whether changes to policies, procedures, or practices are warranted; and identify issues that require further study. The following report is based on the findings and recommendations of the mortality peer review committee, which convened on April 6, 2017. The review was based on the following infonnation: l ) Mr. RAYSON's LDF medical records, emergency medical services (EMS) and community hospital records; 2) notification reports; 3) ICE ENFORCE Alien Removal Module (EARM) and ICE ENFORCE Alien Detention Module (EADM) database records; 3) Mr. RAYSON's LDF detention file; 4) Mr. RAYSON's Alien file; 5) LDF post logs; 6) Mr. RAYSON's death certificate and auto s re ort· 7 an on-site review and staff interviews conducted by fact-finder b)(5); (b)(?)(C) t LDF on March 28 and 29, 2017; and 6) applicable LDF and ICE Detention Standards. Qhsryatiops apd Becoroweudations: Sequence ofEvents November 24, 2014 mandatory disclosure under the Freedom o l . Do not release without prior , ustoms Enforcement, ICE Health Service Corps. Pll:Ef)&<:J.',S,Wl.JAk/fl�MBe/MT:VE PROC-eii8 P€JR 1i1,q:p,ff/hfh B{SCUSS.'Oi'I 9.vtI'/!i()r F8R D1�TJlJ.S(.1'FJQ.N Mortality Review - Roger RA YSON,j(b)(B); (b)(?)(C) Page 9 of33 Mr. RAYSON entered the U.S. as a non-immigrant visitor and was found in possession of cocaine. He was released to the custody of the U.S. Marshal's Service (USM) and subsequently convicted and sentenced to federal prison with a projected release date of January 28, 2017. December 21, 2016 ERO, Oakdale, LA, notified the LDF HSA ofMr. RAYSON's January 28, 2017 pending release date from the BOP Federal Medical Center (FMC), Lexington, Kentucky (KY), and requested a determination of whether he was medically cleared for housing at LDF. ERO provided the HSA with a copy of Mr. RAYSON's BOP medical summary. The medical summary showed that Mr. RAYSON had the following health conditions: Burkitt's non-Hodgkin lym phoma; OM; anemia; H1N; GERO; metabolic disorder; gout; pain; and a history of arthritis. [Investigator's note: The medical summary did not include information about Mr. RAYSON's diagnoses ofHIV and AIDS.] Other information included in Mr. RAYSON's medical summary included the following treatment plans: weekly weights, daily VS, three times a day (TIO) blood glucose monitoring. lower bunk, elevator pass, pennanent sedentary work, regular- no pork, no milk diet. crutches. eye glasses, and no travel restrictions. [Investigator's note: The medical summary did not include information that Mr. RAYSON was pending an evaluation by a hematologist/oncologist (a doctor thal specializes in the treatment ofblood disorders and cancer).J The medical summary showed that Mr. RAYSON was prescribed the following medications: abacavir (ABC) 600 mg, daily (for HIV), acetaminophen (APAP) 325 mg, every six hours, PRN (for pain), acyclovir 200 mg, twice daily (BID) (for HIV), allopurinol 300 mg, daily (for gout), enteric coated aspirin (ECASA) 81 mg, daily (for HTN/DM), dolutegravir sodium (DTG) 50 mg, daily (for HIV), ferrous gluconate 648 mg, daily (for anemia), fluconazole 200 mg, daily (for HIV), glipizide 10 mg, BID (for OM), hydrochlorothiazide (HCTZ) 12.5 mg, daily (for HTN), indomethacin 25 mg, BID, PRN (for gout), regular insulin per sliding scale, TIO (for OM), lamivudine (3TC) 300 mg, daily (for HIV), levofloxacin 500 mg, daily (for infection), lisinopril 10 mg. daily (for HTN), and metfonnin 1000 mg, BID (for OM). January 17, 2017 ERO Oakdale, LA, reminded the LDF HSA that they were still awaiting a response regarding whether Mr. RAYSON was medically cleared for admission into LDF. The HSA forwarded the medical summary to the LDF CD (hereafter identified as CD-1 ), who in tum stated that LDF could medically accommodate Mr. RAYSON if the LDF Assistant Field Office Director (AFOD) concurred. [Investigator's note: the LDF clinic did not contact FMC Lexington to request additional information or records.] The AFOD informed the HSA and CD-1 that Mr. RAYSON would be admitted to LDF ifIHSC medically cleared him for admission. o ins pre-decisional and/or deliberative rocess i not ,v/ease Enforcement, ICE wilhoul prior PREBECIS:l6lfAt/E>ELIBElbt1-JJ'E .Ofl9C/£&& 1C€>R INFENl,1/:; Bs16GUS81QV €Jlt,flYl N0'f1fu:9R B,!STRJBUFJQY Mortality Review - Roger RAYSON,l(b)(6); (b)(7)(C) Page 10 of33 [Irwesligator 's note: the LDF HSA and CD-I did not notify LDF health care staffofMr. RAYSON 'spending admission.] January 28, 2017 (Saturday) At 2:30 a.m., Mr. RAYSON arrived at LDF. Mr. RAYSON's medical transfer summary and 56 pages of medical records from the BOP listed the following health problems: Burk.itt's non­ Hodgkin lymphoma, HIV, HTN, DM, gout, nausea, arthritis, anemia, GERD, metabolic disorder, and pain. His BOP medical transfer summary listed all the medications noted above plus oxycodone/acetaminophen (APAP) 5 mg/325 mg, two tablets, every six hours, PRN (a narcotic pain medication), and ondansetron 4 mg, every eight hours, PRN (for nausea). These medical records did not include information about the history, prior treatment, and current treatment plan for the Burkitt's lymphoma, or any other medical provider evaluations, observations, or treatment plans. At 3:40 a.m.• during the medical intake screening, Mr. RAYSON reported "feeling bad" secondary to 9/10 pain all over his body for the past one to two days. His VS were: temperature (T) 97.3, pulse (P) 94, respirations (R) 18, blood pressure (BP) 132/85, oxygen saturation (02 sat) l 00 percent (%), height 65 .5 inches, weight 179 pounds (lbs.), and body mass index (BMI) 29.33. His finger stick glucose was 233. The nurse did not observe any physical abnormalities. The intake screening nurse consulted with an APP who ordered Mr. RAYSON housed in the MHU until evaluated by a medical provider later that morning. A nurse also administered pain medication (oxycodone/AP AP). Later that morning, an APP performed a health appraisal and physical exam. Mr. RAYSON reported he was diagnosed with HIV in December 2014 and Burkitt's non-Hodgkin lymphoma in August 2016, while incarcerated in a Florida (FL) prison. Mr. RAYSON received one chemotherapy {chemo) treatment in September 2016 while incarcerated in FL, and reported he was supposed to receive chemo every three weeks, but did not receive it. Mr. RAYSON transferred to FMC Lexington, KY, in November 2016. During this encounter, Mr. RAYSON complained of constant 7/10 aching left upper forearm pain for the past four to five weeks. He also reported the following symptoms: nausea, vomiting, intermittent midline upper and lower abdominal pain and swelling, swollen glands in his head and neck, unintentional significant weight loss over a period of several months, ringing in his ears since a motor vehicle accident in 1992, cold intolerance, occasional weakness, and light headedness. Mr. RAYSON's VS were: T 98.2, P 89. R 18, BP 124/76, 02 sat 98%, and weight 179 lbs. The following abnonnalities were observed during the physical exam: General Appearance - ill appearing, thin, uncomfortable due to pain, visibly upset; Head - some edema with pain to the right lower scalp area extending up posteriorly to the right auricle, hair scarce and patchy; Neck posterior cervical nodes enlarged, submandibular nodes enlarged; Lymph nodes - cervical nodes or mandat ins pre-decisional EnforcemenJ, ICE · · races · o not release without prior .''REf>EC,!&.'-Oll,H,lfJ,F,ll-B€JM 'F:V-E .OR.06€,SS F0R.WTERIJ,4b J;NJ;GUS&'f>..I' QW.¥/ ,1101'.r.f>R. F>/S'FR/Blffi.'911 Mortality Review - Roger RA YSONJb)(6); (b)(7)(C) Page 11 of33 hard, cervical nodes enlarged, shoddy; Chest - port pa]pated in the left upper chest wall; Abdomen - small umbilical hernia; Musculoskeletal - slow shuffling gait; Extremities - hard fixed nodule palpated with tenderness left upper posterior foreann; Psych- depressed. The APP diagnosed Mr. RAYSON with the following conditions: type 2 DM, anemia, HTN, GERO without esophagitis, gout, Burkitt's lymphoma, HIV, and osteoarthritis. The APP continued all the medications listed on Mr. RAYSON's transfer summary and ordered the following: a referral to the LDF physician for continuation of oxycodone; an oncology consultation; an infectious disease (ID) consultation; and a diet for health. [Investigator's note: The JD referral was sent out on January 31,2017. On February 9,2017 the ID denied the request "at this time. "A referral to mental health or a requestfor additional medical records were not initiated] The APP admitted Mr. RAYSON to the MHU because of his non-Hodgkin lymphoma and HIV, with nursing rounds and VS every eight hours. The APP attempted to consult with CD1 by telephone; however, CD-I was unavailable and the CD's voice mailbox was full. [Investigator's note: From January 27-February 11, 2017, another temporary duty CD was assigned to LDF; hereinafter identified as CD-2.] January 29, 2017 An APP noted Mr. RAYSON had inflamed lymph nodes and was ashen, weak, and dehydrated. His health appraisal and examination were otherwise unchanged from the previous day. Mr. RAYSON was concerned about not receiving chemo. His VS were: T 98.3, P 88, R 18, and BP 122/85. The APP consulted 'with CD-2 and referred Mr. RAYSON to the Rapides Regional Medical Center (RRMC) ER for evaluation and treatment of his ill, dehydrated+ and weak appearance, and frequent bouts of nausea and vomiting while taJcing ondansetron. He was transported to the ER via facility van because he could walk and did not have any respiratory or cardiac dysfunction. Mr. RAYSON was evaluated in the �C ER for a chief complaint of acute onset of nausea and vomiting that day. Mr. RAYSON's examination and VS were within normal limits (WNL), except he had palpable lymph nodes on the right side of his neck. His laboratory studies included a complete blood count (CBC), comprehensive metabolic panel (CMP), and urinalysis (UA). The results were WNL except as follows: red blood count (RBC) 3.35; hemoglobin (Hgb) 10.3; hematocrit (Hct) 30.6; white blood count (WBC) 3.3; monocytes 18.0; metamyelocytes l.0; sodium (Na) 134; glucose 119; osmolality 269; calcium (Ca) 5.44; lipase 8; and urobilinogen 2.0. The ER physician diagnosed Mr. RAYSON with vomiting, treated him with one liter of intravenous (IV) fluids, ondansetron 4 mg IV, and discharged him back to LDF. At approximately 6 p.m., Mr. RAYSON returned to LDF and was readmitted to the MHU under the previous admission orders. His VS were: T 97.6, P 98, R18, BP 131 /9 I, finger stick glucose 270, and pain level 7/10. Throughout the evening Mr. RAYSON continued to complain of 7/10 aching pain in his left shoulder and ann. At approximately 10 p.m., his VS were: T 97. 7, P 125; ins pre-decisional a Enforcemenl, ICE · · lease withou/ prior m �!S/Os.V.45'.©61,JBeR:,� +!JlE 1�rJCEES iC9R IN:i:EIW�f.J; B1•SC1:JSBJ€h\' QVLJ'l1V0T1reR D.'STR!B'=IT.'f>ill/ Mortality Review - Roger RAYSON. rb)(6); (b}(7)(C) Page 12 of33 BP 97/64, R 18. An RN acknowledged Mr. RAYSON's increased heart rate and noted that Mr. RAYSON was ill-appearing but did not have chest pain or shortness ofbreath. He was encouraged to relax and was given two tablets of oxycodone/AP AP S mg/325 mg, for pain. His VS were not rechecked, and a medical provider was not consulted. January 30� 2017 The LDF HSA sent the following email to the LDF AFOD: "Medical Hx: Non-Hodgkin's Lymphoma Burkitt's, Diabetes, multiple other medical conditions. Received from Etowah, unannounced, over the weekend ... He has serious medical conditions and we have already sent him to ER. We need to look at moving him out as soon as possible. Please advise." An APP evaluated Mr. RAYSON. He complained of constant aching generalized 7/10 pain. with worse pain in his neck. He also complained of nausea, lower abdominal discomfort. and feeling cold. His physical examination was WNL except: General Appearance - ill appearance, uncomfortable due to pain, moaning, occasional crying; Neck- anterior and posterior cervical nodes enlarged; Lymph Nodes - cervical nodes firm, inguinal nodes enlarged and tender. His VS were: T 97.7, P 125, R 18, BP 97/64. [Jm,estigator's note: These VS were taken at approximately IO p.m. the previous evening. The APP presumed they were taken that morning.] The APP ordered the nurses to monitor Mr. RAYSON's VS every two hours and to report all abnormal findings and significant changes "by way of [telephone encounter]." The APP reordered all of Mr. RAYSON's previously ordered medications and added APAP 325 mg, one tablet. four times a day (QID), PRN. The APP also requested staff obtain Mr. RAYSON's laboratory studies (labs) and records from the previous facility. [Investigator's note: Every two-hour VS were not documented. An attempt to obtain the medical records in response to this request was not documented.] An LDF staff physician (hereinafter identified as MD-I) evaluated Mr. RAYSON. MD-1 documented that Mr. RAYSON reported the following: in August 2016 a specialist performed a needle aspiration of an area of swelling in his right anterior neck; initially, the specialist informed Mr. RAYSON that he had a cyst, but three days later the swelling returned and a biopsy revealed he had Burkitt's lymphoma; Mr. RAYSON transferred to Lexington FMC and started chemo; he was supposed to receive eight cycles of chemo - every 21 days, but he received only one treatment; Mr. RAYSON received a positron emission tomography (PET) scan and a CT scan in January 2017, but he did not know the results; the BOP informed him that due to his impending release, his treatment should be completed at home. Mr. RAYSON complained of periodic 5/10 pain in his shoulders, left upper arm, knees, and ankles. He informed MD-I that he did not want to continue taking oxycodone/APAP, because he did not want to develop a drug dependency, and indomethacin 50 mg adequately controlled his pain at Lexington FMC. He also complained of intermittent fatigue and swollen glands. · ment contains pre-decisional and/or deliberati11e roce For O 1c1a mandatory disclosure under the Free (5)_ Do no/ release without prior migration and Customs Enforcement, ICE Health Service fl.REl}6CISK».',4-b©QJB&�4T!J'E .�()� ,M+J.� JA'+FtRll�l, JJ,'S(J.'(,J.�,K)N 0-NI:.¥/ NO'l'FGJR 9.'STRJBfH.'9.¥ Mortality Review - Roger RAYSON, fb)(B); (b)(?)(C) Page 13 of33 Mr. RAYSON's physical examination was WNL except: General Appearance - frail; Lymph Nodes - healed surgical scar over the right anterior neck with some tenderness on palpation. His VS were: T 98, P 91, R 18. BP 121/81, weight 179 lbs., and finger stick glucose 210. MD-1 changed the indomethacin from 25 mg, BID, PRN, to 50 mg, BID, and did not continue the order for oxycodone/APAP. A UA was ordered for the next day. [Investigator's note: The UA was performed two days later, on February I, 2017.] VS frequency changed to every shift and PRN, and Boost supplement BID was ordered. [J,n,esligator's note: MD-1 started an extended period of/eave the next day. MD-I handed-off care for Mr. RAYSON to CD-2 prior to his departure.] At 5:46 p.m., an RN noted Mr. RAYSON was ill-appearing. tearful, intermittently upset, and complaining of 7/10 lower abdominal pain for which he received his evening dose of indomethacin. January 31, 2017 At 5:44 am.• nursing staff noted Mr. RAYSON had severe (9/10) generalized pain. Nursing staff notified an APP about Mr. RAYSON's pain and were informed that CD-2 needed to order additional pain medication; pain medication was not ordered at that time. At approximately 10:24 a.m., Mr. RAYSON had an episode of chest pain with exercise, with VS: T 97.7, P l 12, BP 124/88. His electrocardiogram (EKG) was WNL and no further treatment was ordered. At approximately 11 :22 a.m., during MHU APP rounds. Mr. RAYSON complained of generalized moderate (5/10) pain. His physical examination was WNL except: Neck- anterior and posterior cervical nodes enlarged. The APP noted his VS: T 97.7, P 112, R 18, BP 124/88. No additional pain medication was ordered. At 12:43 p.m .• nursing staff noted Mr. RAYSON had moderate (7/10) pain. No additional pain medication was ordered. At I :42 p.m., CD-2 ordered tramadol I 00 mg (narcotic pain medication) orally, every six hours, PRN, for left leg pain, for one day only. At 7:26 p.m., Mr. RAYSON reported that his pain level was mild (3/10). [Investigator's note: Nursing slqf/did not document when the inilia/ dose of tramadol was administered] Mr. RAYSON received an additional dose of tramadol at 9: 15 p.m. February 1� 2017 At 2:20 a.m., Mr. RAYSON cried hysterically and reported excruciating severe (10/10) pain in his left knee, which was not relieved by trarnadol. He also vomited once but denied nausea and refused anti-nausea medication. The on-call APP ordered a one-time dose ofketorolac 60 mg, intramuscularly (IM) (a nonsteroidal anti-inflammatory drug (NSAID)), and diphenhydramine 50 mg, IM (an antihistamine with sedating effect). At 4:07 a.m., Mr. RAYSON reported that his leg pain was moderate (4/10). At approximately 6:15 a.m., an APP evaluated Mr. RAYSON. He complained of vomiting without nausea; "it just came up; my stomach was not hurting or anything." He also complained ment containspre-decisional and/or deliberative process in or . Do not release without prior mandatory disclosure under the Free m1grat1on and Custo ms Enforcement, ICE Health Service orp . ?"/tEMC}fHO,\'Ab'BEt.Y1ER:A Tf-J'-E PReCE:55 reR }jlJfEll:N,f.J. Bl6Cl:JS&'Q/1/ �.U!¥/ ...10rf:QR. Dl$T..PJ.SL/+lQW Mortality Review - Roger RA YSON,1Cb)(6); (b)(7)(C) Page 14 of33 of severe (8/10) generalized and left knee pain, and he was visibly limping. Mr. RAYSON refused his breakfast because he was not hungry and in pain. His physical examination revealed no swelling, heat, or erythema in his left knee; however, it was tender to palpation. The APP noted it was too soon to order additional pain medication because Mr. RAYSON received an injection at 2:30 a.m. The APP also noted the labs ordered the day before were still pending. The APP was concerned about Mr. RAYSON's deteriorating condition from when she first evaluated him two days earlier, and at approximately 8 a.m., consulted with CD-2 about Mr. RAYSON's pain, adjustment of his pain medication, and the possibility of sending him back to the hospital. CD-2 elected to wait for the pending lab results to evaluate Mr. RAYSON's immunocompetency. CD-2 recommended that if Mr. RAYSON was not immunocompromised, he should be discharged from the MHU to GP, which may help with his mental health status and pain. CD-2 did not adjust Mr. RAYSON's current pain medications, which were indomethacin 50 mg, BID, and an order for tramadoJ I 00 mg orally, every six hours, PRN, that was due to expire at 1:30 p.m. that day. The APP also submitted a request to the IHSC ID consultant to review Mr. RAYSON's records when the lab results were available. On February 1, 2017, the following labs were drawn (non-fasting): RPR, CD4, HIV-RNA, Lipid panel, CMP, CBC with differential, and Hgb AIC. On February 2, 2017, the lab results were received and WNL except: Hct 29.8; Hgb 10.l; CD4 247; WBC 3.1; % CDS pos. lymph. 67.7; neutrophils 1.3; CD4/CD8 ratio 0.28; RBC 3.38; % CD4 pos. lymph. 19.0; HIV-I RNA by PCR < 20; logl0 HIV-I RNA TNP; genotype assay TNP; LDL 137; HDL 38; triglycerides 152; cholesterol 205; eGFR 53; Ca 11.4; potassium (K) 5.3; creatinine 1.53; glucose 113; Hgb Ale 7.9. In response to these results the following labs were ordered for the following week: Ca, CMP, and parathyroid hormone (PTH). At approximately 12:45 p.m., an RN noted Mr. RAYSON complained of severe 7/I0generalized pain, with nausea and vomiting, and the RN observed that Mr. RAYSON appeared uncQmfortable due to pain and he had limited range of motion in his left arm due to pain. The RN did not administer pain medication to Mr. RAYSON. At approximately 3:50 p.m., a detention officer notified an RN that Mr. RAYSON was crying in his MHU room. The RN evaluated Mr. RAYSON. He complained of severe 10/10 pain in both legs and the right side of his neck. The RN observed Mr. RAYSON moaning in pain and was ill appearing. At approximately 4:30 p.m., an APP gave a one-time dose order for ketorolac 60 mg, IM, and diphenhydramine 50 mg, IM, and the RN administered the medication. At approximately 6:30 p.m., an RN received an order from an APP to give Mr. RAYSON promethazine 25 mg, [M, now, and may repeat once in eight hours (anti-nausea medication), and an additional order that the RN "may give" only two more doses of ketorolac 60 mg, lM, and diphenhydramine 50 mg, IM, every six hours. For man contain.s pre-decisional omo toms Enforcement, ICE · · .OR&IN!:C.'S.ffi»1,�b'f)als/.S6ll 4Tfl!i' .�0CE&S ,fi+JR J,�q:Ji,.'?;}IAJ. 9.'SGUESlf»lfJN-lf/NOr.r.eR:. Dti.TRf.att:r:taN Mortality Review - Roger RAYSON,fbl(6); (b)(?)(C) Page 15 of33 February 2t 2017 At approximately 5:45 a.m., Mr. RAYSON complained of constant , knife-like, 10/10 severe pain in his right knee and back, that was unrelieved with medications. An RN observed Mr. RAYSON appeared severely ill, uncomfortable secondary to pain, disheveled, tearful, and lethargic. His VS were: T 97.5, P 98, R 18, BP 134/97, and finger stick glucose 137. Mr. RAYSON did not receive any PRN pain medication. At approximately 8:30 a.m., the HSA emailed CD-2 to inform him that the APPs were concerned that Mr. RAYSON's condition was worsening and he may need to be admitted to a hospital. The HSA asked CD-2 to "look at him and advise how you feel we need to manage [him]." The HSA also infonned CD-2 that he included Mr. RAYSON on the Serious Detainee Illness (SDI) list which was submitted to the IHSC Regional CD and Regional HSA. The HSA wrote the following information about Mr. RA YSON's condition on the SDI list: "dx HIV+, Burkitt's lymphoma, DM, HTN, Nausea, Severe Lymphadenopathy." No further information was provided. At approximately 10 a.m., Mr. RAYSON received PRN APAP. At approximately 10:30 a.m., CD-2 reviewed the following labs that were drawn (non-fasting) on February I: RPR, CD4, HIV-RNA, Lipid panel, CMP, CBC with differential, and Hgb AIC. These lab results were WNL except: Hct - 29.8; Hgb- 10.1; CD4 - 247; WBC - 3.1; % CDS pos. lymph. - 67.7; neutrophils - 1.3; CD4/CD8 ratio - 0.28; RBC - 3.38; % CD4 pos. lymph. - 19.0; HIV-I RNA by PCR < 20; loglO HIV-I RNA TNP; genotype assay TNP; LDL- 137; HDL-38; triglycerides - 152; cholesterol - 205; eGFR - 53; Ca - 11.4; potassium (K) - 5.3; creatinine 1.53; glucose - 113; Hgb A le - 7.9. In response to these results CD-2 diagnosed Mr. RAYSON as having hypercalcemia (elevated blood calcium level) and ordered the following labs in one week: Ca, CMP, and parathyroid hormone (PTH). In addition, CD-2 discharged Mr. RAYSON from MHU to GP. CD-2 continued all of Mr. RAYSON's medications, which included the following pain medications: indomethacin 50 mg, BID, and one tablet of APAP 325 mg, PRN, QID. CD-2 also ordered a follow-up visit in one week, 1800 calorie ADA diet, full activities, no special needs, and cafeteria privileges. At 10:45 a.m., an RN acknowledged CD-2's order to release Mr. RAYSON to GP. The RN also noted Mr. RAYSON complained of7/I0 pain with nausea and vomiting. He was ill appearing and uncomfortable due to pain, and ate 50 percent of his breakfast and drank a nutritional supplement. His VS were: T 98, P 100, BP 122/88, R 18. Mr. RAYSON was given a cool pack for his left knee pain. At approximately 11:40 a.rn., the IHSC ID consultant reviewed Mr. RAYSON's medical record and made the following assessments and recommendations: ment conlains pre-decisional and/or deliberative rocess For ,c,a mandatory disclosure under the Free om '5). Do not release without prior a ,on and Cusloms Enforcement, ICE Health Service orp . PR:£9EC.'&/9iVlfl::/E>E-b1�� TfJCE 1DR0CEfrS i'G9R: llfFER}l, 11> E>/6CUSSf9N 8,11£]l,' 1'1€Jl!1COR. Bi'&'FRJ9br:f.'9AI Mortality Review-Roger RAYSONJb)(6); (b)(7)(C) Page 16 of33 AIDS based on neoplastic process, in need of additional treatment given hypercalcemia and hyperkalemia (? Paraneoplastic vs bone mets), mild renal insufficiency. 1) Continue current [anti-retrovirals] ARVs; if [DTG] is not available in Jamaica can be substituted with raltegravir 2x/day. 2) May need hospital admission, needs oncology asap to detennine, appt. pending per referrals tab; maintain good hydration, IVF if necessary. 3) Advise on how long he is likely to be in custody. 4) Ge/chlamydia NM. 5) Per [immunizations] records, he should receive, Hep A dose #2 now to complete initial series. Already has Hep B seroprotection. Prevnar followed by pneumovax in 8 weeks. Manactra dose # I followed by dose #2 in 8 weeks. 6) Defer other chronic care management to ( MD-I]; ID consult placed by [LDF APP] pending appt. given complexity of case, and collocated with oncology, may be best to manage with local ID. Please advise when remainder of labs are avai!able or if any additional questions .arise. The recommendations were provided to [LDF APPs and MD-I]. On February 2, 2017, the oncologist' s office informed LDF they would need a pathology report con finning Mr. RAYSON's cancer diagnosis and his previous chemo treatment notes before they would schedule an appointment. The LDF medical records department requested these records from BOP. At approximately 12:20 p.m., the following UA dip results were reported: Leukocytes- negative (Neg); Nitrate-Neg; Urobilinogen-0.2; Protein-2+; pH -6.0; Blood - Neg; Specific Gravity1.030; Ketones - Moderate; Bilirubin - Moderate; Glucose-Neg; Color - Amber; Clarity - Dark. [Investigator's nole: These test results were not WNL and were not reviewed by CD-2 until February 6, 2017.] Mr. RAYSON was not immediately transferred to GP and remained in the MHU. At approximately I: 15 p.m., he complained of pain. CD-2 gave a verbal order to start tramadol I 00 mg every six hours PRN for pain, for seven days. Mr. RAYSON received a dose of this medication at I :30 p.m. At 2 p.m., Mr. RAYSON received morphine 30 mg orally, in response to a verbal order from CD-2. [Investigator's note: An orderfor the morphine was not written. CD-2 stated he intended to start Mr. RAYSON on PRN morphine.] At approximately 2:30 p.m., Mr. RAYSON was crying and telling a nurse that he was in a lot of pain, afraid he was going to die, and needed to be sent out to a hospital. At approximately 4:50 p.m., an RN noted Mr. RAYSON was pain free. At approximately 6 p.m., an RN submitted a mental health referral for Mr. RAYSON indicating he may need medication for anxiety. At approximately 7 p.m., Mr. RAYSON was transferred from the MHU to GP. An RN noted Mr. RAYSON was pain free at that time and he received a dose of PRN APAP. or mandatory disclosure · document contains pre-decisional and/or deliberative rocess · under the Fre i). Do not re/ea.re without prior f'RJJ:BECfS/0'J.•hfb'B£f:.lB£R,t T{f'E i°"R:0CF.i8 F9R JltFF·E:R:N,fob BfSCl:J8S!,9/\1 QV,J,;¥,1N0f fZOR 8.fSTHHJEJ:r.fQ,H Mortality Review - Roger RA YSON,Kb)(6); (b)(?)(C) Page 17 of33 Detainees in the donnitories reportedly did not want Mr. RAYSON housed with them because of his medical issues. At approximately 8 p.m. Mr. RAYSON was transferred to SMU for "protective custody," after an RN medically cleared Mr. RAYSON for SMU housing. The RN noted that Mr. RAYSON "did not appear to have any acute or unresolved medical conditions that may worsen in segregation." During this evaluation he complained of 3/10 pain, and his VS were: T 98.6, P 112, BP 127/91, R 18. At approximately 11 :45 p.m., Mr. RAYSON received PRN tramadol. February 3, 2017 At approximately 9 a.m., Mr. RAYSON received PRN APAP. During SMU rounds at approximately 9:30 a.m., an RN noted Mr. RAYSON did not complain of pain. At approximately 2: IO p.m., Mr. RAYSON showered. At approximately 3:53 p.m., a detention officer (DO) informed medical staff that Mr. RAYSON was crying and wanted to see a nurse. At approximately 4:15 p.m., an APP and RN evaluated Mr. RAYSON in SMU. He complained of weakness and severe aching 1 0/10 pain in the right side of his neck. He received a one-time dose ofpromethazine 25 mg, IM, diphenhydramine 50 mg, IM, and ketorolac 60 mg, IM. At approximately 9:07 p.m., Mr. RAYSON was crying and requesting medical attention. The SMU DO contacted the medical clinic. The DO's log indicates that the pill line nurse gave Mr. RAYSON pain medication at approximately 9:27 p.m. and 11:44 p.m., however, the nurse did not document administering pain medication. February 4, 2017 During SMU rounds at approximately 8:53 a.m., an RN noted Mr. RAYSON did not complain of pain. At approximately 10:30 a.m., Mr. RAYSON received PRN tramado I. At approximately 2:30 p.m., Mr. RAYSON received PRN APAP. At approximately 4 p.m., Mr. RAYSON received PRN ondansetron. At approximately 5: 11 p.m., Mr. RAYSON refused dinner because he felt ill. He also refused to shower at approximately 8:51 p.m. At approximately 11 p.m., Mr. RAYSON received PRN ondansetron. For 1c1 ment contains pre-decisional and/or deliberative rocess · '5). Do not release without prior ICE Health Service orp . mandatory disclosure under the Freedom a ,on and Customs Enforcement, A.�A 1:,/9-El,.'-BERA J:!-l'E P�QGESS !t-N Mortality Review - Roger RAYSONJb)(6); (b)(7)(C) Page 18 of33 February 5, 2017 During SMU rounds at approximately 8:41 a.m., an RN noted Mr. RAYSON did not complain of pain. At approximately 8:49 a.m., Mr. RAYSON returned to his cell after three minutes in the recreation yard because he felt ill. At approximately 9 a.m., he received PRN tramadol and ondansetron. At approximately 2:30 p.m., Mr. RAYSON received PRN ondansetron, and at approximately 3 p.m., he received PRN tramadol. At approximately 3: 15 p.m., Mr. RAYSON was brought to the medical clinic and evaluated by an RN. Mr. RAYSON complained of nausea and electric, knife-like 10/10 severe generalized pain, and pain to his back, upper shoulders, right side of neck, and back of head. His physical examination was WNL except: General Appearance - unsteady gait with ambulation, in wheelchair, severely ill appearing, uncomfortable due to pain; Head - pain to right occipital area; Lymph Nodes - cervical nodes enlarged and extremely tender to palpation; Skin - pale; Musculoskeletal - can ambulate but unsteady gait at times; Psych - moaning and crying with pain complaints. His VS were: T 97.6, P 96, R 20, BP 133/96. The on-call APP ordered a one-time dose of promethazine 25 mg, IM, and ketorolac 60 mg, IM. Approximately 90 minutes later, Mr. RAYSON was no longer moaning and crying and stated his pain decreased to 8/10. He had a poor appetite and ate a banana for dinner. He appeared extremely weak and his VS were: T 97.7, P 89, BP l25/86, R 16. At approximately 7: 10 p.m., Mr. RAYSON was transported back to the SMU in a wheelchair. At approximately 9 p.m., Mr. RAYSON received PRN APAP, ondansetron, and tramadol. February 6, 2017 During a morning medical staff meeting, a psychologist infonned the HSA, CD-2, APP, and a visiting IHSC Associate Medical Director (AMO) that Mr. RAYSON was looking bad and should not be in SMU. The APP recommended hospitalization, but CD-2 countered that recommendation and ordered additional pain medication; oxycodone/APAP 7.5 mg/325 mg two tablets, PRN, three times (TID) a day, for 10 days. The AMD commented that Mr. RAYSON needed to get released or get access to a higher level of care. A medical provider did not evaluate Mr. RAYSON and he remained in SMU. At approximately 9 a.m., Mr. RAYSON complained to an RN during segregation rounds that he needed something for his pain. He complained of weakness and constant 10/10 neck and head pain that was worsening and not relieved with the current treatments. The RN observed that Mr. nt contains pre-decisional and/or deliberative process in or or 1c1 mandatory disclosure under the Freedom o . o not release withoflt prior , ustoms Enforcement. ICE Heallh Service Corps. PRflJ.EC/.£'0.��41.,(J).El. qu;�4Tlt. BlSTHJMU1=!Qltl Mortality Review - Roger RA YSON,l(b}(B); (b)(?)(C) Page 19 of33 RAYSON was ill appearing, lying on the bed, and weak when he repositioned himself. Mr. RAYSON received PRN tramadol. The RN informed the HSA, Assistant HSA (AHSA), and CD-2 about Mr. RA YSON's deteriorating status. CD-2 ordered the additional pain medication noted above, and the clinic administrators informed the RN that they were collaborating with ICE to deport Mr. RAYSON by commercial air. At approximately 11 :45 a.m., a psychiatrist evaluated Mr. RAYSON. Mr. RAYSON stated that he did not need psychotropic medications, because he was doing well emotionally and had no problems with sleeping or appetite. He also reported that his pain was manageable with his current medications. At approximately 12 p.m., Mr. RAYSON asked a DO to call medical because he had lower back pain. [Investigator's note: There is no documentalion in the medical record or SMU log that demonstrates a response to this request.] At approximately 3 p.m., Mr. RAYSON received oxycodone/APAP. [Jrrvestigator 's note: CD-2 prescribed this medicalionfor PRN administration; however, the medication was transcribed onto the medication administration record, and administered by nurses, for routine administration TID at 9 a.m., 3 p.m., and 9 p.m.] The HSA emailed the following SDI list update to IHSC headquarters: "Complaining of increased pain; MD and [APP] are addressing problem." At approximately 8 p.m., Mr. RAYSON showered. At approximately 9 p.m. he received PRN Tramadol and oxycodone/APAP. February 7, 2017 At approximately 5 a.m., Mr. RAYSON received PRN tramadol. He also refused his breakfast because he did not get a no meat tray as requested. The HSA emailed the following request to the AFOD: "Since he wants to go home and his condition seems to be worsening, any chance for a commercial flight?" During segregation rounds at approximately 8:30 a.m., Mr. RAYSON complained of9/10 lower back pain and light headedness that was aggravated with any physical activity. He reported the oxycodone/AP AP helped relieve the pain. The RN observed that Mr. RAYSON walked across his cell to the door. At approximately 9 a.m., and 3 p.m., Mr. RAYSON received oxycodone/APAP. At approximately 9:52 p.m., the pill-line nurse entered Mr. RA YSON's SMU cell to administer his 9 p.m. medications (including oxycodone/APAP) because Mr. RAYSON had difficulty ins pre-decisional and/or deliberative process in . Do not release without prior P�tcg4/,,(.[J-al.l.ll>&ll.4 T!VE AAO� FQR. J.,•,q:��fl:, I»S(;f,/SSJ(,)N Q•(-l,Y'Jl/.01' Fi'9R 8{-8TR:HJf:l+.W' Mortality Review - Roger RAYSON, fb>(5); (b)(?)(C) Page20 of33 standing up and was too weak to walk to the door. The nurse stated Mr. RAYSON's lips were not dry or cracked at this time, and he did not complain of vomiting. February 8, 2017 At approximately 4:42 a.m., the SMU DO informed medical staff that Mr. RAYSON was in pain. At approximately 4:45 a.m., the pill-line nurse, detention supervisor and DO entered Mr. RAYSON's cell to administer PRN tramadol, because he was unable to walk to the cell door. At approximately 6:50 a.m., Mr. RAYSON was transported to the medical clinic for laboratory tests. The following labs were drawn (fasting): CMP and Ca. A PTH was ordered but not submitted to the lab. The RN who drew Mr. RAYSON's labs stated his condition did not appear appreciably different from when she cared for him in the MHU. At approximately 6:50 a.m., Mr. RAYSON was transported to the medical clinic via wheelchair for laboratory tests. The following labs were drawn (fasting): CMP and Ca. A PTH was ordered but not submitted to the lab. On February 9, 2017, the laboratory results were received and WNL except: Ca ionized 6.4; Ca 11.7; chloride 93; and glucose 112. During morning shift change report. the night shift pill-line nurse reported that the last time she administered Mr. RAYSON's medication, it took three people to sit him up in his cell because of his weakness, pain and vomiting. Other nurses also commented that they observed similar issues with Mr. RAYSON over the past several days. During SMU rounds at approximately 8:30 a.m., an RN noted Mr. RAYSON had no complaints. At approximately 9 a.m., 3 p.m.• and 9 p.m., Mr. RAYSON received oxycodone/APAP. He also received PRN ondansetron at approximately 9 p.m. A request was sent from IHSC HQ to LDF to send a copy of Mr. RAYSON's medical records and his attending physician contact infonnation to the IHSC DAD of HCC because the IHSC Medical Director/Acting Assistant Director requested a review of Mr. RAYSON' s care. [Investigator's note: The DAD ofHCC did not receive the requested medical r�cords and did not review them in the IHSC electronic health record system. The DAD ofHCC based a report/summary ofMr. RAYSON's care, dated March 6, 2017. on a summary ofcare and SDI reports written by LDF staff Ofnote, there was no mention in this report ofwhere Mr. RAYSON was housed while in LDF] February 9, 2017 During SMU rounds at approximately 5:45 a.m., an RN noted Mr. RAYSON had no complaints. At approximately 6 a.m .• Mr. RAYSON received PRN tramadol and ondansetron. ins pre-decisional and/or d. Enforcement, ICE Health Serwce orps. release withoutprior .fl..�JS.TC,&�41,,(J)El. l'.B&2.d1JKi Pll.OCESS F.Qll. fbL'.l:ill.)'A"' I)fS{;.�lS.SlW/ Q,W,Y/N()'TFf)Jl. 9{$TJUIJ i/+.',QN Mortality Review - Roger RAYSONJ(b)(5); (b)(?)(C) Page2I of33 CD-2 reviewed Mr. RA YSON's BID finger stick glucose logs and lab results. CD-2 made the following medication changes: start glipizide 5 mg, at noon; stop tramadol I00 mg, every six hours, PRN; start tramadol 50 mg. every six hours, PRN; stop indomethacin; start alendronate sodium 5 mg, every morning (for hypercalcemia); stop HCTZ. Repeat labs were ordered for February 15, 20 17, and follow up with the physician in two weeks. At approximately 9 a.m., 3 p.m., and 9 p.m., Mr. RAYSON received oxycodone/APAP. At approximately 10:08 a.m., Mr. RAYSON showered. At approximately 12 p.m., he refused lunch. February 10, 2017 During SMU rounds at approximately 10:30 a.m., an RN noted Mr. RAYSON complained of chronic pain. At approximately 9 a.m., 3 p.m., and 9 p.m., Mr. RAYSON received oxycodone/APAP. At approximately 1 :20 p.m., CD-2 ordered promethazine suppository25 mg BID PRN, and Boost supplement BID. [Investigator's note: The indicationsfor why this order was written are not documented in Mr. RA.YSON's medical record] At approximately 5:43 p.m., Mr. RAYSON refused his dinner because of feeling ill. He also refused a shower at approximately 8:02 p.m. February 11, 2017 At approximately 6 a.m., Mr. RAYSON received PRN ondansetron. At approximately 7:32 a.m., the SMU CO notified medical that Mr. RAYSON was crying. During SMU rounds at approximately8:52 a.m., an RN noted Mr. RAYSON had no complaints. At approximately 9 a.m. and 3 p.m., Mr. RAYSON received oxycodone/APAP. At approximately 4: l 0 p.m., the evening pill-line nurse noted Mr. RAYSON' s blood sugar fingerstick was 64 (low). The nurse did not administer Mr. RAYSON's 4 p.m. diabetes medication and gave him a Boost supplement to drink. Mr. RAYSON reported he was unable to hold anything down because of nausea and vomiting. He also complained of severe 10/1 O pain "all over" and nothing relieved his pain. The nurse administered PRN ondansetron, tramadol, and APAP, and notified an RN. For 1c1a nt contains pre-decisional and/or deliberalive mandatory disclosure under the Free '5). Do nol release without prior , . . mm1grotion and Customs Enforcement, ICE Health Service Corps. om P-R,WliCJ&!-<»'Al:lf>el.lS&'1.,4'1:,CJ(.E e�i;;i� ,fi+J.R. PCJ',i�W. i).f�C�'f)..UQ.Nlf/ IA'S'J:RJ.Ji �CJ'.��' ,corF-0R Mortality Review - Roger RAYSONJb)(6); (b)(?)(C) Page 22 of33 At approximately 4:30 p.m., an RN evaluated Mr. RAYSON in his SMU cell. He complained of severe 10/10 pain, vomiting, and weakness. His lips were dry and cracked, his appearance was poor and fragile. He appeared notably weaker from the last time the RN saw him a week before. Mr. RAYSON' s eel I smelled of urine, there was a half-filled bucket of vomitus, and vomitus on the floor. Mr. RAYSON was lifted into a wheelchair, because he was too weak to transfer himself, and transported to the medical clinic. His VS were: T 98.9, P 111, R 22, BP 112/78, and weight 167 lbs. (a 12-lb. weight loss since January 28, 2017). The RN notified an APP of Mr. RAYSON's condition and he was transferred to LaSalle General Hospital (LGH) via ambulance at approximately 5:45 p.m. Mr. RAYSON was admitted to LGH with diagnoses of dehydration, hypercalcemia, and possible sepsis. February 13, 2017 BOP responded to the February 2, 2017 LDF medical records request. They did not have a pathology report. The following was the oncologist's impression and recommendations: Mr. RAYSON is a 47-year-old man with a diagnosis of [deleted by BOP] and [deleted by BOP] associated Burkitt's lymphoma with high risk disease features at diagnosis [bulky adenopathy, multiple sites of disease, bone marrow involvement and high LDH]. He has so far received only l cycle of Hyper-CVAD with IT MfX and has been without treatment for the past 3 months. The optimal treatment of Burkitt's lymphoma using R­ hyper-CV AD is for the delivery of 8 cycles of hyper-CVAD alternating with methotrexate and hi dose [illegible] with IT chemotherapy given every 21 days...He needs to be started on therapy very soon since he was at high risk of disease progression due to the delay in his treatment. His case is further complicated by his social situation and impending deportation. Starting cycle 2 with Methotrexate and high dose cytarabine in the next week or so will render cytopenic at the time of his deportation [illegible] put him at a risk of infectious complications, serious bleeding complications and potential fatal outcome if he has no access to health care at that time. Due to this I am very hesitant to initiate chemotherapy at this point if appropriate follow up and access to medical care cannot be guaranteed. I plan on corresponding with [BOP physician] of the FMC regarding these concerns. February 12-15, 2017 Mr. RAYSON's condition slowly improved while hospitalized. He was weak, but able to ambulate to the bathroom. He had less vomiting and tolerated clear liquids. · document contains pre-decisional and/or deliberative roce '.5 . Do not release without prior under the Free , 1grat1on and Customs Enforcement. ICE Health Service Corps. mandatory disclosure pR,EJ;},E€,'&'0.';41,.19e1:,HJ,alMTl-l'E p�gCF,SG ,r.fJfH.tJ+F,RN,fl, EJ.'8}�'FR..'-Bw:!�' Mortality Review - Roger RAYSON, fb)(6); (b)(?)(C) Page 24 of 33 March 4-9, 2017 Mr. RAYSON was transferred to Lafayette General Hospital and admitted to the intensive care unit (ICU) for treatment of sepsis. During this hospitalization, his condition did not improve appreciably. He remained lethar gic and was unable to swallow. Despite continued antibiotic treabnent, he had a fever. A repeat CT scan showed the subdural hematoma was stable. March 10-12, 2017 Mr. RAYSON was placed on "Do Not Resuscitate'' status. He was not deemed a candidate for systemic therapy to treat his lymphoma and sepsis, and he received palliative care consisting of IV antibiotics and morphine for pain. His condition continued to deteriorate. March 13, 2017 At 3:20 p.m., Mr. RAYSON went into cardiac arrest and died. Cause ofDeath Immediate cause: remote subdural hemorrhage due to unknown factors. Underlying causes: • • • Hypertensive atherosclerotic cardiovascular disease Diabetes mellitus Complications of HIV Manner ofDeath Could not be detennined [Investigator's note: The medical examiner (ME) could not determine the manner ofdeath, i.e., natural causes, accident, homicide, suicide, because the ME could not determine what event{s) caused the subdural hematoma.] Strengths and Best Practices The reviewers could not determine whether the care provided to Mr. RAYSON by LDF staff directly or indirectly contributed to his death, because the manner of his death was undetennined. During this review, it was readily apparent that the LDF staff are earnest and dedicated professionals. Additional program strengths included: ERO providing advanced notification to LDF of Mr. RAYSON's pending release from BOP and his serious medical conditions; and LDF's MHU where a detainee can receive skilled nursing care 24/7. or umenl contains pre-decisional and/or deliberative rocess . Do not release without prior mandatory disclosure under the Freedom a ,on and Customs Enforcement, ICE Health Service Corps. ,D.REf>EG.'SKJN,U:l9&l.f./MIM'Ff-1'£.'l.R.8CF:&S f.f>RNFFER:N,tl:. B,'8C-f:JS&'-0N0.Vll'li'IO'f'FOR ».'8'Fli'..IBY+½»I Mortality Review- Roger RAYSON, rb)(B); (b)(?)(C) Page25 of33 Weaknesses, LeYsons Learned, and Process Improvement Recommendations ICE detention standards used for this review: PBNDS 2011. 1. Continuity of care. Mr. RAYSON did not receive access to appropriate and timely continuity of care in accordance with PBNDS 2011 standards and IHSC policies. Five weeks prior to Mr. RAYSON's pending release from BOP, ERO notified the LDF HSA and CD. However, they did not take appropriate steps to ensure Mr. RAYSON had access to appropriate and timely continuity of care upon intake into ICE custody. Although indicated, the LDF HSA and CD did not request additional medical infonnation from the BOP and CD1 medically cleared Mr. RAYSON for admission into LDF, based solely on the information contained in the BOP medical summary. ERO provided LDF with a medical summary that did not list HN and AIDs as medical problems, even though this summary listed numerous HIV related medications and a diagnosis ofBurkitt's lymphoma (an AIDs defining condition). In addition, Burkitt's lymphoma is a cancer known for rapid progression and the medical summary was silent about the status of Mr. RAYSON's treatment for this condition. Based on the infonnation contained/omitted from the medical summary, additional information was needed to determine whether LDF had sufficient health care resources in the facility and community to support Mr. RAYSON's medical needs. Had additional information been obtained in advance of Mr. RAYSON's arrival, it would have shown that he did not receive appropriate care for his cancer while in BOP eustody. In addition, according to the BOP hematologist/oncologist, Mr. RAYSON was at high risk for disease progression, he needed to restart chemotherapy as soon as possible, and because of the potential complications associated with chemo, the hematologist/oncologist recommended that Mr. RAYSON should not receive this treatment while in a short-tenn custody status. Had this information been known in advance, LDF medical staff could have shared it with ERO for consideration in expediting Mr. RAYSON's ICE processing and return to Jamaica. Mr. RAYSON stated he was already in communication with a physician in Jamaica who was willing to resume the recommended chemotherapy. Also, the HSA and/or CD-I did not inform their staff about Mr. RAYSON's pending transfer and impeded LDF's ability to better prepare for his arrival. On January 28, 2017, actions were not taken to ensure Mr. RAYSON received timely continuity of his pain medication and medical diet while housed in MHU awaiting an APP evaluation. At approximately 3:40 a.m., an APP was notified telephonically about Mr. RAYSON's arrival, medical conditions, medications, and current status (i.e., 9/1 O pain). In response, the APP only ordered Mr. RAYSON housed in the MHU until evaluated by an APP (sometime after 7 a.m. that morning) and did not give orders for continuity of pain medication, or a diabetic diet in the interim. An RN did administer oxycodone/APAP to Mr. ument contains pre-decisional and/or deliberati11e process in For , mandatory disc:losure under the Freedom o . o not release withoutprior i'-R:EB£€.'li,.t0,l/,4b'B&,'-BER:,f:r:l-i'EM@C-E&S ,"+>R:§lff'Em.',fb B,T&eU&&ff:JiV0.VLJ'/N0'FP9R: &:.'SrR:HJfl::J1'/6-N Mortality Review - Roger RAYSON, fb)(6); (b)(7)(C) Page 26 of33 RAYSON; however, this was done without appropriate authorization (see discussion below about medication management). On January 30, 2017, an APP wrote an order to obtain additional medical records from BOP. This order was not implemented. Applicable standards of care for this finding: • PBNDS 2011: 4.3, Medical Care; sections II.5, 11.6, II.8, 11.13, 11.20, and V.Z. • IHSC Directive: 03-16 (Effective March 25, 2016), Medication Administration; section 4-2.c. 2. Medication management. LDF staff did not prescribe and administer medications to Mr. RAYSON in accordance with PBNDS 2011 standards, IHSC policies, and DEA regulations. On January 28, 2017, an RN administered oxycodone/APAP to Mr. RAYSON without an order from a medical provider. The RN believed he was authorized to administer this medication to Mr. RAYSON without an LDF medical provider order, because Mr. RAYSON arrived at LDF with a BOP medical transfer summary listing the medication and the medication arrived with Mr. RAYSON as well. IHSC does not authorize this practice and requires that all administered prescription medications must have an order from an authorized prescriber. Frequently, nursing staff administered PRN medications without noting in the medical record the subjective and/or objective findings to support administration of the medication, e.g., complaints of nausea or pain. In addition, nursing staff frequently did not document appropriate timely monitoring of Mr. RAYSON's response to PRN medications administered, e.g., the patient's response within one hour of administration. On February 2, 2017, CD-2, who was present in the clinic, gave a verbal order to an RN to administer a dose of Morphine 30 mg, orally, to Mr. RAYSON, and to obtain the medication from another patient's supply. An order for this medication -was not written in Mr. RAYSON's medical record, nor did CD-2 complete a wet-ink hard copy of this controlled substance prescription. These actions were not in accordance with IHSC policy and DEA regulations. On February 3, 2017, an APP gave a verbal order for medication, even though the APP was present in the clinic and it was not an emergency. contains pre-decisional �o toms Enforcemem. ICE · · /� NfEM£1S;'Q,'o4b'B£l,'B£lbfffl'£P-R.00£&& F9R..'.W�.fb DfSCUSS.1Q.H QHLY1111',l;r: 'i:O� DIS'f.RJBf:ITffJ-N Mortality Review .. Roger RAYSONJb)(S); (b)(?)(C) Page 27 of33 On February 6, 2017, CD-2 wrote an order for oxycodone/APAP 7.5 mg/325 mg two tablets, PRN, TIO, for 10 days. This order was incorrectly transcribed on to the MAR as TID, with regularly scheduled administration times at 9 a.m., 3 p.m., and 9 p.m. Applicable standards of care for this finding: • PBNDS 201 I: 4.3, Medical Care; sections Il.20, V.A.2., V.G. • IHSC Directive: 03-16 (Effective March 25, 2016), Medication Administralion; section 4-2.c. • IHSC Medication Administration Guide {Effective March 13, 2015); sections I.A., II., Ill. • IHSC Directive: 09-02 (Effective March 25, 2016), Pharmaceutical Services and Medication Managemenl; sections 4-1.f.(5), 4-5.c. 3. Access to an appropriate level health care provider. Mr. RAYSON did not receive timely and appropriate referral to an appropriate level health care provider in accordance with PBNDS 2011 standards. On January 28, 2017, an APP attempted to consult with CD-1 by telephone; however, CD-1 was unavailable and the CD's voice mailbox was full. The APP did not attempt to notify the HSA of CD-1 's unavailability to receive instructions for an alternate CD to consult with. On January 29, 2017, at approximately 10 p.m., Mr. RAYSON's VS were abnonnal (P 125, BP 97/64). A n RN acknowledged Mr. RAYSON's increased P and low BP and noted that he was ill-appearing, but did not have chest pain or shortness of breath. He was encouraged to relax and was given two tablets of oxycodone/APAP 5 mg/325 mg for pain. Although indicated, his VS were not rechecked, and a medical provider was not consulted. On February 2, 2017, Mr. RAYSON was discharged from the MHU for placement in GP. It was inappropriate to discharge Mr. RAYSON from the MHU because he required skilled nursing care. APPs informed CD-2 that they did not feel comfortable caring for Mr. RAYSON and wanted CD-2 to assume primary responsibility for Mr. RAYSON's medical management. CD-2 remained in a consultant/CD role. On February 6, 2017, a psychologist informed the HSA, CD-2, APP, and IHSC AMO that Mr. RAYSON was looking bad and should not be housed in SMU. In response to this report, a medical provider did not evaluate Mr. RAYSON and he remained in the SMU. Although APPs repeatedly recommended transferring Mr. RAYSON to a hospital, CD-2 persisted in managing Mr. RAYSON at LDF. Mr. RAYSON's condition warranted transfer to a higher level of care prior to February 11, 2017. ins pre-decisional · · lease wilhout prior �.'SK»'Al:,,'95b,YJeR.fT.W£ PR0C-fiS8 ,CfJR .'IFFERN,U. 9fS€lJSS.'0.\'0NLJ'/N!STP..z.WC./1:JQ1'.1 Mortality Review - Roger RAYSON, fbl(6); (b)(?)(C) Page28 of33 Throughout Mr. RAYSON's detention at LDF, nursing staff regularly reported during shift change about Mr. RA YSON's deteriorating health status. In response to these reports, LDF clinic administration (HSA, AHSA, and CD-2) focused their efforts on communicating to ERO the need to deport Mr. RAYSON as soon as possible. LDF clinic administration did not ensure Mr. RAYSON received an appropriate level of care while he was detained, e.g., housing in MHU, appropriate monitoring and treatment planning, and timely referral to a hospital or another facility that had community resources to support Mr. RAYSON's medical needs. Applicable standards of care for this finding: • PBNDS 201 I: 4.3, Medical Care; sections Il.8, V.A.2., V.A.7. 4. Access to appropriate medical care. Mr. RAYSON did not receive timely and appropriate access to medical care accordance with PBNDS 2011 standards. On January 31, 2017, from approximately 6 a.m. to 1 p.m., Mr. RAYSON complained of moderate (5/10) to severe (9/10) pain. In the morning, APPs referred ordering stronger/narcotic PRN pain medication to CD-2. CD-2 ordered tramadol at approximately 1:42 p.m. On February 2, 2017, Mr. RAYSON was weak, ill-appearing, and had uncontrollable pain. The IHSC ID consultant noted that Mr. RAYSON was at risk for dehydration and may need IV fluid administration. Despite these indications for remaining in MHU for skilled nursing care/monitoring, CD-2 discharged Mr. RAYSON to GP. CD-2 did not review Mr. RAYSON's abnonnal urinalysis results that were reported on February 2, until February 6, 2017. CD-2 did not develop an appropriate treatment plan in response to these abnonnal results which indicated Mr. RAYSON may have been dehydrated. CD-2 stated that he evaluated Mr. RAYSON numerous times while he was in MHU, but he did not document these encounters in the medical record. CD-2 did not examine or observe Mr. RAYSON after he discharged him to GP on February 2, 2017. CD-2's care and treatment planning throughout Mr. RAYSON's LDF detention, as evidenced by the medical record, appears as if CD-2 deliberated Mr. RAYSON's care from afar without examining the patient when indicated and requested by the APPs. On February 3, 2017, an APP evaluated Mr. RAYSON in SMU for complaints of uncontrolled pain and nausea. The APP did not document this evaluation in Mr. RAYSON's F; onloins pre-decisional mo oms &forcement, ICE · · ocess o not release withoul prior p,.�'-()NAI,,t�,'-8,i�O:,!lla PRg� flJ,il.V:f+,f,�,41.J;)fSC.L'S&'f>N 9;1'l,¥,9'-01".fi.fJR BiSf.Rf-BW:.'QN Mortality Review - Roger RAYSON, fb)(6); (b)(7)(C) Page 29 of33 medical record. It is incumbent on all health care professionals to document the care they provide. On February 6, 2017, a psychologist informed CD-2 and an APP that Mr. RAYSON "was looking bad" and should not be housed in SMU. A medical provider did not examine Mr. RAYSON. Although APPs repeatedly recommended transferring Mr. RAYSON to a hospital, CD-2 persisted in managing Mr. RAYSON at LDF. Mr. RAYSON's condition warranted transfer to a higher level of care prior to February 11, 2017. Applicable standards of care for this finding: • PBNDS 2011: 4.3, Medical Care; sections ll.8. V.A.2. 5. Access to appropriate nursing care. Mr. RAYSON did not receive timely and appropriate access to nursing care accordance with PBNDS 2011 standards and IHSC policies. Nursing staff did not develop a nursing plan of care for Mr. RAYSON during his MHU admission. Based on Mr. RAYSON's condition. a nursing care plan should have included at a minimum appropriate monitoring and interventions to ensure adequate nutrition, pain management, hygiene, and safety. While Mr. RAYSON was admitted to MHU, nursing staff did not routinely document Mr. RAYSON's ability to engage in activities of daily living, e.g., how much did he eat/drink, hygiene, toileting. or recreation. Some nursing staff reported they were unable to provide skilled nursing care in MHU to support assistance with bathing because the beds could not be elevated to a level where nursing staff could perform bed baths without injuring their backs. In addition, the nurses reported the MHU beds could not be adjusted (e.g., elevate head or foot of the bed) to improve patient comfort. On January 29, 2017, Mr. RAYSON's VS were abnonnal (P 125, BP 97/64). The RN caring for Mr. RAYSON did not monitor/repeat VS to determine if they returned to within normal limits, or consult with a medical provider. On January 30, 2017, an APP wrote an order for every two hours VS. Nursing staff did not document taking VS every two hours. On February 1, 2017, at approximately 6:41 a.m., Mr. RAYSON complained of8/10 pain. At · pre-decisi · · oce.ss; o not release without prior Mortality Review - Roger RAYSON, l(b)(6); (b)(?)(C) Page 30 of33 approximately 12:46 p.m., Mr. RAYSON complained of7/l0 pain with nausea and vomiting. Nursing staff did not administer PRN tramadol for pain or ondansetron for nausea. Mr. RAYSON did not receive medication for pain or nausea until approximately 4:30 p.m. On February l, 2017, nursing staff perfonned a dip urinalysis and the results were abnormal (showed Mr. RAYSON may have been dehydrated). Nursing staff did not immediately notify a medical provider about these abnonnal results. On February 2, 2017, at ap proximately 5:44 a.m., an RN noted Mr. RAYSON com plained of 10/10 severe, knife-like pain, and nothing com pletely relieves his pain. The RN did not administer PRN ketorolac and di phenhydramine IM that was ordered for pain control. At approximately 10:45 a.m., Mr. RAYSON complained of severe 7/10 pain. An RN administered PRN APAP 325 mg for pain, but did not administer PRN ketorolac and diphenhydramine IM that was ordered for pain control or PRN ondansetron that was ordered for nausea. At approximately 1 :30 p.m., Mr. RAYSON received tramadol 100 mg. At approximately 2 p.m., Mr. RAYSON received morphine 30 mg. From February 3-4, 2017, while Mr. RAYSON was housed in the SMU, he had an order for PRN tramadol, eve ry six hours. On February 3, 2017, nursing staff did not administer tramadol. However, at approximately 4:30 p.m., nursing staff contacted an APP about Mr. RAYSON's 10/10 pain and received an order for a one-time dose ofketorolac 60 mg and Phenergan 25 mg IM, which was administered. On February 4, 2017� Mr. RAYSON received one dose of PRN tramadol at 10:30 a.m. On February 6, 2017, at approximately 12 p.m., Mr. RAYSON complained of pain and a SMU CO notified medical. There is no evidence in SMU logs or Mr. RA YSON's medical record to demonstrate a response to this notification. CD-2 wrote an order for PRN oxycodone/APAP 7.5 mg/325 mg two tablets, every six hours, at approximately 8:37 a.m. Mr. RAYSON did not receive this pain medication until approximately 3 p.m. Generally, when nursing staff administered PRN pain medications or anti-nausea medications, they did not document Mr. RAYSON's symptoms that warranted administering these medications. In addition, they did not reevaluate Mr. RAYSON within an hour to determine if the medication relieved his symptoms. Nursing staff observed Mr. RAYSON's deteriorating status while in SMU and rep orted it verbally during shift reports; however, they did not routinely document these observations in his medical record or during SMU rounds. Applicable standards of care for this finding: • PBNDS 2011: 4.3, Medical Care; sections Il.8, V.A.2. For , ment contains pre-decisional and/or deliberative r om '5 . Do not release without prior mandatory disclosure under the Freedom o , Pi'?:£EHi£18!-0H,jL'BEb.�I:rff'E ,UR,(;}CII,S& ,r::f}1'. J,I''feN�41, 9-l&C-U�o• Q/l'l,Yl '¥01' ,'"-+}R D,'SrRHJlHI-911 Mortality Review - Roger RAYSONJb}(6}; (b}(7}(C} Page31 of33 • IHSC Directive: 03-17 (Effective March 25, 2016), Medical Housing Units; section 53.c. • JHSC Medication Administration Guide (Effective March 13, 20 l 5); section II. 6. A�cess to appropriate mental health care. Mr. RAYSON did not receive timely and appropriate access to mental health care in accordance with PBNDS 2011 standards and IHSC policies. During Mr. RAYSON's February 28, 2017 health assessment and physical examination, an APP noted Mr. RAYSON was depressed. The APP did not refer Mr. RAYSON to mental health. Applicable standards of care for this finding: • • PBNDS 201 l: 4.3, Medical Care; sections ILL, V.A.2., V.0.1.b., V.0.3. IHSC Behavioral Health Services Guide (Effective March 25, 2016); sections VII., VIII. 7. Patient advocacy. LDF professional health care staff did not advocate in a timely and appropriate manner for Mr. RAYSON to receive necessary and appropriate health care in accordance with PBNDS 2011 standards and their licensed health care professional duty of care. On Janmuy 31, 2017, RNs and an APP reported that Mr. RAYSON was in moderate to severe pain (5-9/10) from approximately 5:44 a.m., until 12:43 p.m. During this period, Mr. RAYSON did not receive any PRN pain medication because the RNs and APP were awaiting an order for narcotic pain medication from CD-2. This order was not written until I :42 p.m. Nursing staff and/or the APP did not take additional steps to advocate for Mr. RAYSON so an order for PRN pain medication was written in a timely manner. On February 2, 2017, an RN medically cleared Mr. RAYSON for the SMU even though he observed Mr. RAYSON "looked like he needed to be in a hospital." The RN cleared Mr. RAYSON because CD-2 just released him from the MHU to GP, and if custody could not house Mr. RAYSON in GP, "then he had to go somewhere." The RN did not take additional steps to advocate for a more appropriate placement for Mr. RAYSON, e.g., notifying CD-2 that Mr. RAYSON was not housed in GP as ordered, and/or notify up the chain of command if CD-2 assented to this placement. LDF health care administrators frequently advocated for Mr. RAYSON's rapid deportation, which was indicated. However, they did not take steps to ensure he received appropriate care while in detention. The LDF HSAs did not visit with Mr. RAYSON, even though he was · ent contains pre-decisional and/or deliberative roce. or mandatory disclosure unckr the Freedom '5 . Do no/ release withou/ prior , a ion and Customs Enforcement, ICE Health Senice Corps. .RR];9,/i,G�,.IO,l',ib'�Me1MT!-1'E .�0CFJ,S .r:.f>R .W+FJW,fl:. D.'SGUSB,'9.V (;}.lVlJ'l>l0'f,%}R !JIEFFRHJT:J'F.'O;V Mortality Review� Roger RAYSON,Kb)(6); (b)(?)(C) Page 32 of33 listed on the SDI list and on February 6, 2017, a psychologist raised concerns about Mr. RAYSON's deteriorating status in SMU. LDF health care administrators stated they did not have a local community physician to consult with and arrange direct admissions to local hospitals. In addition, the administrators stated the local hospitals did not want to care for detainees and usually returned them after brief evaluation and treatment in the ER, rather than admit the detainees to the hospital. Considering these challenges, LDF administrators did not take proactive steps to identify community resources to overcome these challenges or make arrangements for Mr. RAYSON's transfer to a detention facility with community resources that could meet Mr. RAYSON's needs. On February 8, 2017, the IHSC Medical Director/ Acting AD requested the DAD of HCC to review the care Mr. RAYSON received at LDF. The DAD of HCC did not conduct an independent review of Mr. RAYSON's medical records and relied on summaries and reports created by LDF staff. Applicable standards of care for this finding: • PBNDS 2011: 4.3, Medical Care; sections II. J .• 11.6. 8. Special monitoring unit. Mr. RAYSON did not receive appropriate access to SMU health care monitoring in accordance with PBNDS 2011 standards and IHSC policies. On February 2, 2017, an RN medically cleared Mr. RAYSON for placement into the SMU without consulting a medical provider, even though the RN believed this placement was medically contraindicated. During SMU rounds on February 3, 4. 5, 8, 9, and 11, 2017, RNs documented that Mr. RAYSON had no medical complaints, was in no acute distress, he was well developed and well nourished. They also noted that he did not appear to have any acute or unresolved medical conditions that may worsen in segregation. The quality of these observations are suspect considering reports from nursing staff during shift change meetings and interviews to the contrary, and other records documenting Mr. RAYSON's deteriorating status. Applicable standards of care for this finding: • PBNDS 2011: 4.3, Medical Care; section 11.27. • PBNDS 2011: 2.12, Special Management Units; sections 11.7., V.P. • IHSC Directive: 03-06, Heallh Evaluation ofDetainees in Special Management Units (SMU) (Effective March 24, 2016); sections 4-l.a.(l), 4-2.a. cumenl contains pre-decisional and/or de/iberalive process in or I mandatory disclosure ul'Jder the Free om o . Do not release without prior ustoms Enforcement, ICE Hea/Jh Senm::e �.t&l,O,UAl,,'�.�4rn.V €JiYtJ',' i'fflfPf>R EHS'FRHJfdT.'f»J Mortality Review - Roger RAYSONJ{b)(B); {b)(7)(C) Page33 of33 Recommendations • Forward these findings to the IHSC DAD of HCC. • The IHSC DAD of HCC will share these findings through appropriate communication channels to ICE, the LDF administrator and health authority for review and to create a corrective action plan (CAP). • The respective IHSC HCC Unit and ICE will ensure the CAP is implemented and sustained. For c,a s contains pre-dec�ional and/or deliberative process in . o not release withoutprior mandalory disclosure under the Freedom o ustoms Enforcement, ICE Health Service Corps. lB 7 Detainee Death Review: Roger RAYSON, fb ( ); (b)( )(C) Medical and Security Compliance Analysis LaSalle Detention Facility, Jena, Louisiana As requested by the ICE Office of Professional Responsibility (OPR), External Reviews and Analysis Unit (ERAU), Creative Co1Tections participated in a review of the death of detainee Roger RAYSON while in the custody of the LaSalle Detention Facility, Jena, Louisiana. A site l ERAU Inspection and visit was conducted April 11 through 13, 2017 by Kb)(6); (b)(7)(C) b)(6); (b)(?)(C) Compliance Specialist and team leaded I Inspection and Compliance l Program Manager for the Specialist; Creative Co1Tections contract personnel fb)(6); (b)(?)(C) ICE/OPR contract; kb)(6); (b)(?)(C) I Security Subject Matter Expert; and �b)(6); (b)(?)(C) l Registered Nurse, Medical Subject Matter Expert. Contractor paiticipation was requested to determine compliance with the ICE Performance Based National Detention Standards (PBNDS) 2011 governing medical care and secmity operations. Included in this report is a case synopsis, description of the facility and its medical services, detention summary, a narrative review of events, and conclusions. RAYSON's vital signs documented during medical encounters ai·e appended. The information and findings herein are based on analysis of detainee RAYSON's medical record and detention file, tour of the medical area and housing units, interviews of staff, and review of policies, video surveillance recordings, and available incident related documentation. SYNOPSIS Roger RAYSON was transferred to ICE from the Federal Bureau of Prisons and admitted to the LaSalle Detention Facility (LDF) on January 28, 2017. He was 47 years old. RAYSON arrived with a lengthy medical transfer summary and multiple medications for conditions that included cancer, HIV, diabetes, and hypertension. Medications for these conditions were continued, as were medications for ongoing pain. RAYSON was placed in a cell in the medical housing unit prior to completion of the intake process. The day after his arrival, he was sent to a hospital emergency room due to his declining health. He returned to LDF within hours and was reassigned to the medical housing unit. Five days later, a physician directed his release to general population housing. Because RAYSON disclosed his medical diagnoses to other detainees, he was quickly removed from the housing unit and, upon clearance for segregation by a nurse, was placed on protective custody in the Special Management Unit. Over the course of the next nine days, his condition deteriorated and on Februai-y 11, 2017, he was sent to the local hospital. RAYSON was moved to different hospitals on two occasions and did not return to LDF prior to his death on March 13, 2017. DETAINEE DEATH REVIEW: Roger RAYSON Medical and Security Compliance Analysis October 4, 2017 Page 1 An autopsy was conducted on July 10, 2017. According to the pathologist's report, primary findings showed evidence of remote subdural hemorrhages, causing a traumatic brain injury. Contributing factors of obesity, hypertensive atberosclerotic cardiovascular disease, meningitis and complications of HN were cited. The manner of death was undetermined pending further investigation. There is no documentation detainee RAYSON sustained an injury caused by assault or other means while at LDF. FACILITY DESCRIPTION LDF is operated by the GEO Group, Inc. (GEO) of Boca Raton, Florida. On October 30, 2006, the LaSalle Economic Development District (LEDD) announced procmement for the operation and management of a detention facility. GEO was awarded the contract on July 25, 2007, and under an Intergovernmental Service Agreement, contracted with ICE for 1160 beds. The first detainees were admitted on October 22, 2007. The facility was initially accredited by the American Correctional Association in 2009, and most recently reaccredited on February 9, 2015. LDF houses both male and female detainees and bas a design capacity of 1335. On March 13, 2017, the date of RAYSON' s death, the total detainee population was 1121. A double fence with razor wire along the top encircles the LDF perimeter. Visitors must enter through a secure external sallyport, the gates to which are operated by officers in the central control center. Once inside the gates, visitors must display identification and pass through a metal detector before being permitted entry into the secure section of the facility. Personal items must be placed on a belt for screening through an X-ray machine. Video surveillance cameras are used throughout the facility to monitor and record events. MEDICAL SERVICES Healthcare is provided 24 hours a day, seven days a week by Immigration Health Services Corp (IHSC) and contractor InGenesis Medical Staffing headquartered in San Antonio, Texas. InGenesis subcontracts with STG International, Incorporated (STG) based in Alexandria, Virginia. IHSC personnel who are commissioned officers of the Public Health Service include the Health Services Administrator (HSA), Assistant HSA, Nurse Manager, three registered nurses (RN), a dentist, pharmacist, program manager, and a mental health professional. In addition, an IHSC physician employed under the General Schedule for Federal Pay serves as Clinical Director. The December 22, 2016 contractor staffing plan lists 49 positions, including a staff physician, five midlevel providers, 17 RNs, ten licensed practical nurses (LPN) and licensed vocational nurses (LVN), one psychiatrist, two mental health professionals, a pharmacist, two DETAINEE DEATH REVIEW: Roger RAYSON Medical and Security Compliance Analysis October 4, 2017 Page 2 pharmacy technicians, six medical records technicians, two radiology technicians, one dental assistant, and an administrative assistant. Additionally, two RNs and two LPN/LVNs provide services on an as needed, per diem basis. Review of the current employee list against the staffing plan fow1d no vacancies. HSA, the contractor staff physician was hired According to (b)(5 ); (b)(?)(C) after detainee RAYSON's death. (b)(6); (b)(7)(C) was present at LDF on a limited basis during RAYSON's detention due to family medical leave. He returned a week prior to the site visit and was interviewed for this review. IHSC physician Kb)(6); (b)(7)(C) I provided rotational coverage during i(6); (b)(?)(C) reported that shortly thereafter, officers called to say the detainee was "hmting and crying." She had him brought to I I DETAINEE DEATH REVIEW: Roger RAYSON Medical and Security Compliance Analysis October 4, 2017 Page 3 the clinic pending full medical and mental health intake screening. According to the Medical Housing Unit 1 (MHU) log, detainee RAYSON was placed in the unit at 3 :48 a.m. on January 28, 2017. It is noted that the Housing History Grid documents the detainee's initial housing assignment was Eagle Block (unit) A and that he was transferred to the MHU 14 minutes later. Based on staff interviews, the MHU log, and the short period of time the Housing History Grid reflects he was assigned to Eagle Unit A, it is concluded the assignment to Eagle A was based on a preliminary classification of high (see below), prior to the detainee's direct placement in the MHU. There is no information suppo1ting that he was ever physically moved to Eagle Unit A. The MHU has one double occupancy and five single occupancy cells, all of which have standard metal bunks, mattresses, and security fixtures. There is no general infirmary area. During interview of!(b)(6);(b)(7)(C) I he stated LDF removed hospital beds from cells in the MHU due to destrnction by detainees. Recreation is provided in the yard used by detainees in Falcon unit. Detainee RAYSON was assigned to MHU cell 6, one of the five single occupancy cells. There are two windows in the top half of the cell door, a cot in the middle and a toilet/sink combination fixture on the right side. After detainee RAYSON's placement, the count in the MHU was three detainees. Officers are required to check on each detainee every 30 minutes, electronically recording their rounds by inserting a pipe into a sensor positioned at each cell. Per IHSC Directive 03-17, Medical Housing Units, a provider is to make rounds at least daily; rounds by nursing staff are required at least once per shift. The directive does not detail requirements for nursing rounds with respect to conducting assessments, taking vital signs, or inquiring about a patient's pain level. I rb)(6); (b)(7)(C) documented completion of intake screening at 5 :23 a.m. He wrote that RAYSON spoke English and use of interpretation assistance was not needed. With the exception of a high blood glucose level of 233 2, baseline vital signs were within normal limits. His height was 65.5 inches, and he weighed 179 pounds. l(b)(6);�documented RAYSON's medical conditions were lymphoma 3, diabetes, IIlV infection4, hypertension 5, anemia 6, gout 7, arthritis, and gastrointestinal reflux disease (GERD) 8, for which he was receiving the following medications: I 1 The logbook is labeled "SSU" for Short Stay Unit, which at LDF, is used synonymously with Medical Housing Unit (MHU). The area is referred to as MHU in this report. 2 Normal blood glucose (sugar) levels are 72-108 when fasting and up to 140 two hour after eating. 3 Lymphoma is cancer of the lymph nodes. 4 HIV is the virus that causes Acquired Immune Deficiency Syndrome (AIDS). 5 Hypertension is high blood pressure. 6 Anemia is a condition caused by low iron levels. 7 Gout is a form of arthritis characterized by severe pain, redness, and tenderness in joints. 8 Shortened to GERD, this condition causes reflux of acid from the stomach into the lower esophagus. DETAINEE DEATH REVIEW: Roger RAYSON Medical and Security Compliance Analysis October 4, 2017 Page4 Purpose Antiretroviral (ARV) Abacavir ARV Acyclovir ARV Dolutegravir ARV Lamivudine Antibiotic Levofloxacin Antifungal Fluconazole Anti-diabetic Glioizide Anti-diabetic Metformin Anti-diabetic Regular Insulin Gout treatment Allopurinal Anti-hypertensive Hydrochlorothiazide Lisinipril Anti-hypertensive Oxycodone with acetaminophen Pain treatment as needed (Percocet) 10 Anti-inflammation and pain treatment Tndomethacin Acetaminophen Pain treatment Pain treatment Enteric-coated aspirin Anti-nausea Ondansetron Fen-ous gluconate Iron supplement Medication 9 All medications arrived with detainee RAYSON and were reconciled with the transfer summary provided by the Federal Bureau of Prisons (FBOP), Federal Medical Center (FMC), Lexington, Kentucky. l(b)(6); �!wrote that detainee RAYSON complained of constant, "all over" pain at a level nine on a pain scale of zero to ten, with ten being worst. The medication administration record (MAR) documents that at 3:45 a.m., when he arrived in the clinic, RAYSON was given a dose of Percocet for pain. Administration of this and other medications was authorized per the transfer summary, which states, "All medications to be continued until evaluated by a physician unless othe1wise indicated." Due to the abnormal screening results, he was referred to a provider. Medical conditions detailed on the transfer summary are discussed below. stated RAYSON's arrival Consistent with tb)(6); (b)(?)(C) I comments to the review team,\�/\�/;,._, was unanticipated. He also shared that he was concerned about the detainee's placement at LDF because the facility cannot provide the level of care necessary for a patient with multiple, serious diagnoses. Although was unaware the detainee was approved for admission, email messages provided to the review team by l(b)(6); (b)(?)(C) !document clearance for admission was granted. The HSA stated that when he is contacted regarding accepting detainees with serious medical conditions, he consults the Clinical Director who may attempt to defer acceptance, but I\�/�/;,._, I 9 An antiretroviral is a drug that, in combination with other drugs, prevents the replication of the molecule viral ribonucleic acid (RNA) such as in HIV. 10 Oxycodone with acetaminophen is the generic form of Percocet. Percocet will used in this report in the interest of brevity. DETAINEE DEATH REVIEW: Roger RAYSON Medical and Security Compliance Analysis October 4, 2017 Page 5 may or may not succeed. The referenced email traffic is between �(l b_)(_6)_; (_bl_(? )_ (C_)_____� b)(6); (b)(?)(C) who served as LDF's acting Clinical Director beginning work. Per email dated Januaiy 17, 2017 from l(b)(5); _ prior to (b)(6); (b)(?)(C) "We can accommodate these patient [sic] in our facility if AFOD fb)(6);(b)(7)(C) concurs." In a preceding email dated December 21, 2016, reference is made to LDF being provided with FBOP medical summaries of RAYSON and other "subjects set to enter ICE custody next month." The email requests clearance for housing at LDF which as noted, was granted byfbl(5); (b)(?)(C) I I I Although he arrived at 2:15 a.m. on January 28, 2017, detainee RAYSON was not fully booked into the facility until later that morning. l; (b)(?)(C) !(b)(6); brder. (b)(5); (b)(?)(C) ; 6 ) (b)(?)(C) b)( 1C !however, the medical record does not document review of the recommendations or issuance of related orders by any of the three providers. There is no documentation the recommended vaccinations were given, or that the gonococcal and chlamydia tests were completed. In addition, there is no evidence of further contact with fbl(6); (b)(?)(C) Ito report results of the laboratory studies that were pending at the time of her telephone encounter. 31 NAA tests are the Center for Disease Control's preferred method to detect sexually transmitted diseases. This method detects the genetic material of the bacteria causing the infection by amplifying or making numerous copies of the genetic material so that the bacteria can be identified. 32 Prevnar is a type of pneumococcal vaccine to prevent pneumonia. 33 Pneumovax is a type of Pneumococcal vaccine to prevent pneumonia 4 3 Menactra is a meningococcal vaccine to protect against meningitis and other meningococcal diseases. DETAINEE DEATH REVIEW: Roger RAYSON Medical and Security Compliance Analysis October 4, 2017 Page 15 �\\�\ir , conducted nursing rounds at 1:47 p.m., documenting detainee RAYSON's complaint of generalized pain at level seven accompanied by nausea and vomiting. His vital signs were all within normal limits. There were no active orders for as-needed pain medication at this time, the supply ofPercocet sent with RAYSON by the FBOP having been depleted on January 30, 2017. Although his last dose ofregularly scheduled pain medication, indomethacin 50 mg, was given at 9:00 a.m. and not scheduled again until 9:00 p.m.,l<�/C�);___ did not contact a provider to obtain an order for pain medication. Asked during interview if she considered seeking an order, her reply was that RAYSON was difficult, demanding, and cantankerous. Other staff interviewed by the review team did not voice that opinion. I The MHU logbook documents that at 3:50 p.m., detainee RAYSON was crying and the nurse was informed. At 4:08 p.m. a nurse whose name was not noted entered detainee RAYSON's cell to check his vitals. There is no corresponding documentation in the medical record. ICb)(5); (b)(?)(C) I documented evening nursing rounds at 7:14 p.m., at which time detainee RAYSON complained of severe level ten pain in his right neck and in both lower extremities. Vital signs were all within normal limits with the exception of a mildly elevated blood pressure of 134/82. His finger stick glucose was elevated at 206 for which he was given regular insulin and was educated on diet and the importance of good blood glucose control. The nursing note documents he was given another injection of Toradol and Benadryl for pain management per one time dosing order ofl(b)(6); (b)(?)(C) I; however, no corresponding entry was made on the MAR Per order ofl(b)(6); (b)(?)(C) I via telephone encounter. l(b)(6); (b)(?)(C) I documented she administered an injection of Phenergan at 6:30 p.m.; however, the medical record does not indicate why this medication, which is commonly used for acute nausea and vomiting, was offered at this time. However, as noted, RAYSON previously experienced nausea and vomiting, symptoms not uncommon given his condition. At 6:54 a.m. on Thursday, February 2, 2017, (b)(5); (b)(?)(C) documented that detainee RAYSON reported severe pain at level ten in his right knee and back, stating that nothing completely relieved it. Vital signs were within normal limits with the exception of a mildly elevated blood pressure of 134/97. Kb)(6); (b)(?)(C)! noted there were no symptoms related to the elevated blood pressure, although RAYSON was educated on the need to rep011 any headache, dizziness, or visual changes should they develop. His general appearance was "elderly", severely ill appearing, uncomfortable due to pain, disheveled, tearful, and lethargic. His complexion was "gray looking", he had poor eye contact, and his affect was initable. He was assisted back to a reclined position for comfort. Pain medication was not offered at this time, possibly because he was scheduled to receive his regular dose ofpain medication at 9:00 a.m. The next medical record entry, also dated February 2, 2017, was by kb)(6); l As Reason for Appointment, he entered, "MHlJ [Discharge] Note", specifying in the narrative that the time of approved discharge was 10:30 a.m. the same day. He also wrote that RAYSON's physical condition was stable. There is no documentationj(b)(6); __ physically assessed RAYSON prior to I DETAINEE DEATH REVIEW: Roger RAYSON Medical and Security Compliance Analysis October 4, 2017 Page 16 making the discharge determination. Hands-on physical examination, to include routine examination of the heart, lungs, stomach and bowels was not documented, nor was subjective assessment of the detainee's current pain level, effectiveness of pain medication, and other complaints of discomfort. The reviewer notes that less than three hours earlier, l(b)(6); I described RAYSON as severely ill appearing, lethargic, uncomfortable due to pain at level ten, and needing assistance to recline to a more comfortable position. Medical record documentation also does not provide evidence !(b)(6); !physically assessed the detainee at any point prior to or following this date. Other than telephone encounters, the February 2, 2017 MHU Discharge Note was his only entry. During interview by telephoneJb)(61 fbl(6>lwas asked if he ever evaluated RAYSON in person. He said he recalled going to meet the detainee when he returned to LDF from RRMC, noting he was conversant and not in acute pain at the time. �/\�\.,, stated that in the following days, he was given the impression RAYSON felt isolated in the MHU and believed that the isolation was detrimental to his mental health. For that reason, and after reviewing lab studies, he decided to discharge the detainee from the infirmary. Reviewers were unable to establish whetherl(b)(�);___ I evaluated RAYSON, but did not document in-person assessment, or whether the decision was made based on his review of the lab results and conclusion that transfer from the MHU would support RAYSON's mental health. !documented lab studies showing a continued elevation in In his MHU Discharge NoteJb)(6); RAYSON's calcium level, which as noted previously, is indicative of a cancerous process. He did not address what the results indicated with respect to compromised immunity secondary to HIV infection. Review found the lab studies showed detainee RAYSON's white blood count was low at 3.1 compared to the laboratory's reference range of 3.4 to 10.8; in addition, his CD4 count was low at 247 compared to the reference range of 359 to 1519. CD4 cells are a type of white blood cell which normally attack infection, but are destroyed by HIV infection, compromising immunity. Counts lower than 200 meet the diagnosis of AIDS. Orders included an 1800 calorie diabetic diet and cafeteria privileges, with no activity restrictions or special needs allowance for a device to assist with ambulation. Follow up in one week was scheduled. The reviewer's final observation pertaining to the MHU Discharge Note is that two versions were provided. The first was electronically signed by ,�/\�t,._ , at 6:31 p.m. on March 6, 2017, more than a month following the discharge order of February 2, 2017. Under Treatment, an order to start indomethacin twice a day for 30 days was noted, as was approval for cancellation of the prescription on February 9, 2017. Although electronically signed, the "Sign off status" showed as pending. The second version of the note was electronically signed on March 27, 2017, almost two weeks following detainee RAYSON's death. Under Treatment, receipt of approval to cancel the prescription for indomethacin appears, although the order to start the medication was removed. The March 27, 2017 version also shows the sign off status as pending. The reviewer cannot positively explain why there are two, slightly different versions of the note. However, it is preswned that the first was updated after the medical record was provided to DETAINEE DEATH REVIEW: Roger RAYSON Medical and Security Compliance Analysis October 4, 2017 Page 17 ERAU shortly following the death. The reviewer also cannot explain the delay in signing the notes, or modification following the death. The MHU logbook documents detainee RAYSON refused recreation on the day !\bl\�/;__ _ approved his discharge from the MHU. An entry timed 1:15 p.m. states that after he asked for a nurse "due to his pain," an EKG was performed and the detainee was given pain medication. He was then noted to be "calming down." A 2:26 p.m. entry documents RAYSON "is continuously crying and telling the nurse he needs to go to hospital. He's afraid he's going to die and that he's in a lot of pain." According to the logbook, the detainee's blood pressure was taken at 3:45 p.m. Medical record entries loosely correspond with the MHU log. t?!\�!;,�- I documented at 1:11 p.m., detainee RAYSON complained of level seven pain throughout his body, accompanied by nausea and vomiting. Vital signs were within normal limits with the exception of a slightly elevated heart rate of 100. His weight remained 179 pounds. Tramadol 100 mg, to be repeated every six hours as needed for seven days, was ordered by !(b)(6); I via telephone encounter timed l :23 p.m. There is no corresponding reference to the order for tramadol in fb)(B); (b)(7)(C) !nursing I note. The MAR documents the medication was administered at l :30 p.m. by l(b)(6); (b)(7)(C) 7 6 7 (b)( b)(B) )(C) fb)( ); (b)( )(C) at 1 :30 p.m. At 2:00 p.m., l< ; Ialso administered morphine tablets. 2:00 p.m. was also the timefb)(6); (b)(7)(C) !signed out the morphine, a narcotic pain medication, on the Controlled Substance Administration Log. The order, handwritten on the MAR as, is not referenced in any progress note, telephone "Morphine tabs 30 mg (per I\?!\�!��encounter, or order. During interview o[Kb)(6); (b)(7)(C) I she could not recall which RN instructed her to administer the morphine. Administration of a controlled substance, absent a prescription written by a DEA-registered provider, is illegal; therefore, based on available information, the reviewer notes this is a grievous medication error. There is no documentation the apparent error was investigated and addressed. The reviewer also notes that only 30 minutes elapsed between administration of tramadol at 1:30 p.m. and 30 mg of morphine at 2:00 p.m., an insufficient amount of time to determine the effectiveness of tramadol in relieving RAYSON's pain. Tramadol levels in the blood peak up to two hours after dosing. Oral doses of morphine and tramadol together increase sedation and drowsiness, requiring close clinical monitoring for potentially serious interactions. lt is noted that l(b)(B); (b)(?)(C) was adamant that she administered both the tramadol and the morphine after detainee RAYSON was moved to the segregation unit, which as discussed below, was not until the evening. Her claim is contradicted by her own MAR entries (1:30 p.m. for tramadol and 2:00 p.m. for morphine), as well as�b)(6); (b)(7)(C) I documentation of completion of a nursing round in the MHU at 6:04 p.m. l(b)(6); (b)(?)(C) lnote describes detainee RAYSON was alert and oriented, and his respirations were even and unlabored. He was provided acetaminophen (Tylenol) per his request to help prevent the return of pain. Vital signs were all within normal limits. I D", A 7:04 p.m. entry in the medical record by fbl(6); (b)(7)(C) �ocuments that per GEO, RAYSON was transferred to Eagle Charlie unit (Eagle C). The MHU logbook documents 6:55 p.m. was the time of the transfer. A notable outlier to these times is recorded on the Housing Histo1y Grid, which documents RAYSON's transfer to Eagle C at 11 :34 a.m. It is surmised Eagle C was DETAINEE DEATH REVIEW: Roger RAYSON Medical and Security Compliance Analysis October 4, 2017 Page 18 designated as the housing unit to which the detainee would be assigned when security was first notified he was cleared for general population, well before actual transfer from the MHU. It is noted that although Eagle C appears in all written documentation, the review team learned through interviews that he never entered that unit. Instead, he was transferred from the MHU to Eagle A unit. Both Eagle A and Eagle C units are 48-bed, general population dormitories for detainees classified high and medium high. Nowhere is it documented that RAYSON was placed in Eagle A rather than Eagle C. fbl(5); (b)(?)(C) linfonned the review team that following the detainee's transfer to Eagle A, an officer called him to report several detainees were objecting to RAYSON's placement. fb)(6); (b)(7)(C) I stated that although both Eagle A and Eagle C units are maximum security dormitories, detainees housed in Eagle A are less tolerant than detainees assigned to Eagle C unit. When he repo1ted to Eagle A, l(b)(6); (b)(7)(C) lwas informed by a group of detainees that RAYSON told them of his medical condition, including that he was HIV positive. l; __ that RAYSON be returned to a hospital. I Discharge from the MHU On the morning of February 2, 2017. Kb)(6); !ordered RAYSON's discharge from the MHU upon detennination that he was stable and would benefit from housing in a less restrictive environment. His determination followed review of lab studies and a nursing assessment which described the detainee as being in severe level ten pain, lethargy, and tearfulness; however, there is no documentation l(�);___ prdered narcotic medication tramadol as needed for six days. Morphine was also given for pain. The order for discharge from the MHU I in favor of general population housing remained in place. Reviewers are unclear as to l(b)(6); vision for how RAYSON's pain which, since his arrival at LDF, was best managed with as­ needed medications, would be monitored and effectively addressed in general population. From a security perspective, placement of a seriously ill detainee with ambulatory challenges, experiencing periodic nausea and vomiting, and receiving narcotics for widespread, frequent pain, was well beyond what officers are trained and should be expected to handle. I I Se re ation goal of supporting RAYSON's mental health by decreasing his isolation and moving \�!\�L, him to general population is understood given the restrictive nature of medical housing at LDF. However, when the attempt to house RAYSON in general population quickly failed due to other detainees' objections, he was cleared for housing in segregation by an RN. In clearing RAYSON for segregation, )�()�(;r. , accurately stated a provider had discharged him from the MHU; however, the RN did not appear to take into account the totality of RAYSON's condition ordered the discharge, including the order for as needed narcotic and events sincetb/(6);___ medication. The RN's documentation that the detainee "did not appear to have any acute or I DETAINEE DEATH REVIEW: Roger RAYSON Medical and Security Compliance Analysis October 4, 2017 Page 43 unresolved medical condition that might worsen in segregation" is contradicted by the medical record. At the very least, notification and deferral of the clearance decision to a provider was warranted given RAYSON's advanced ilh1ess. Although cells in the MHU are configured and equipped in the same manner as cells in the SMU, and detainees housed therein are subject to much the same restrictions as detainees on segregation, medical monitoring in the MHU far exceeds that in the SMU. I and l<�/;___ I and !(b)(6); (b)(7)(C) I indicated, they were not comfortable with RAYSON's housing in the SMU, it was within their authority to readmit him to the MHU. l10: M206839701 Facility Code: JENADI..A 47 Y old Male, DOB: 05/03/1969 Account Number: 1000537503 830 Pine Hill Rd, JENA, LA-71342 Appointment Facility: Jena/Lasalle Detention Facility Afb\/6t Appointment Provider: llh\/n\· /h\17\IC:\ Reason for Appointment 1. Intake Saeening@0340 History of Present Illness Intake: Initial Assessment was the Pre-Saeening Progress Note reviewed? Yes Patient was identified by2 sources: Picture, Verbally If detainee was transferred from another facility, did a medical transfer summary acrompanythe detainee? Yes Wiat language do ',OU speak? English lnterpretion provided? Not applicable, patient speaks English Chaperone Present? Yes Do ',OU have an e-mail address? No Medical Screening How do)OU feel today? Bad Me ',OU currenUyin pain? Yes The severityof pain is rated at 9/10 The pain began 1-2days ago The pain is located a// over The character of pain is oonstant Me there anyaggravating or alle1.1ating faoors? Yes �lain: arlhrilis, lyphoma Do ',OU have anycurrent or past medical problems? Yes lf}es, eiq:>lain. , Non -Hodgkin lymphoma, OM HTN, Anemia, GERD, M3tabo/ic disorder, Gout, Nausea, Pain, Mhrilis, HIV Me ',OU currenUyor have)OU ever taken any medication on a regular basis, induding over the counter and herbal? Yes Do ',OU ha-.e ',()Ur medications with )OU? Yes List medications: Abacavir 300mg 2caps po daily, Acetaminophen 325mg po eve,y 6 hours pm, Acyclovir 200mg po bid, Allopurinol 300mg po daily, ASA EC 81mg po daily, Dolutegravir 50 mg po daily, Ferrous G/uoonate 324 mg 2tabs po daily, Ruconazole 200mg po daily, G/ipizide 10 mg po bid, HCTZ 12.5mg po daily, lndomethacin 25mg po bid pm goui Regular Insulin SQ pm per sliding scale, Lamivudine 150mg 2tabs po daily, Levoffoxacin 500mg po daily, Lisinopril 10mg po daily, M3tformin 1000 mg po bid, Oxycodonelacetaminophen 51325mg 2tabs po eve,y 6 hours pm, 07dansetron 4 mg po every 8 hours pm nausea Do ',OU have anyallergies to include allergies to medication or food? No Me ',OU nowor have)Ou ever been treated bya doctorfor a medical condition to indude hospitali2ations, surgeries, infectious or communicable diseases? Yes lf}es, eiq:>lain. For Ox above Have ',OU ever had a persistent cough for more than three weeks, coughed up blood, had a persistent fever, night sweats, or uneiq:,lained weight loss? No Do ',OU have previous hx of lB? No Have ',OU had anyrecent acute changes with ',Our 1.1sion or hearing? No v\ears glasses Do ',OU have anyspecific dietaryneeds? No Me ',OU a Transgender? No Have ',OU ever had or have)Ou e1.er been vaccinated against Chicken Pox? Admits prior infedion Oal Screening Me ',OU ha1.1ng anysignificant dental problems? No M:lntal Health Screening Have ',OU ever tried to kill or harm ',Ourself? No Me ',OU currenUythinking about killing or harming ',Ourself? No Do ',OU have a history of assaulting or attacking others? No Do ',OU have a physical or emotional trauma due to abuse or 1.1ctimization? No Do ',OU know of someone in this facilitywhom ',OU wish to attack or harm? No Do ',OU now or have ',OU ever heard 10ices that other people do not hear; seen things or people that others do not see; or felt others were lr)ing to harm ',OU for no logical or apparent reason? No Have ',OU ever recei1.ed counseling, medication or hospitali2ation for mental health problems? No Have ',OU been a victim of physical or se)(IJal abuse or engaged in beha1.1ors that would put ',OU atrisk? No Do ',OU feel that ',OU are ourrendyin danger of being physicallyor sel4.lallyassaulted? No Have ',OU ever se)(IJallyassaulted an',One? No Trauma Screening Have ',OU ever witnessed, eiq:>erienced, or been confronted with an event or events that in10lwd actual or threatened death or serious injury? No Leaming/Cultural/Religious Assessment Is there anything important to know about',()ur religious oroultural beliefs that are of concem to ',OU while in detention? No Have ',OU ever had difficulties learning or understanding written information? Yes �lain Limited reading and witing ability Substance Use/Pbuse Screening Have ',OU ever been treated for drug or alcohol problems or suffered withdrawal synptoms from drug use? No Do �u now or have �u ever used toba= products? No Do �u now or have �u ever drank alcohol? No Do �u now or have '.,(JU ever used drugs? No Yitai Signs Painscale 01/28/2017 04:19:20 A'v1 9 outof 10 (b)(6); (b)(7)(C) Temp 97.3F 01/28/2017 04:19:20 A'v1 1-R 01/28/2017 04:19:20 A'v1 BP 01/28/2017 04:19:20 A'v1 RR 01/28/2017 04:19:20 A'v1 Wt 01/28/2017 04:19:20 A'v1 94 /min 132185mm Hg 18 /min 1791bs H 01/28/2017 04:19:20 A'v1 BMI 01/28/2017 04:19:20 A'v1 65.5in 29.33 Index Rnaerstick Gucose 01/28/2017 04:19:20 A'v1 233 Oxvaensat¾ 01/28/2017 04:19:20 A'v1 100% RA/#Uters 02 via: RA 01/28/2017 04:19:20 A'v1 Examination Intake Screening: Intake Exam Patient appears to have normal physical/emotional characteristics and no barriers to communication? Yes ls the patient oriented to person. place and time? Yes Biiarre or a:az!f behavior observed: No Skin Broken out in bumps/rash observed: No El«;essive sweating observed: No .Abnormal breathing (persistent cough, hwerventilation, etc) observed: No Physical disabilities observed: No ,llgitation observed: No l\lalnourished appearance observed: No Cuts, bruises.jaundice, lesions, scars or tattoos observed: No Nits or Jlctive lice observed: No Developmental disabilities observed: No Inability to foous or concentrate observed: No Shaking/lremors observed: No Needle Tracks observed: No Does the patient wear glasses or contacts? No Assessments 1. Jlbnormal intake sa:eening, referred to medical provider - 00.4 (Primary) Treatment 1. Abnormal intake screening, referred to mecical prOllider Notes: Tuberculosis and CXR e:,q:>lained to patient and process completed with appropriate shielding. Physical e>0m scheduled for patient Pccess to medical/dental/mental health care, grievance process e:,q:>lained to patient. Patient given the 11/edical Oientation and Health Information Brochure and Dealing with Stress Brochure based on the language spoken by the patient. Patient verbalized understanding of any teaching or instruction. Patient was asked if he or she had anyadditional questions, and anyquestions were addressed.l'.Ei:illiDFNP contacted. Detainee placed in M-lU until seen bya provider this PM Pain meds given as ordered on transfer. Procedure Codes 82962 GLUCOSE BLCX)D TEST Disposition: 11/edicallyCleared for Custody; with TB dearance Notes: ln M-lU #6 until seen bya provider Appointment Provider:!(b)(6); (b)(7)(C) Electronically signed byl(b)(6); (b)(7)(C) Time) Ion 01/28/2017 05:23:08 (Central Standard Sign off status: Completed Jena/Lasalle Detention Facility 830 Pl�U. ROAD JENA, LA71342 Tel: 318-992-7613 Fax: Patient: RAYSON, ROGER DOB: 0SJ03/1989 Progress Note:fb)/6): (b)/7)/C) Note generated by eC/inica/Works EMPIPM Softv..are (vw.w.eC/inica/Works.com) 01/2812017 U.S. Immigration and Customs Enforcement RAYSON,ROGER A:!(b)/6): ! SublD: M206839701 Facility Code: JENADI..A 47 Y old Male, DOB: 05/03/1969 Account Number: 1000537503 830 Pine Hill Rd, JENA, LA-71342 Appointment Facility: Jena/Lasalle Detention Facility Appointment Provlder:Kb)(6); (b)(7)(C) 01/28/2017 Surgical History surgeryto remo-.e cy.;t, also separate surgery for port2016 Family History M>ther: ali\e Father: ali-.e Daughter(s): ali-.e Son(s): ali-.e Sister(s): aliw Brother(s): ali1.e 3 brother(s), 6 sister(s). 2 son(s), 2 daughter(s)­ healthy. Has no communication with his familyelCel)t for one sisterkbl/6\: Patient stays in touch with his children. I Social History TobaocouseTobacx:o Use Do )OU now or ha-.e )OU e1.er used lobacx:o products? No Drugs/Alcohol: Drugs Haw }OU used drugs other than those for medical reasons in the past 12 months? No .Alcohol Screen Do )OU drink alcohol? Yes Wlat twe ofalcohol do }Ou drink? Beer How often do )OU drink? daily How much do }OU drink when }OU drink? 24 Wien was yiur last drink? M>re than 24 months ago Do )OU notice 01.er a period oftime that }OU need to drink more for the same effect? No Ha1.e }OU ever been in treatment ofalcohol use? No Ha-.e )OU e-.er gone through alcohol withdrawal in the past? No Ha-.e )OU e-.er been con1,1cted for dri1,1ng under the influence of alcohol? No &use History Physical /lbuse Ha-.e )OU e-.er suffered from physical abuse? No SeJUal /lbuse Ha-.e yiu e-.er been a l.ictim ofseJUal abuse? No Allergies N.KDA Hosp"allzatlon/Major Diagnostic Procedure non-hodgkin's l}ITlphoma fall 2016 Ml/A injuries to bilateral jaw line, other lacerations 1992 Review of Systems HIV: klore>Ur last colonoscopy? 0812016 Ha-.e yiu had a DRE? Admits Wien was }<>Ur last one? 0112015 Patient Identification: Patient Identification Patient properlyidentified by2 sources induding: Picture, Verbally Chaperone Present? No Interpretation Pro1,1ded? Provider fluent in detainee's native language Patient properlyidentified by2 sources induding: Picture, Verbally Interpretation Pro1,1ded? Detainee speaks English fluently Chaperone Present? No Patient Identification Patient propenyidentified by2 sources induding: Picture, Verbally Chaperone Present? No Interpretation Pro1,1ded? Provider fluent in detainee's native language Patient properlyidentified by2 sources induding: Picture, Verbally Interpretation Prol.ided? Detainee speaks English fluently Chaperone Present? No Pain /lssessment: Pain Ne \OU currenUyin pain? No Ne )OU currenUyin pain? Yes The pain is located left upper forearm The se-.erityofpain is rated at 7110 The sewrityofthe pain is moderate The pain began 4-5 IMieks ago The character of the pain is aching,is constant The associated S'.)ffiptoms are abdominal pain,light headedness The pain is aggravated by none The pain is relieved by other Describe: a shot given (name unknow,) Pain /lre yiu currenUyin pain? No Ne }OU currenUyin pain? Yes The pain is located left upper forearm The sewrityofpain is rated at 7/10 The se1erity ofthe pain is moderate VVeight loss admits, is unintentional, is significant O\er a period of s8\el'al months. Q;>hthalmolooic: Blurred l.ision denies. Diminished 1.1sual acultydenies. Discharge denies. Itching and redness denies. Pain denies. §f[: Blocked ear denies. Decreased hearing denies. Decreased sense of smell denies. Difficulty swallowing denies. Dry mouth denies. Ear pain denies. Nosebleed denies. Ringing in the ears admits, affecting both ears since MVA. Sinus pain denies. Sore throat denies. Endocrine: Cold intolerance admits, that is moderate. Diffirultysleeping denies. Dizziness denies. Bcessil.e sweating denies. E>«:essi1.e thirst denies. Frequent urination denies. Heat intolerance denies. VVeakness admits sometimes. VVeight loss admits after chemo. RespiratoN. Breathing pattern denies. Chest pain denies. Cough denies. Hemop!}sis denies. Pain with inspiration denies. Shortness of breath at rest denies. Shortness of breath with exertion denies. Sputum production denies. 'Mleeiing denies. Cardiovascular: Chest pain at rest denies. Chest pain with exertion denies. Claudication denies. C�nosis denies. Difficultyla,ing flat denies. Dizziness denies. D),spnea on exertion denies. Fluid aCOJmulation in the legs denies. Irregular heartbeat denies. 01hopnea denies. Palpitations denies. Shortness of breath denies. VVeakness admits at times. Gastrointestinal: .-6bdominal pain admits intermittently midline of the abdomen upper and lower sections. Blood in stool denies. Change in bowel habits denies. Constipation denies. Decreased appetite denies. Diarrhea denies. Diffirulty swallowing denies. �sure to hepatitis denies. Heartburn denies. Hematemesis denies. Nausea admits, frequent. Rectal bleeding denies. IA:lmiting admits. VVeight loss admits after chemo. Hematology. Breastlump denies. Dizziness denies. Easy bruising denies. Fe1.er denies. Q-oin mass denies. Prolonged bleeding denies. Recent transfusion denies. SWollen glands admits i n neck/head. VVeakness sometimes . VVeight loss admits after chemo. Mm..Q]!v. Difficultyinitiating stream denies. Dribbling after urination denies. Hard testide denies. Hernia denies. Hypospadias denies. Lump in groin denies. Penile discharge denies. Rash or blisters on penis denies. Scrotal pain denies. Scrotal swelling denies. Undescended testicle denies. Genitourinary. .-6bdominal pain/swelling admits intermittently midline upper and lower. Blood in urine denies. Difficultyurinating denies. Frequent urination denies. Painful urination denies. Peripheral Vascular: Posent pulses in hands denies. Posent pulses in feet denies. Blanching of skin denies. Cold extremities denies. Decreased sensation in extremities denies. Pain/cramping in legs after exertion denies. Painful extremities denies. Ulceration of feet denies. fQQialric: khilles pain denies. .Ankle pain denies . .Ankle swelling denies. Ball of foot pain denies. Big toe pain denies. Difficultywalking denies. Fe1.er denies. Foot numbness denies. Joint dislocation denies. Sole pain denies. IJ\lound ooii ng denies. Skin: The pain began 4--5 v.eeks ago The character of the pain is aching.is constant The associated s,mptoms are abdominal pain,/ight headedness The pain is aggravated by none The pain Is relie1.ed by other Desaibe: a shot given (name unknow-,) �: 47 �ar old male detainee presents for PE-C with multiple diagnosis. He reports he was detained for smuggling in cocaine. He states his familyhas turned their back on him. Wlile he incarcerated Dec 2014, he found out he had HIV. In Pugust 2016 he had a bump on his neck, was told it was a cy;;t and was surgicallyremol.ed, Jackson1.1lle Fl hospital. The area swelled up like a baseball and he was returned to the hospital where theydiagnosed him with Non-Hodgkin L,mphoma. He had his first Chemo at a hospital in Florida "sometime in September". States he was suppossed to have chemo e1.erythree weeks and hasn't had chemo since the first time in Sepl Was at D. RayJames Correctional facilitywhen diagnosed, mo1.e to FI\IC Lexington in November 2016. I ha1.e found the name of Larkin community Hospital in South Marni hospital but he does not belie-.e this is the hospital that diagnosed him or where he receil.ed chemo. Pain to the left upper arm. Pt. other times pain is more generalized. He reports nauseal\Omiting, swollen l,mph nodes of neck, intermittent fatigue. Denies fe-.er, night sweats, anorexia. fvbst meats make him nauseous such as bolognia, turkeyham, all pork, beef. He states he has been in touch with a phySician in fvbntego Bay that is readyto treat him. rv'edical Housing Unit Nursing Rounds Diagnosis/Reason for admission to M-IU: Use Notes Section .CX:Jservation Non-Hodgkin's Lymphoma/HIV Date/time for admission Use Notes section 1/2812017 11:09 Le1.el of Care required: M,dical Level 1 Care needed: oral medication, routine observation. Frequencyofnursing checks: Every8 hrs. Frequencyof1.1tal signs: every8 hrs. l\ll'ldication orders: Yes, see medication orders Diagnostic Tests/Treatment orders: Yes, see orders Diet Orders: Yes, see Spedal Needs kti'vities or Resbiction orders: As tolerated Follow-up plan (frequency of prol.ider rounds): Use Notes Section .FIU by physidan Patient education: . Discharge plan: .Unknow, at this time Vital Signs 7 outof10 982F 89 /min 124176 mm Hg 18 /min Pain scale 01/28/2017 09:59:02 PM Temp 01/28/2017 09:59:02 PM 1-R 01/28/2017 09:59:02 PM BP 01/28/2017 09:59:02 PM RR 01/28/2017 09:59:02 PM b)(6); b)(7)(C) Wt 1791bs 01/28/2017 09:59:02 PM H 65.5 in 01/28/2017 09:59:02 PM BMI 29.33 Index 01/28/2017 09:59:02 PM Oxvaensat¾ 98% 01/28/2017 09:59:02 PM Examination General Examination: GENER6L .6PPE.AR.t>NCE: alert, in no acute distress, male , ill-appearing, thin, uncomfortable due to pain, cooperati1.e, 1.1sibly upset, tearful. HE.AD: Some edema with pain to the right IOIMlr scalp area extending up to posterior to the right auricle. Hair scarce and patchy. ENT: EYES:, normal, P ERRI.A, conjuncti\0 clear, EARS:, normal, auditay canal clear, light reflex present, NOSE:, nares patent, SINUSES:, sinuses non-tender to palpation, ORAL CAVITY:, mucosa moist, missing se1.eral molars, lHROAT:, normal, no erythema, no exudate, pharynx normal, tonsils normal. EYES: pupils equal, round, reactive to light and accommodation. EAAS: normal, auditory canal clear. NOSE: nares patent. ORPL CA\IITY: normal, mucosa moist, no lesions, palate normal, tongue in midline, missing teeth. lHRQA.T: no erythema, no exudate, pharynx normal, tonsils normal, U\A.lla midline. NECK/THYROID: carotid pulse normal, no thyroid nodules, no thyromegaly, thyroid nontender, trachea midline, posterior ceNcal nodes enlarged, submandibular nodes enlarged. LYM>H NOOES: cer\ical nodes hard, ceNcal nodes enlarged, shoddy. SKIN: normal, no rashes, no suspicious lesions. HE.ART: no murmurs, regular rate and rhythm, S1, S2 normal. LUNGS: normal, clear to auscultation bilaterally, no wheezes, rales, rhonchi. Hi\eS denies. Rash denies. Scaly lesions of skin/scalp denies. Skin lesion(s) denies. Neurolooic: Balance difficultydenies. Coordination admits. Difficultyspeaking denies. Dizziness denies. Fainting denies. Gait abnormality denies. Headache denies. Irritability denies. Loss of strength admits sometimes. Loss of use of e>dremity denies. Low back pain denies. �mory loss denies. Pain admits to left ann. Sei21Jres denies. lies denies. Tingling/Numbness denies. Transient loss of vision denies. Tremor denies. Ps',Chiatric: A-lJOetydenies. Aiditoryvisual hallucinations denies. Delusions denies. Depressed mood admits. Difficulty sleeping denies. Eating disorder denies. Homicidal Thoughts denies. lnabilityto concentrate denies. Loss of appetite denies. �ntal or Ph')6ical abuse denies. Stressors admits due to current situation. Substance abuse denies. Suicidal thoughts denies. Pain to the left upper forearm. CHEST: normal, no gross rib defonnity , noonal shape and expansion, port palpated to the left upper chest wall. BREASTS: normal. />BDOVEN: bowel sounds present, lil.ef edge one finger breadth below costal margin, no guarding or rigidit y , no hepatosplenomegaly , no organomegaly , no rebound tenderness, soft, nontender, nondistended; small umbilical hernia. RECTftl..: not examined. BPCK: normal, full range of motion. MALE GENITOORINJIRY: not done. M.JSCULOSKELETftl..: stow shuffling gait, no deformities, full range of motion,. PERIPHERAL PULSES: 2+ dorsalis pedis, 2+ radial, 2+ ulnar, 2+ brachia!, 2+ carotid. EXIREMTIES: nodule palpated in area of tenderness to the left upper forearm posteriorly , hard nodule palpated that is fixed. NEUROLOOC: alert and oriented, cooperafr,e with exam. PSYCH: alert, oriented, cogni!i\e function intact, good ey e contact, no auditory or visual hallucinations, speech clear, thought content without suicidal ideation, delusions, mood depressed, affect sad. Assessments 1. Type 2 diabetes mellitus without complications-E1 1.9 (Primary) 2 . .Anemia in other chronic diseases dassified elsewhere• D63.8 3. Essential (primary) h',PE)rtension -110 4. Gastro-esophageal reflux disease without esophagitis • K21.9 5. Burkitt l)-ffiphoma, unspecified site• C83.70 6. Gou� unspecified-M10.9 7. Unspecified osteoarthritis, unspecified site• M19.90 8. Human immunodeficiency virus [HIV] disease• B20 Treatment 1. Type 2 diabetes mellitus without complications Start />spirin EC Tablet Dela� Release, 81 M3, 1 tablet, Q-ally, Daily /lM, 90 da')6, 90, Refills 0, Ka>: No, Drug Source: In House Pharmacy, Notes: Required for tra-el Start GipiZIDE Tablet 10 M3, 1 tablet Q-ally, BID, 90 da')6, 180 Tablet Refills 0, Ka>: No, Drug Source: In House Pharmacy, Notes: Required fortra1el Start Insulin Regular Solution, 100 units/ml, Sliding Scale, Subcutaneous, BID, 30 da')6, 1, Refills 2, Ka>: No, Drug Source: In House Pharmacy, Notes: Not required for tra1el Start �tformin HCI Tablet, 1000 M3, 1 tablet with meals, Q-ally, BID, 90 da')6, 180 Tablet, Refills 0, Ka>: No, Drug Source: In House Pharmacy, Notes: Required fortra1el Notes: Last labwork • last Wonday at FM:: Kentucky. DFH diet Patient education on dieVe,ercise/ifest}le for self care Education on disease process and complications from uncontrolled blood glucose Educated on s/s of h>f)ergl;cemia/hw<>9l;cemia Education on medication and side effects acc:uchecks bid to s/s. 2. Anemia in other chronic diseases classified elsewhere Start Ferrous Gluconate Tablet, 324 (38 Fe) M3, 2 tablets, Q-ally, Daily /lM, 90 da)S, 180, Refills 0, Ka>: No, Drug Source: In House Pharmacy, Notes: Required fortra1el 3. Essential (primary) hypertension Start H}drochlorothia.zide Capsule, 12.5 M3, 1 capsule, Cxally, Daily MA, 90 da')6, 90, Refills 0, KOP: No, Drug Source: In House Pharmacy, Notes: Required for tra1el Start Lisinopril Tablet, 10 M3, 1 tablet Cxally, Daily PM. 90 da')6, 90, Refills 0, Ka>: No, Drug Source: In House Pharmacy, Notes: Required fortra1.el Notes: 81P stable, continue current PCx:: DFH diet. 4. Glstroesophageal reflux disease without esophagitis Notes: Denies this problem at current time. 5. Burkitt lymphoma, unspecified site Start Qidansetron HCI Tablet, 4 M3, 1 tablet as needed for nausea, Cxally, TIO, 90 da')6, 270 Tablet, Refills 0, Ka>: No, Drug Source: In House Pharmacy, Notes: Required for tra1el Notes: Last ppd 115/16-0 mm negati-e Hepatitis A vaccine gi1.en Last labwork-last Wonday at FM:: Kentucky Diagnosed 812016. one chemo treatment gi1en in Sept 2016 Qicologyreferral made ,lllso taking Oxy:odone 5/325- will refer to Dr. Q or Dr. Holloway. for now nursing can continue to gi-e medication as directed. Referral To:Qicclogy (Pending /lpproval) Reason:Qicclogy- Non-Hodgkins 6. Gout, unspecified Start lndomethacin Capsule, 25 M3, 1 capsule with food or milk as needed, Orally, BID. 90 da')6, 180 Capsule, Refills 0, Ka>: No, Drug Source: In House Pharmacy, Notes: Required for tra1.el Start l>cetaminophen Tablet 325 M3, 1 tablets as needed, Cxally, QID,90 da')6, 360 Tablet, Refills 0, Ka>: No, Drug Source: In House Pharmacy, Notes: Not required for tra-el Start,llllopurinol Tablet 300 M3, 1 tablet 0-ally, Daily PM, 90 da')6, 90, Refills 0, Ka>: No, Drug Source: In House Pharmacy, Notes: Required fortra1el Notes: No current episode. 7. 1-llman immunodeficiency virus [HVJ disease StartPbacavir Sulfate Tablet 300 NG, 2 tablet, Q-ally, Daily MA, 90 da')6, 180, Refills 0, KOP: No, Drug Source: In House Pharmacy, Notes: Required for tra1el Start DU.UTEGRA\1R SOOIUMTablet, 50mg, 1 tablet, Q-ally, Dailyf,M, 90 da')6, 90, Refills 0, Ka>: No, Drug Source: In House Pharmacy, Notes: Required for tra1el StartPcydovir Capsule, 200 fv'G, 1 capsule, 0-ally, BID, 90 day.,, 180 Capsule, Refills 0, K�: No, Drug Source: In House Pham1acy, Notes: Required for Ira.el Start Fluconaiole Tablet 200 IVl3, 1 tablet Cxally, Daily .AM 90 da,.s, 90, Refills 0, KCJP: No, Drug Source: In House Pham1acy, Notes:Required for Ira.el Start Lamiwdine Tablet 300 fv'G, 1 tablet, 0-ally, Daily .AM 90 da,.s, 90, Refills 0, K�: No, Drug Source: In House Pham1acy, Notes:Required for Ira.el Start Le1,0ftoJ0cinTablet, 500 IVl3, 1 tablet, 0-ally, Daily.AM 90 day.,, 90, Refills 0, KCJP: No, Drug Source: In House Pham1acy, Notes: Required for Ira.el Notes: PPD 06 /04115 negati,e 0mm Hep Agi.en 2119115 Infectious Disease Referral Consult Referral To:lnfectious Disease(Pending /lpproval ) Reason:lnfectious Disease- HIV 8. Others Pelion Started- Facility Tasks - \Aew Cxders Preventive Medicine Educated on access to care via sick-call processor for any medical/dental. or mental health issues. Educated on handwashing before meals and when hands dirty, Educated on maintaining h;dration of atl east 10-12 cups of water daily to pre,ent deh;dration and promote good health, Pt 1.erbalized understanding . F/U with own phy.;ician if deported and/or released. Follow Up daily(Reason: M--iU ) Appointment Provider:fb)(6); (b)(7)(C) Confirmatory sign off: _ _ );_ (b_)(_7)(C �l(b)(6 _ )_ --�Pl/31/2 017 03:14:04 PM Electronically signed by!(b)(6); (b)(7)(C) !on 01/28/201711:30:21 (Central Standard Time) Electronically co-signed by Kb)(6); (b)(7)(C) Sign off status: Completed !on 01/31/2017at 03:14 PM MDT Addendum: 01/28 /201712:23 PMl(b)(6):(b)(7)(C) � Tried to notifykb)(6): (b)(7)(C) Jena/Lasalle Detention Facility 830 Pl�Ll. ROIID JENA, LA 71342 Tel: 318-992-7613 Fax: Patient: RAYSON, ROGER DOB: 05/0311969 Progress Note:fh\/fi\• /h\(7)/C:\ Note generated by eC/inica/Works EMP/PM So/twire {WNN.eC/inice/Works.com) 01/2812017 !Cell 1,0ice box was full. Appendix 2.2.A: ICE Custody Classification Worksheet ICE Custody Classification Worksheet Initial Field/Sub Office: Reclassification � i)-F... ·- · · ·· · ·····-··-- · S ecial Classification -D:rte :--·-f--;-�r,-/ - . _... - .. . .. -·-·- . Language(s) Used during the Interview: Officer Name: DOB: Alien Number: 5,3. Gender: ,OF First Name: Last Name: Part 2. Special Vulnerabilities and Management Concerns � a Special VuJnenlbilhy exist? Inquire, obsel"\·e, aod re\ie,r ail documeot.ation. II ba..�d on your a.sae5Sment the "-ulDerability existS, select the appropriate boxes belmr Also mdicau whet.her there are other management concerns that a,.ay affect tbe C'tlROdy ·--··-·· decision. . ·o;ri�;;� .phy�i�-�-iii��� .............. l C]Y o� • • · • • • •.O O O-• • ·"'•••••· • • • • · · · TO O • • • • •• • ••• · · • • ·· · • • • • • · • · • · • • • • o I D serious mental illness D disability 0 elderly ! f Opreguancy 0 nursing D sole caretaking re,pon.;ubility 0 risk based o?l rexual orieotatioo/gender identity 0 victim o( perEE<:Ution/torture : I I 0 victim of se:rual abuse or violent crime I 0 victim of human traffickiDg 0 other (specify): Provide further explanation as necessary: . ,. - . I - . Ifany boxes are checked. consult with the local ICE Field Office reguding :ippropn'ate puoemeat 8.Dd other management considerations, and record t/Je date and time ofconsultation here: 2.2 I Custody Classification System ' ·- 78 PBNOS 20U (As Modified by February 20J.3 E.mHa} Page 093 Withheld pursuant to exemption of the Freedom of Information and Privacy Act Page 094 Withheld pursuant to exemption (b)(6); (b)(7)(C); (b)(7)(E) of the Freedom of Information and Privacy Act Case Number: ..... b_)ICf7_ )(E _ )_____. REPORT OF THE FORENSIC PATHOLOGIST LOUISIANA FORENSIC CENTER, LLC P.O. Box398 Youngsville, LA 70592 Phonel(b)(6); (b)(7)(C) I Fax 337-5()4..2808 Dateflime of Death: 03/13/17, 1520 hours Name or Decedent: Rayson, Roger Date/'llme of Autopsy: DJ/14/17, 0945 hours Address: LaSalle Detention Facility Body Identified By: Homeland Secmity Social Security NIDDber: Not avalJable Date of Birth: 05/03/69, age 47 Place of Death: Lafayette General Medical Center Investigator: None Witnesses: None .,...,,,.,.......,,....,.,,"'"'= ,..,... (b )(6); (b )(7)(C )----� -----=-----"--­ l · Prosector: , ---::=:::::!!!! Kb)(6); (b)(7)(C) Completed: ____...:.7.:....:/l=-=0'--------'-'2=0="-7l Forensic Pathologist �isted By: l(b)(6); _. jLouisiana Forensic Center CAUSE OF DEATH Remote subdural hemorrhage due to unknown factors with contribution of hypertensive atherosclerotic cardiovascular disease, diabetes mellitus, obesity (BMl=33) and complications of HIV MANNER OF DEATH Undetermined ANATOMIC SUMMARY I. Il. ID. Blunt force injuries to head: A. Subdural hemorrhages, remote, bilateral, adherent: I. Right sided, 12 x 10 x 2.0 cm, light brown, concave underlying brain 2. Left, 8.0 x 5.0 x 0.2 cm, brownish red Mass effect: 3. Right to left 1.0 cm shift a. 4. Status post burr holes x.2, right B. Subarachnoid hemorrhage, bilateral temporal lobes C. Loss of gray-white interface at vertex (consistent with ischemic siroke) No skull fracture D. No scalp hemorrhages E. F. No brain contusions G. Brain fixed in fonnalin and saved in formalin following sectioning Miscellaneous injuries: A. Contusion, left abdomen, left chest and left axilla B. Ecchymosis, right antecubital space (likely venipuncture) C. No internal body organ injuries No injuries to the hands D. Hypertensive atherosclerotic cardiovascular disease: CardiomegaJy, 550 grams A. B. Atherosclerosis. aorta and coronary arteries, minimal to moderate Rayson, Roger Page 2of8 C. IV. V. VI. VII. Vlll. Case Nwnber: �.... b_)(_7)_(E_) ___, Nephrosclerosis, bilateral, minimal to moderate Obesity, BMI=33: A. Hepatosplenomegaly, renomegaly and cardiomegaly Meningitis Evidence of medical intervention/fluid overload: Edematous extremities and scrotum A. Bilateral pleural effusions (1000 cc apiece) and ascites fluid (100 cc), serosanguinous) 8. Port-A-Cath, left chest C. Toxicology positive: A. Morphine Clinical histcry of HIV+ slalus: A. No evidence of AIDS Rayson, Roger Case Number: .... l(b_)C_7)(__ E_) ____. Page 3of'8 EXTERNAL EXAM.INATION The decedent has edematous extremities and scrotum. The body is that of a normally-developed, obese black Hispanic man accompanied with no personal items. The body is identified by the Homeland Security. An identification tag is present on the left toe and wrist. The body weighs 200 pounds, is 65 inches in height and appears compatible with the reported age of 47 years. The body is cold. Rigor is present to an equal degree in all extremities. Fixed lividity is distributed on the posterior surfaces of the body, except in areas exposed to pressure. The scalp hair is brown and 2.0 cm in length. Facial hair consists of a beard. The irides are brown, the corneas are clear, the sclerae white, and the conjunctivae are tan and free of petechiae. The pupils measure 3.0 mm bilaterally. The external auditory canals are free of foreign material and abnormal secretions. The nasal skeleton is palpably intact. The nares and oral cavity have blood within them but are otherwise free of foreign material. The lips are without evidence of injury. The teeth are natural without restorations. Examination of the neck reveals no evidence of injury. The chest is unremarkable. The abdomen is unremarkable. The extremities show no gross bony deformities. The fingernails are intact. There are no tattoos. Needle tracks are not observed. The external genitalia are those of a normal adult, appearing circumcised man. The posterior torso is essentially without note. The anus is atraumatic. The skin is free of abrasions, lacerations and bums. Scars from prior trauma are noted. EVIDENCE OF THERAPY There is no evidence of recent medical intervention Evidence of prior medical intervention consists of a Port-a-Cath in the left upper chest and a healing incision over a burr hole on the right head. There is no evidence of organ procurement. EVIDENCE OF EXTERNAL /INTERNAL INJURY Blunt force injuries to head: There are subdural hemorrhages that are adherent over bilateral hemispheres. On the right the subdural hemorrhage is light brown measuring 12 x 10 x 2.0 cm with an underlying concavity. On the left the subdural hemorrhage measures 8.0 x 5.0 x 2.0 cm and is brownish red. There is a mass effect with a right to left 1.0 cm shift. The decedent is status post neurosurgery with two burr holes on the right. There are subarachnoid hemorrhages on bilateral temporal lobe poles. There is a loss of gray-white interface along the vertex. There are no skull fractures and no scalp hemorrhages. There are no brain contusions. The brain is fixed in formalin prior to sectioning and saved in formalin following sectioning. Rayson, Roger Page4of8 Case Number: f b_)(?_)(_E_) .... ___. Miscellaneous Injuries: There is a contusion over the left abdomen and an ecchymosis over the right antecubital space, both possibly due to medical intervention. There are no internal body organ injuries. There are no injuries to the hands. There are also contusions on the left mid chest and near the axilla. INTERNAL EXAMINATION Body Cavities: The body is opened by the usual thoracoabdominal incision and the chest plate is removed. No adhesions are present in any of the body cavities. There is 1000 cc of serosanguinous fluid within each thoracic cavity and 100 cc of serosanguinous ascites fluid. All body organs are present in the normal anatomical positions. The subcutaneous fat layer of the chest wall is 2.0 cm thick. The subcutaneous fat layer of the abdominal wall is 4.0 cm thick. Musculoskeletal System: Muscle development is normal. No bone or joint abnormalities are noted. Examination of the soft tissues of the neck. including strap muscles, thyroid gland and large vessels. reveal no abnormalities. The hyoid bone and larynx are intact. Cardiovascular System: The heart weighs 550g and has a normal configuration. The pericardial surfaces are smooth, glistening and unremarkable; the pericardial sac is free of significant fluid or adhesions. The coronary arteries arise normally, follow the usual distribution and are widely patent with evidence of minimal to moderate atherosclerosis but no thrombosis. The chambers and valves exhibit the usual size-position relationship and are unremarkable. The left venuicle measures 0.8 cm thick, the septum measures 0.8 cm thick and the right ventricle measures 0.3 cm thick. The myocardium is red-brown, firm with no focal lesions; the atrial and ventricular septa are intact. The foramen ovale is closed. The aorta shows minimal to moderate atherosclerotic involvement. The pulmonary trunk does not show significant atherosclerotic involvement. The aorta and the pulmonary trunk and their major branches arise normally and follow the usual course. The ductus arteriosus is closed. The vena c avae and their major tributaries return to the heart in the usual distribution and are free of thrombi. Respiratory System: The lungs are congested with pleural effusions as described above. The upper airway is clear of debris and foreign material; the mucosal surfaces are smooth, yellow-tan and unremarkable. The right lung weighs 500g; the left lung weighs 550g. The pleural surfaces Rayson, Roger Page5of8 Case Number: "-!(..;..; b)(...;. 7)(.;_E_) --' are smooth and glistening with no focal lesions. The pulmonary parenchyma is pink and soft except in areas of dependent congestion which are dark red and firmer. No mass lesions are noted. The bronchial tree and pulmonary arteries are normally developed. There is no evidence of thromboembolic disease. Alimentary System: The tongue exhibits no evidence of recent injury. The esophagus is lined by gray-white, smooth mucosa. The gastric mucosa is unremarkable and the lumen contains 10 cc of brown fluid. The small and large bowels are unremarkable. The pancreas has an autolyzed, red/tan, lobulated appearance and the ducts are clear and of normal caliber. The appendix is present. Liver and Biliary System: The liver weighs 2700g. The hepatic capsule is smooth, glistening and intact covering moderately firm, red/brown parenchyma. The usual lobular architecture is identified on section. No mass lesions are noted. The gallbladder contains 30 ml green-brown bile; the mucosa is velvety and unremarkable. The extrahepatic biliary tree is patent, without evidence of calculi. Genitourinary System: The right kidney weighs 300g; the left kidney weighs 300g. The renal capsules are smooth and thin, semitransparent and strip with the usual difficulty. The underlying cortical surfaces are coarsely granular and red-brown. On section the cortices are sharply delineated from the medullary pyramids, which are red-purple and unremarkable. The calyces, pelves and ureters are without note. The urinary bladder contains no urine; the mucosa is gray-tan and smooth. The prostate gland, seminal vesicles and testicles are without note. Reticuloendothellal System: The spleen weighs 750g. It has a smooth, intact capsule covering red-purple, moderately firm parenchyma; the lymphoid follicles are unremarkable. The regional lymph nodes appear normal The bone ID.aITOW is red and firm. The thymus is absent. Endocrine System: The pituitary, thyroid and adrenal glands are unremarkable. Head/Central Nervous System: Evidence of Injury to the brain is described above. The brain has been fixed in formalin prior to sectioning and saved in formalin following sectioning. There are burr holes but otherwise the scalp is reflected and is intact. There are burr holes otherwise the calvarium of the skull is intact and removed. The dura mater is disrupted secondary to burr holes. The dural sinuses are patent. The brain is removed and weighs 1300g. The basilar portion of the cranial vault is Rayson, Roger Page 6 of8 Case Number: .._fb_)(7_)(_E)____. intact. The leptomeninges are thin and delicate. The cerebral hemispheres are symmetrical. The structures at the base of the brain, including the cranial nerves and blood vessels, are intact. Coronal sections through the cerebral hemispheres reveal no focal lesions. The ventricular system is of normal caliber. Transverse sections through the brainstem and cerebellum reveal no abnonnalities. The spinal cord is not dissected. Histologic Sections: Representative samples from various organs are preserved in a storage container in 10% formalin. Representative tissue samples are submitted for histology in 10 cassettes (neuropathological examination). Neuropathological examination and block key: 1. Left subdural hemorrhage: The section shows lysed red blood cells and a layer of fibroblasts measuring 6 cell layers thick as well as multiple layers of lymphocytes and capillary formation. 2. Right subdural hemorrhage: The section shows lysed erythrocytes with ca1cifications, fibroblasts in a 20 cell layer thick as well as layers of lymphocytes with capillary formation. 3. Pons: The section shows edema and necrosis along with lymphocytes in the leptorneninges. 4. Medulla: The section shows edema and necrosis along with lymphocytes in the leptorneninges. 5. Cerebellum: The section shows edema and necrosis. 6. Hippocampus: The section shows lymphocytes in the leptomeninges. 7. Cerebral cortex, watershed, left: The section shows lymphocytes in the leptomeninges as well as decreased cellularity in the cerebral cortex. 8. Globus pallidus, right: The section shows edema and necrosis. 9. Internal capsule, left: The section shows edema and necrosis. 10. Corpus callosum and cingulate gyms, right: The section shows edema and necrosis. Toxicology: Femoral vein blood and vitreous humor are collected and submitted to the laboratory. A toxicology screen is requested. Rayson, Roger Page 7 of8 � )(7)( E )___. Case Number: "-b.;_;_ ...;,c'--' Photography: Photographs are taken during the course of the autopsy. Radiology: X-Rays are not obtained. Diagrams Used: Male diagram. Comment: CIRCUMSTANCES: The decedent was a 47-year-old black Hispanic man who was reportedly an inmate under ICE detention at the GEO facility in Jena, LA. He apparently died on 03/13/17. No investigation is provided but there are medical records. According to admission records on 02/11117 at LaSalle General Hospital he was brought from the jail for vomiting for four days with associated weakness, weight loss and anorexia. He reportedly was HIV seropositive since 2014 and diagnosed with Burkitt's lymphoma with an excisional biopsy in 2016. It is also noted that he had hypertension, non-insulin dependent diabetes, gout and chronic pain syndrome. At that time medications were listed as Tramadol, oxycodone, indomethacin, Allopnrinol, acetaminophen, ondansetron, !evofloxacin, zidovudine/lamivudine, fluconazole, acyclovir, abacavir-dolutegravir-lamivudine, abacavir, lisinopril, Metformin, glipizide, aspirin and insulin as well as ferrous sulfite. Bleeding times were normal. An assessment on 02/17/17 refers to a transfer from LaSalle to Tulane for treatment for a subdural hematoma. He was reportedly transported to Tulane where he apparently had neurosurgery. A CT of the head from 02/28/17 describes a recurrent su bdural hematoma evacuated on 02/ 18/ l 7 without focal findings. The subdural is reportedly right-sided with a mild mass effect. A note from 03/03/17 reports a platelet count of 51,000 and a white blood count of 2, 290. The hematocrit is 28.4%. According to this note!(b)(6); lof Tulane Neurosurgery said the mass on imaging was a bygroma requiring no treatment at present. A note of assessment on 03/04/17 reports the previous cerebrovascular accident and also notes hepatitis as well HIV. This note reports that he was transferred to Lafayette General Hospital without incident but no medical records are available. A CT from 03/04/17 describes a stable mixed density right extra-axial collection most consistent with a subdural hematoma with a mass effect on the right frontal lobe and a leftward shift. This exam is not changed from 02/28/17. A discharge summary from 03/13/17 describes methicillin-resistance staphylococcus aureus as well as subdural hematoma and pancytopenia. Reportedly he was transfused with two units of packed red blood cells on February 13, 2017. During his hospital course he reportedly had a temperature up to 102.8°F. He was observed to be leukopenic, hypoglycemic and hypercalcemic. The CD4 count was 226. Reportedly he was transferred to Tulane Medical Center Neurosurgery but no records are available. The autopsy was on 03/14/17 in the morning and he was presumed to die on 03/13/17 or early on 03/14/17. Rayson, Roger Page 8 of8 Case Number: �l(b_)(7_)(_El____, FINDINGS: The primary finding at autopsy is evidence of remote subdural hemorrhages causing a traumatic brain injury. In addition there is hypertensive atherosclerotic cardiovascular disease and obesity. There are subdural hemorrhages over each hemisphere with the larger being on the right with an apparently older age of being light brown while the left is remote but younger and smaller. There is a mass effect with a right to left midline shift of 1.0 cm. There are subarachnoid hemorrhages on the bilateral temporal lobe poles. There are burr holes secondary to neurosurgery intervention. There is an ischemic stroke with loss of gray-white matter interface. There are no skull fracture, no scalp hemorrhages, and no brain contusions. There are also contusions on the left mid chest and near the left ax.ilia. There is evidence of hypertensive atherosclerotic cardiovascular disease with enlarged heart at 550 grams, minimal to moderate atherosclerosis of the aorta and coronary arteries, and nephrosclerosis of the kidneys. The decedent is obese with a BMI of 33 and has organomegaly likely as a result of this. The heart, kidneys, liver, and spleen are all enlarged. There is evidence of meningitis with inflammation of the leptomeninges. There is evidence of medical intervention and fluid overload. The extremities and scrotum are edematous. There are bi1ateral pleural effusions and ascites fluid. There is a Port-a-Cath on the left chest. Toxicology is positive for Morphine. There is no evidence of AIDS opportunistic infections identified at autopsy. OPINION: Likely the subdural hemorrhage led to a traumatic brain injury which ultimately caused the death. The complications of contributing factors such as obesity, hypertensive atherosclerotic cardiovascular disease, meningitis and complications of HIV including treatment cannot be ignored as well. Subdural hemorrhages are of different ages on the left and right but both are at least weeks old. The subarachnoid hemorrhages on the bilateral temporal lobe poles may be countercoup injuries indicating a fall but are not typical of this. The platelet count of 51,000 is not low enough for a spontaneous hemorrhage as a cause of the subdural hemorrhages. Since it is not known what caused the subdural hemorrhage, the manner of death is best considered undetermined until further investigation has ruled out a possible homicide. y LOUISIANA F ORENSlC - Crnrer • �.,.-:_�:, ... •';'";. �- �---:-. ·�- -�-��-�·;"'. ,.d, •.•. • ., • • .. . J.. . ·Y"'" , M�L�·-·�·���M �03/\41\1 � CASE No.: ________:__ NAME: ________________ ! I J I ) LCG FORM 32449-5 (!!/10) J 6NMS I I 3701 Welsh Road, PO Box 433A, Willow Grove, PA 1909().()437 Phona:Kb)(6); (b)(7)(C) Fax: (215) 657-2972 I l AB s Kb)(6); (b)(7)(C) kh\/R\· /h\/7\W\ To: Patient Name Patient ID 03/23/2017 10:03 Chain Age 47Y Gender Workorder 10592 Louisiana Forensic Canter, LLC Attnl(b)(6); (b)(7)(C) I !PhD, F-ABFT, DABCC-TC, Laboratory Director Toxicology Report Report Issued 68NFIDEN=FIA.._ NMS Labs ! Page 1 of3 PO Box 1320 Broussard, LA 70518 RAYSON, ROGER 068-17 HOME 17084815 DOB 05/03/1969 Male 1708"+815 Positive Findings: I compound Bu.u.11 76 Morphine - Free .Llnlll. ng/mL Matrix source 001 -Blood See Detalled Findings section for additional information Testing Requested: Description Postmortem, Basic wNilreous Alcohol Confirmation, Blood (Forensic) Analysis Code 8041B Specimens Received: ID Tube/Container 001 Gray Top Tube 002 Gray Top Tube 003 Red Top Tube Volume( Mass 8.5ml 4.3ml 5.4ml All sample volumeslweighls are approximations. Collection Date/Time Not Given Not Given Not Given Matrix Source Blood Blood Miscellaneous Information Vitreous Fluid Specimens received on 03/17/2017. NMS v.16.0 6NMS I I GO NFIDEN=FlifcL Workorder Chain Patient ID LABS 17084815 17084815 068-17 HOME Page 2 of 3 Detailed Findings: Analysis and Comment& Result Unit& Morphine - Free 76 ng/ml Rpt. Limit Specimen Sourc::e A.nalyslsBy 5.0 001- Blood LC-MS/MS Other than the above findings, examlnatlon of the specimen(&) submitted did not reveal any posllve findings of toxlcologlcal significance by procedures outllned In the accompanying Analysis Summary. Reference Comments: 1. Morphine - Free (Codeine Metabolite) - Blood: Morphine Is a DEA Schedule II narcotic analgesic. In analgesic therapy, it is usually encountered as the parent compound, however, ii is also commonly found as the metabolite of codeine and heroin. In illicit preparations from which morphine may arise, codeine may be present as a contaminant. A large portion of the morphine is bound to the blood proteins or is conjugated; that which Is not bound or conjugated Is tenned 'free morphine'. Hydromorphone Is a reported metabollte of morphine. In general, free morphine is the active blo!oglc agent. Morphine has diverse effects that may include analgesla, drowsiness, nausea and respiratory depression. 6-monoacetylmorphine (6-MAM) is the 6-monoacetylated form of morphine, which Is pharmacologically active. It is commonly found as the result of heroin use. Peak serum concentrations occur within 10 to 20 minutes of a 10 mg/70 kg intramuscular dose, with an average concentration of 60 nglmL 30 minutes following administration. IV administration of the same dose resulted In an average concentration of 80 ng/mL after 30 minutes. Chronic pain patients receiving an average of 90 mg (range 20 - 1460) daily oral morphine had average serum concentrations of 73 ng/mL (range 13- 710) morphine. In 15 cases where cause of death was attributed to opiate toxicity (heroin, morphine or both), free morphine oonoentratlons were O - 3700 ng/mL (mean = 420 +/- 940). In comparison, in cases where COD was unrelated to opiates (n=20) free morphine was 0- 850 ng/mL (mean= 90 +/-200). The ratio ofwhole blood concentration to serum or plasma concentration is approximately one. Unless altemate arrangements are made by you, the remainder of the submitted specimens wlll be discarded one (1) year from the date of this report; and generated data will be discarded five (5) years from the date the analyses were performed. Workorder 17084815 was electronically signed on 03/23/2017 09:06 by: r )(6); (bl(7)(C) Certifying Scientist Analysis Summary and Reporting Limits: All of the following tests were performed for this case. For each test, the compounds listed were lnduded In the scope. The Reporting Limit llsted for each compound represents the lowest concentration of the compound that will be reported as being positive. If the compound Is listed as None Detected, It Is not present above the Reporting Limit. Please refer to the Positive Findings section of the report for those compounds that were identified as being present. Acode 50016B - Opiates - Free (Unconjugated) Confirmation, Blood (Forensic) -Analysis by High Performance Liquid Chromatography/ TandemMass Spectrometry (LC-MS/MS) for: Compound 6-Monoacetylmorphlne - Free Codeine - Free Dihydrocodelne / Hydrocodol -Free Rpt Limit 1.0 ng/mL 5.0 ng/ml 5.0 ng/mL Compound Hydrocodone - Free Hydromorphone - Free Morphine - Free Rpt Limit 5.0 ng/ml 1.0 ng/ml 5.0 ng/mL NMSv.16.0 .NMS I LAB s GONFI0ENllAL I Worlc::order Chain Patient ID 17084815 17084815 068-17 HOME Page 3 of 3 Analysis Summary and Reporting Limits: Compound Bot, Limit Compound Oxycodone - Free Oxymorphone - Free 5.0 ngtmL Acode 8041 B - Postmortem, Basic wNitreous Alcohol Confirmation, Blood (Forensic) Rpt. Limit 1.0 ng/mL -Analysis by Enzyme-Linked lmmunosorbentAssay (ELISA) for; Compound Amphetamines Barbiturates Benzodiazepines Buprenorphine / Metabolite Cannabinoids Cocaine / Metabolites Bpt Limjt 20 nglmL 0.040 mcgfmL 100 ng/mL 0.50 ng/ml 10 ng/mL 20 ng/mL Compound Fentanyl / Acetyl Fentanyl Methadone / Metabolite Methamphetamlne / MOMA Opiates Oxycodona I Oxymorphone Phencyciidine Rpt. Limit 0.50 ng/mL 25 nglmL 20 ng/mL 20 nglmL 10 ng/mL 10 ng/mL compound lsopropanol Methanol Rpt. Limit -Analysis by Headspace Gas Chromatography (GC) for: compound Acetone Ethanol Rpt. Limit 5.0 mg/dL 10 mg/dL 5.0 mgldl 5.0 mgldl NMS v.16,0 CERTIFICATION OF DEATH I BIRTH NUMBER: DECEDENT STATE FILE NUMBER: 2017-024-00687 DECEDENT'S w.ME - (LAST. FIRST, MIDDLE. SUFFIX) DATE OF BIRTH RAYSON,ROGER ANTHONY 0510311969 OJ/1712017 MALE NONE PLACE OF BIRTH• (CIY,STATE, COUNl'RY) NEGRIL, WESTMORELAND JAMAICA PERSONAL EVER IN U.S. ARMED FORCES? OCCUPATION INDUSTRY OF OCCUPATION CLUB PROMOTER bl(6) (bl(7l(Cl MOTHERIP� SAMUELS,RC INFORMANT' ",v : • F, ' _ OF HSPANIC ORIGIN?; NO, NOT PWll>tl!HI SFflNli/1I'� RACE: BLACK OR AFRICAN AME IQ'-N PLACE OF DEATH "...,LK" U. ili.i CREMATI IN I l PLACE ut O _,J I >N (C I FUNERAL FACILITY • LOUISIANA FUNERAL SERVICES ANO CREMATORY I b)(6): (b)(7)/C) I MEDICAL INFO I CAUSE OF DEATH b)(6) ; (b)(7)(C) "' V � .wgc, ,., , 010 TOBACCO USAGE CONTRIBUTE TO DEATH? 11EDI CENTER .. �Lro- ':I l."' ... ADDRESS OF FUNERAL FAC[LI I� ,, PARISt\'COUN"TY 1',FAYETTI: u L ;;"' >I I.I �lnti1AI �I UNc J 1111 / / \ F'ir:.J'��- ,/c� NJ y ATE OF DISPOSITION 3/29/2017 108 HARDWARE RD., BR��O. LA 70518 UNITED STATI:S LICENSE NUMBER / / CORONER NOTIFIED? I CO\A.D NOT B,-U ETERMINED MANNER OF DEATH IF FEMALE? - �" I / .. / / ,., ,--, ..,... -..\I r:, (b)(6rJ ·o-s!grr fr\\lr'-:\ ltlfOR.. - \ I'\ I\' "-.,JI\ \ \I NAME OF FUNERAL DIRECTOR (LAST,FIRST, MIDDLE,SUFFIX) SIGNATURE OF FUNERAL DIRECTOR (CITY,STATE,COUNTRY) "'.,..E OF BIRTH• (CITY, STATE, COUNTRY) P COOE. C 0 NTR � � 1 J i:�:::::r�.J AT �V;;/ BROUSSA� , l\" Nlrtl: STA FUNERAL FACILITY NAME 1 � E Y7 j'T J ._ v ..,_, , - .. V.. .. ��" --:-;;, FACILITY i') R ·(� !� ...,� 1214 C0C Sl ,c,L METHOD F ·-.)II i�·- INPATIEl'lf UI ENTERTAJNMEl'lf NAME OF SURVIVING SPOUSE (LAST,FIRST, MIDDLE,SUFFIX) ll "7 LASALLE l'Ji\lci1 EN" -, ·-i "�"n .., ,.�$Th il!!III r�n,91, Ml._:;� b)(6); (b)(7)(C) NO fl<§?@n n iE rm tC w- 'W I � s ��r=., "" :nMrr n;11ttTc!®, �� ��ni:;,::i \:Jtl \,W" . -, •JUU ;tNJ - ...., r - � ... --· - EDUCATION: 8TH GRAD E OR LES, DISPOSITION PARISK'COUNTY NO FATHERIPAREl'lf NAM E · (LAST,FIRST,M I 47YEARS MTHIN CITY LIMITS? NEVER MARRIED DEATH INFO 03:20PM AGE RESIDENCE OF DEC EDEl'lf, (STREET ADDRESS, CITY, STATE.ZIP CODE. COUNTRY) 830 PINEHILL RD., JENA,LA 71342UNITED STATES MARITAL STATUS I TIME OF DEATH SOCIAL S ECURITY NUMB ER SEX DECEDENT'S ALIAS NAME(SJ • ti.AST. FIRST,MIDDLE.SUFFIX). I DATE OF DEATH y OATI: 812/2017 NOT APPU<,i""L E: lJNKNO\Y' oc;tly caused ll'O dcall\ DO NOT onter lerm'nal events such APPROXIMATE ll'lTERVA L PART I. Enler lhe chain ol even1s - diseosos, Jrj.,Jos,or 90,rpicuUono as cardiac arrest, resp'ratory a,resl,or 1Jentricular ' Drina.tion wiltlOut showi 'IC etiology. 00 NOT ABBREVIATE. Onsel to Ooalh � UNK IMMEDIATE CAUSE· (Fina I disease or condllion re11Atlog in dealh) a EMOTE SUBDURAL HEMORRHAGE DUE TO UNKNOWN ACTORS UNK DISEASE Enter lhe ur,.'O ERLYING CAUSE {cfseaso or lrju-y INII lriUaled C. DIABETES MELLITUS UNK averts resubng in death) LAST d. COMPLICATIONS OF HV UNK -�-'"'-"°"• "�. "�--�-�- -�AA-=�MOC =•�=- PA.'U II. Er:.er ether sl(;.·1mcar.t ccta!itions con:riWlng t OBESITY WAS AN AUTOPSY PERFORMED? YES INJURY INFORMATION PLACE OF INJURY LOCATION OF INJUijY • (ST LA UNITED STJ;_(b_)(7>_ (_C�) ----�Fompleted RAYSON's medical intake screening and documented the following: 19 • • • • • RAYSON spoke English and did not require language interpretation assistance. RAYSON's vital signs 20 were within normal limits, with the exception of an elevated blood glucose level of233. 21 RAYSON reported experiencing constant pain throughout his body and rated it -- on a pain scale of zero to ten, with ten being worst -- a level nine. RAYSON reported several existing medical conditions, including lymphoma, 22 . . . .. . ?5 - gout, -?6 arthr1tJs, 21 and dtabetes, 23 HIV m1ect1on, i:-. • hypertens1on, 24 anemia, gastroesophageal reflux disease (GERD).28 RAYSON arrived at LDF with the medications listed in Table 1, below. Table 1 · Medications in RAYSON's possession upon arrival at LDF Medication Purpose Abacavir AntiretroviralL� (ARV) Acyclovir ARV Dolutegravir ARV Lamivudine ARV Levofloxacin Antibiotic See Exhibit 2: LDF eClinicalWorks Appointment (intake Prescreening), dated January 28, 2017. ERAU l□terview witb!(b)(6);(b)(7)(C) !April 12, 2017. 19 See Exhibit 3: LDF eClinicalWorks Appointment (intake Screening), dated January 28, 2017. 20 Nonna I temperature is 98.6; no1mal range for pulse is 60 to I 00 beats per minute; normal range for respirations is 12 to 20 breaths per minute; and, normal blood pressure is 120/80, with 90/60 to 139/89 considered within normal 17 18 range. 21 Nonna! blood glucose (sugar) levels are 72-108 when fasting and up to 140 within two hours after eating. 22 Lymphoma is cancer of the lymph nodes. 23 Diabetes is a disease in which blood glucose, or blood sugar, levels are too high. 24 Hypertension refers to high blood pressure. 25 Anemia is a condition caused by low iron levels. 26 Gout is a form of arthritis characterized by severe pain, redness, and tenderness in joints. 27 Arthritis symptoms include pam, joint inflammation, and swelling. 28 This condition causes reflux of acid from the stomach into the lower esophagus. 29 An antiretroviral is a drug that, in combination with other drugs, prevents the replication of the molecule vrral ribonucleic acid (RNA) such as in HJV. 3 DETAINEE DEATH REVIEW -Roger RAYSON ncMs #201705095 Fluconazole Glipizide Metformin Regular Insulin Allopurinal Hydrochlorothiazide Lisinipril Oxycodone with acetaminophen (Percocet) 30 Indomethacin Acetaminophen Enteric-coated aspirin Ondansetron Ferrous gluconate Antifungal Anti-diabetic Anti-diabetic Anti-diabetic Gout treatment Anti-hypertensive Anti-hype1tensive Pain treatment as needed Anti-inflammation and pain treatment Pain treatment Pain treatment Anti-nausea Iron supplement During the intake screening, \�/(�t,, reconciled all medications in RA YSON's possession with the transfer summary provided by FMC Lexington 31 and gave RAYSON one dose of Percocet for pain. 32 The administration of the Percocet and other medications was authorized by the transfer summary, which stated RAYSON's medication should be continued until evaluated by a physician or unless otherwise indicated. 3 3 At the conclusion of the intake screeningj(b)(6); (b)(7)(C) I refen-ed RAYSON for a provider evaluation based on the detainee's abnormal screening results. At 3:48 a.m., RAYSON was placed in the Medical Housing Unit (MHU). 34 At approximately 7:38 a.m.,l