Detainee Death Review: Carlos Armando MEJIA-Bonilla, l(bl(5>; (b)(7)(C)
Healthcare and Security Compliance Analysis
Hudson County Department of Corrections and Rehabilitation
Kearny, New Jersey
As requested by the ICE Office of Professional Responsibility (OPR), External Review and
Analysis Unit (ERAU), Creative CoITections participated in a review of the death of detainee
Carlos Armando MEJIA-Bonilla while a detainee of the Hudson County Department of
Corrections and Rehabilitation (HCDCR), Kearney, NJ. A site visit was conducted Au ust 7!
@ ,�,
through 9, 2017 by a team consisting of ERAU Management and Program Analysts,�!\�!;
)
)
5)
)
)
!(b)(6); (b)(7)(C )
I and Creative Corrections contract ersonneJ�b ( ; (b (? (C
I Program
5 (b)(7 (C)
)
(b
(
l; l
Manager for the ICE/ERAU contract and
Healthcare Subject Matter
Expert. Creative Co1Tections participation was requested to determine compliance with the 2008
ICE Performance Based National Detention Standards (PBNDS).
The findings of this review are based on analysis of detainee MEJIA's medical record and
detention files, interviews of facility and ICE Enforcement and Removal Operations (ERO) staff,
and review of video surveillance recordings, policies, and available incident related
documentation. This report includes a case synopsis, description of the facility's medical
services, summary information from MEJIA's detention file, chronology of events through his
death, and conclusions.
MEJIA's vital signs documented during medical encounters are
appended.
The reviewers note that the detainee's name as it appears on documentation provided to HCDCR
by ERO, including the Order to Detain or Release Alien, Alien Booking Record, Criminal
History Repmt, and Risk Classification Assessment, is Rolando MEZA-Espinoza. All HCDCR
documentation reflects this name and staff re orted the detainee was known only as MEZA.
Because b)(5); (b)(?)(C)
informed the
review team that MEZA is an alias and MEJIA is the detainee's lawful name, MEJIA is used in
this report.

SYNOPSIS
Detainee MEJIA, 46 years old, was admitted to HCDCR on April 1, 2017. He died on June 10,
2017, two days after he was transferred to the local hospital.
MEJIA reported he was prescribed medications for diabetes, hypertension, anemia, and cirrhosis
of the liver. An HCDCR provider ordered medication for diabetes but medications for the other
conditions, although verified by MEJIA's community pharmacy, were not started and laboratory
testing was not ordered. He submitted seven sick call requests, some of which referenced
medications and symptoms of the known chronic conditions. He was seen by the orthopedic
DETAINEE DEATH REVIEW: Carlos MEJIA-Bonilla
Compliance Review
February 12, 2018
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 physician following a faJI in the shower on June 5, 2017, but was never assessed by a provider as
a chronic care patient.
On June 8, 2017, MEJIA was taken to the clinic after he was observed in medical distress and
medical emergency was called. He was transported to the hospital by way of ambulance
approximately an hour later with diagnoses of dizziness, weakness, bypotension 1, and
gasu·ointestinal bleed. He was pronounced dead on June 10, 2017.
The Ce1tificate of Death issued July 26, 2017 documents the immediate cause of death as gastro­
intestinal hemonhage due to chronic alcoholism.

MEDICAL SERVICES
Medical services at HCDCR are provided by contractor Center for Family Guidance (CFG)
Health Systems and nurses employed by Hudson County. The CFG contract, originally awarded
on May 14, 2011, was recently revised to call for full staffing by CFG and phasing out of county­
hired nurses through attrition. Healthcare position include the Health Services Administrator
(HSA), the medical director, one staff physician, 15 nurse practitioners, a Director of Nursing,
23 registered nurses (RN) and 15 licensed practical nurses (LPN). Dental services are provided
by three dentists and two dental assistants; mental health services are provided by a PhD
psychologist who oversees the department, two psychiatrists, and seven mental health
counselors. In addition, there is an administrative assistant, phmmacy technician, and six records
technicians and clerks. Professional credentials for staff involved in detainee MEJIA's care
were current and primm·y-sow·ce verified. According to the HSA, the facility was awarded
accreditation by the National Commission on Correctional Health Care (NCCHC) in October
2016.
Language interpretation services are provided by Language Line Solutions. Approximately ten
months prior to the site visit, HCDCR implemented the Centricity GE Elecu·onic Medical Record
(EMR).

DETENTION INFORMATION
Detainee MEJIA was classified low custody by HCDCR staff. He was assigned to general
population throughout the te1m of detention and had no disciplinary violations. He filed no
grievances and seven requests, all medical.
I fbl(6); (b)(7)(C) I made deposits to
MEJIA had one visit, on May 27, 2017 from !(b)(6); (b )(7)(C)
MEJIA's commissary account totaling $350.00 and the detainee made multiple purchases. The

1 Low blood pressure

DETAINEE DEATH REVIEW: Carlos MEJIA-Bonilla
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February 12, 2018
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 commissary balance as of last day of the site visit was $124.00. kb)(6h(b)(?)(C)
I informed
the review team that he would release the balance and MEJIA's personal property to ERO.

CHRONOLOGY OF EVENTS
Saturday, April 1, 2017
6:45 p.m.
During
Detainee MEJIA arrived at HCDCR and was processed by l(b)(5); (b)(?)(C)
interview, !(b)(6); (b)(7)(C) I stated that he recalled nothing unusual about MEJIA. He said the intake
process involves conducting a pat search, inventory of property and funds, issuance of jail
clothing, linens and hygiene items, and entry of information into multiple screens of the New
Jersey County Correction Information System (NJCCIS), the electronic management info1mation
system used at HCDCR. The Background Information and Commitment Summary screens both
document MEJIA's primary language was Spanish and "Needs Interpreter"; however, !(b)(6l: I
l<bl/6\ I stated he does not speak Spanish and did not use interpretation assistance.
He informed
the review team that he does not use the telephonic language interpretation service during the
intake process, but may ask Spanish-speaking staff for assistance if available.
Note: Based on interviews conducted during the site visit, recounted below, reviewers
conclude detainee MEJIA's English language proficiency was very limited.
On the Intake Risk Assessment screen, l(b)(6); (b)(?)(C) I entered no to questions, "Do you have any
medical problems?" and "Do you take any prescribed medications?" However, an untitled form
included in MEJIA's detention file documents he responded yes when asked if he has any
medical problems, and no to three other health related questions. Except for an illegible staff
signature at the bottom, other sections of the form are blank, including Inmate Name and number
and Inmate Initials acknowledging the health questions were asked and that he answered
truthfully. In addition, there were no initials acknowledging receipt of information on access to
telephones, sexual assault and awareness information, and notification that the orientation video
is played twice a day, seven days a week.
Note: The form is English.
Valuables Receipt forms completed by fbl(6); (b)(?)(C)
!document MEJIA arrived with $56.79, a
wallet, eight keys, two credit cards, a cell phone with case, New York identification card, New
York Benefit card, and SSI (Supplemental Security Income) card. Detainee MEJIA and Kb)(6); I
!(b)(6); (b)(?)(C)
I signed the forms. The Property Receipt form documents he had one pair of
jeans, two sweaters, one pair of boots, and was provided with jail clothing, linens, "Rule Book,"
and hygiene items. According to !Cb)(6); (b)(?)(C)
l the Rule Book is the facility's detainee
handbook.

DETAINEE DEATH REVIEW: Carlos MEJIA-Bonilla
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February 12, 2018
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 Note: The Property Receipt form was signed by detainee MEJIA but not by a staff
member.
Note: The identity documents were not turned over to ERO for inclusion
detainee' s A-file.

111

the

Note: The forms, including acknowledgement of the accuracy of the inventories and
detainee responsibilities are in English.
The Risk Classification Assessment (RCA) completed at the Varick Street Service Processing
Center prior to detainee MEJIA' s transfer to HCDCR documents ERO classified him as medium
bigb.
Note: This rating was not applied by HCDCR. As discussed below, MEJIA was placed
in a pre-classification housing area until classified low custody by facility staff on April
3, 2017.
8:15 p.m.

I documented completion of the medical and mental health intake
screening. A medical transfer summary did not accompany detainee MEJIA to HCDCR.

l(b)(6); (b)(7)(C)

I informed the review team that initial medical and tuberculosis
Note: fb)(6); (b)(7)(C)
(TB) screening is not performed at the Varick Street Processing Center if detainees are
transfened before approximately 5:30 p.m.
I noted on the screening form that an interpreter was not needed for this encounter.
During interview, l(b)(6); (b)(7)(C) I stated she does not speak Spanish, and although she could not
recall detainee MEJIA, indicated he "must have spoken English" or she would have noted it in
the medical record.
j(b)(6); (b)(7)(C)

Detainee MEJIA's vital signs were within n01mal limits, although his blood sugar tested by
finger stick was abnormally high at 253. He was 46 years old, his weight was 178, and his
height was 57. The review of systems documented MEJIA reported no symptoms related to any
of 14 systems listed on the form. l(b)(6); (b)(7)(C) I documented MEJIA rep01ted he had type 2
diabetes and that he was taking metformin 2 . In the section of the intake screening form titled
Medication Verification, she documented the name of his pharmacy as "Brantwood", but noted
the medication was not verified and entered, "(Verify Later)".
Note: According to CFG's Clinical Care Guidelines, "Nursing staff is responsible for
verifying and confirming a patient's medication(s) with the dispensing pharmacy and/or
the prescribing practitioner. The medication verification fmm must be completed by
2 Metformin is a prescription medication for diabetes.

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 nmsing staff at the time of intake." When asked about this requirement,l<bl(6l; (bl(7)(Cl
stated her job was to simply ask for the name of the pharmacy; a provider or another
nurse is responsible for verifying medications.

I

�b)(6); (b)(7)(C) assigned a Prison Rape Elimination Act (PREA) Sexual Victimization and Abuse
score of zero based on detainee MEJIA's answers to five questions. The mental health and
suicide risk assessments were normal, and the three-question dental screening was negative. �b)(6I
j(b)( 6);__ !documented MEJIA had no TB symptoms and that TB testing by way of chest x-ray was
initiated at the time of intake.
Note: As discussed below, a chest x-ray was not completed until April 3, 2017.
The detainee signed an Infmmed Consent to Medical Services form acknowledging that he
answered all questions truthfully, received instructions on obtaining health services, and
consented to routine health care.
Note: The consent form is in English.
b}(6); (b)(7)(C) cleared detainee MEJIA for housing in general population and referred him to a
prov1 er on an urgent basis. The reason for designation as a priority case was his history of
diabetes, blood sugar level of 253, and need for an evening dose of metfonnin. fbl(6); (b)(7)(C)
Clinical Psychologist, signed the intake screening three days later on Tuesday, April 4, 2017.

I

Note: fbl(6l; (b)(?)(Cl !stated during interview thatl(b)(6); (bl(7l(Cl !reviews all intake screens to
ensure any identified mental health concerns are promptly addressed. The intake
I Clinical Director, or designee. (b)(G);
screening was not signed by �b)(6); (b)(7)(C)
,�/\�t-- , tated she was unaware of this requirement.
-

9:24 .m.
)(7)(C)

.

/h\/7\/0

documented completion of the initial health appraisal.

(b )(6); (b

I

Note: Need for or use of interpreter assistance was not documented. fbl(6); (b)(7)(C)
Kbl(6); (b)(7)(C)
I informed the review team that l<bl(6l; (b)(?)(C) I employment was
terminated; therefore, questioning concerning this and other matters was not possible.

I

In a number of fields on the electronic form, l(bl(6l; (b)(?)(Cl referred to intake screening findings.
She also documented MEJIA reported a history of depression, type 2 diabetes 3 , cirrhosis4 of the
liver, and anemia, but he did not remember the names of his medications. The physical
examination addressed all systems, including abdominal, with findings within normal limits.
3 Type two diabetes is diabetes resulting from insulin resistance.
4 Chronic liver cell damage leading to scarring and liver failure.

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 Note: Proper abdominal assessment may determine the presence of a hepatic mass, or
enlarged, fatty, or cirrhotic liver.
The Practitioner Assessment and Plan identified anemia, depression, cirrhosis, hypertension, and
diabetes as problems. Orders were issued for Glucophage 5 500 mg twice daily, and a 2200calorie diabetic diet. Under Plan Comments, l(b)(6); (b)(7)(C) ladded, "Record release for other
medications", presumably refening to obtaining an autho1ization to release records so the
detainee' s medications could be determined. She also noted MEJIA was to be scheduled for a
chronic care appointment and referred for mental health assessment. The diet order was faxed,
and the medication administration record (MAR) documents he received his first dose of
metforrnin that evening and all subsequent doses.
Note: fb)(6); (b)(?)(C) �id not schedule MEJIA for a mental health appointment; therefore, he
was not evaluated and treated for depression.
Note: !(b)(6); (b)(?)(C) hrders for metformin and a diabetic diet were in accordance with the
CFG Clinical Care Guidelines for diabetes.
However, although she included
hypertension, anemia, and cirrhosis on the problem list,l<b)(6); (b)(?)(C) I plan of care did not
address these conditions. She did not order blood pressure monitoring or low sodium
diet, nor did she order diagnostic testing of any kind, including testing to determine iron
and liver function blood levels. During interview of �b)(6); (b)(7)(C)
I staff physician, he
stated laboratory work should have been ordered, adding, "I don't know what she was
thinking." While identification of MEJIA as a chronic care patient was appropriate, per
policy, the first chronic care appointment would not have occurred for 90 days.
L

Note: The initial health appraisal was not reviewed and signed by the Clinical Director
or her designee. As with the intake screen review, fb)(6) ; (b)(7)(C) !reported she was not
aware that the PBNDS requires Clinical Medical Authority review of health appraisals to
determine priority for treatment.
Time Unknown
Detainee MEJIA signed a Release of Information Authorization directed to Brentwood
Pharmacy of Long Island, NY for release of records. The date stamp reflects it was faxed to the
pharmacy at 8:24 a.m. on April 3, 2017. (b)(6); (b)(?)(C) stated during interview that the form was
completed by an RN upon direction of (b)(6); (b)(?)(C)
Time Unknown
A fmm titled, "Patient Infonnation Fact Sheet- Oral Hygiene" was signed by the detainee.
Note: The form is in English.
5 Glucophage is a brand of metformin.

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 Sunday, April 2, 2017
6:24 a.m.
According to the NJCCIS Cell Assignment screen, detainee MEJIA was transfe1Ted to Alpha 300
East, Cell 414. The review team was informed by fb)(6); (b)(7)(C)
!that male detainees are placed
in this unit pending classification.
Monday, April 3, 2017
12:52 p.m.
A Mobilex Radiology Repmt documents a chest x-ray showed no evidence of active TB. It also
documents heart size was nmmal with no evidence of pulmonary edema and no acute
cardiopulmonary process.
Note: Although fbl(6); (b)(?)(C) I documented TB symptom screening was negative at intake,
testing for the disease was not conducted until this date. fb)(6); (b)(7)(C) I mformed the review
team that chest x-rays are completed for all detainees who arrive without TB clearance;
however, Mobilex mobile x-ray service comes to the facility Monday through Friday,
only.
Time unknown
f(b)(6); (b)(7)(C)
!completed a Primary Assessment Form classifying detainee
MEJIA as low custody. She applied two points for Severity of Most Recent Charge and one
point for Serious Offense History. Although she did not note the specifics of either, the Criminal
History Report received from ERO lists only the charge of driving under the intluence of liquor.
The rating was approved by a supervisor the same day.
Note: fb)(6); (b)(7)(C)
I stated during interview that classification
ratings determined by ERO are not used because they are too high. As noted above, the
rating determined by ERO was medium high.
Note: Althoughfb)(6); (b)(7)(C) I stated detainees are classified within 12 hours of arrival,
detainee MEJIA was not classified for more than 24 hours after anival.
April 4, 2017
4:28 p.m.
Per the NJCCIS Cell Assignment screen, detainee MEJIA was transfe1Ted to housing unit Alpha
300 West, cell 307. This unit is a two-tier, direct supervision general population housing unit
with a total of 32 double-occupancy cells. Detainee MEJIA's cell was on the lower level. The
lower level cells surround a dayroom equipped with tables and seating, telephones, two
televisions, and a kiosk for submitting commissary orders, requests and grievances. Per the
General Population Housing Unit Officer post order, officers are required to make accurate and
chronological entries in the housing unit logbook, and make rounds at least every 30 minutes at
iITegular intervals. During interview offb)(6); (b)(7)(C)
lhe stated rounds are made
DETAINEE DEATH REVIEW: Carlos MEJIA-Bonilla
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 every 15 minutes on midnight shift. He also stated detainees are secured in their cells nightly
from approximately 9:00 p.m. until breakfast, or earlier if scheduled for court or medications.
There are four security cameras inside the unit which monitor and record events from different
angles, and two security cameras in the sallyport area outside the unit.
Thursday, April 6, 2017
Fax documentation from Brentwood Pharmacy was received in the medical unit. Listed
medications were antihypertensive medications spironolactone 100 mg daily and lisinoplil IO mg
daily; iron supplement Ferosol, one tablet twice daily; a multivitamin, one tablet daily;
thiamine, 6 one tablet daily; and metformin at the dose he was receiving. A provider did not
review the medication information.
Note: Because the prescription medications were not reviewed, there were no resultant
provider orders for medications to address hypertension, anemia, and liver disease, and
no attempt was made to identify and seek medical records from providers who ordered
these medications.
Friday, April 14, 2017
Detainee MEJIA was seen by l(b)(6); (b)(?)(C)
f for nursing sick call pursuant to requests
written in Spanish dated April IO and 11, 2017. The English translation 8 of the first is as
follows: "I need a blood test because at home I am taking iron and blood pressure pills and for
the sugar. My blood levels are low, I feel weak. I also use eyeglasses to see." The translation of
the second is, "I need you to check my blood pressure and sugar for my diabetes, and I need you
to see me soon because I feel very sick. Thank you." Both requests were stamped as received
on April 12, 2017. The electronic response from l<bl/6l /bl/7l/Cl
lat 12:14 a.m. stated, "Your
request will be reviewed soon and you will be scheduled accordingly." During the April 14,
2017 sick call encounter, �b)(6); (b)(7)(C) I documented no barriers to communication or use of
interpretation assistance. Vital signs were all within normal limits with the exception of a mildly
elevated blood pressure of 134/83. The nursing assessment findings were all within nomrnl
limits, with the exception of his report of nosebleeds. The Snellen eye test 9 was conducted, and
a history of cataracts and vision changes in the past six months was noted. kb)(6); (b)(7)(C) I noted
that he wore prescription glasses, although she did not note whether the glasses were in his
possession or worn at the time of the acuity testing, which showed vision deficits of 20/50 in the
left eye, 20/40 in the right eye, and 20/50 in both eyes. The nursing impression was alteration in
knowledge deficit. He was provided patient education related to diet, exercise, and medication
compliance.

6 Thiamine is vitamin B 1, which is often depleted in liver disease related to alcohol abuse.
'Vh\ln\·
lwas no longer employed at HCDCR at the time of the site visit.
8 Translation of MEJIA's sick call requests was provided by Creative Corrections Subject Matter Expert�
!who is proficient in Spanish and English.
!(b\/6\:
9 The Snellen test assesses vision by way of an eye chart.

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 Note: Eyeglasses were not included on MEJIA's personal property inventory. There is
no documentation l(b)(6); (b)(?)(C) !contacted security personnel to request confirmation of
whether eyeglasses were in the detainee's property, nor did she refer MEJIA for
examination by an optometrist.

I note did include subjectjve data documenting detajnee MEJIA' s
Note: @)(6); (b)(7)(C)
medical complaints as described. In addition, she did not refer the detainee to a provider
despite his medical history and complaint of feeling poorly. The reviewer notes that as of
trus date, MEJIA had been without medication to treat hypertension, anemia, and
cirrhosis for two weeks.
Saturday, April 15, 2017
The mental health evaluation and initial dental screening examination, due on or before this date
per the standard, were not conducted.
Tuesday, April 25, 2017
Detainee MEJIA was seen at nurse's sick call by fbl(6); (b)(7)(C) I pursuant to a sick call request
dated ApriJ 23, 2017. In Spanish, he wrote, "I need medicine for cough, also I need iron for
anemia." The request was not date stamped to document when it was received; however, triage
�wo days after the date of the request,
of the request was documented by Yb)(6); (b)(7)(C)
April 25, 2017. She noted, "sore throat and requesting blood works" and placed him on the sick
call list. During the sick call encounter,Kb)(6); (b)(7)(C) I noted MEJIA's complaints of cough and
sore throat, but she did not address the need for or use of interpretation assistance. MEJIA' s
vital signs were all within normal limits and be denied pain at the time of the assessment. Per the
nursing protocol addressing upper respiratory infection, he was provided Tylenol 325 mg twice
daily as needed for pain; guaifenesin, one tablet twice daily as needed for cough; and
chlorpheniramine maleate 4 mg twice daily as needed for cold symptoms.
Note: i<b)(5); (b)(? )(C)
�id not refer MEJIA to a provider for evaluation of his request for an
iron supplement. As noted, documentation received from Brentwood Pharmacy on April
6, 2017, confirmed he was prescribed an iron supplement.
11:49 a.m.
j(b)(6); (b)(7 )(C) I docwnented a "Chart Maintenance: Clinical Update" listing new problems of acute
nasopharyngitis 10 and cough.
Wednesday, May 3, 2017
Detainee MEJIA was seen by Kb)(6); (b)(7)(C) I pursuant to a sick call request dated April 30, 2017.
In Spanish, he wrote, "I need something for cough. I feel very bad. I can't sleep. Also,
something for constipation, my stomach is bad." Receipt of the request was date stamped May
2, 2017. �b)(6 ); (b)(?)(C) I documented vital signs were all within normal limits and MEJIA denied
10 Nasopharyngitis is the common cold.

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 any pain. Again, need for or use of interpretation assistance was not noted. He was provided
Tylenol for pain and guajfensen for rus cough.
Note: The additional complaints of constipation, sleep difficulty, and stomach problems
were not addressed, and he was not referred to a provider.
Thursday, May 11, 2017
Detainee MEJIA was seen by fb)(5); (b)(l)(C) I pursuant to a request dated May 9, 2017. In Spanish,
he wrote, "I need to see the doctor because I have an infection on my chest and throat, and I have
an itchy rash." j(b)(6);(b)(7)(C)
!triaged the request on May 10, 2017, and scheduled him for
May 11, 2017 nurse sick. When seen, !(b)(6); (b)(7)(C) lagain did not document the need for or use
of interpretation assistance. Detainee MEJIA's vital signs were all within normal limits and be
denied pain. She noted his complaint of nasal congestion and sore throat and of an itchy rash.
On observation, skin dryness and pin-point size redness on hls upper chest and bilateral upper
extremities was noted. There were no open lesions. The nursing diagnosis was acute
nasopharyngitis. New medications added per nursing protocols included antifungal cream
clotrimazole with self-application to the rash area twice daily, chlorpheniramine maleate twice
daily as needed for allergy symptoms, and acetaminophen two tablets twice daily, as needed for
pam.
!documentation did not address whether she examined MEJIA's
Note: �b)(6); (b)(7)(C)
throat pursuant to his complaint of a sore throat and nasal congestion.
Thursday, May 18, 2017
Detainee MEJIA submitted a sick call request stating, "I need something to sleep, and I'm
having dizzy spells. Could be because my blood is weak. Or the anemia I have." The request
was triaged the same day by Kb)(6); (b)(7)(C) I who referred him to nursing sick call. At 12:08 p.m.,
!(b)(6);(b )(7)(C)
I documented "Append: Nurse Sick Call," noting MEJIA' s vital signs were all
within normal limits and he denied pain. The review of systems was normal with the exception
of the neurologic exam which noted, "Complains of dizziness on and off not know I was
diagnosed with anemia." The nursing impression was recurrent dizziness, and under Additional
Information, l(b)(6); (b)(7)(C) I noted he was fully alert and claimed a history of anemia with
recurring dizziness. He was encouraged to take in fluids and advised he would be followed up
with a medical provider. There is no documentation he was scheduled for an appointment with a
provider following the sick call encounter. Again, !(b)(6); (b)(7)(C) ldid not document need for or
use of interpretation assistance.
Note: This request marked the third time MEJIA complained of anemia, a condition
reported at intake on April 1, 2017 and for which his pharmacy confii-med he was taking
medication on April 6, 2017. He was never evaluated by a provider for this condition.

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 Tuesday, May 30, 2017
l(b)(6); (b)(7)(C)
!documented renewal of the order for metformin 500 mg twice daily. She
stated during interview that a medication nurse asked her to renew the prescription to ensure
continuity of care. She wrote the new order for 60 days after reviewing the initial order. She
acknowledged she was not aware MEJIA's blood sugar level at the time of intake was 253, and
that his blood sugar was not monitored thereafter.
She further stated she did not know
laboratory testing was not completed and that she assumed the detainee was enrolled in chronic
care clinic.
Note: As noted, l<b) (6); (b)(7)(C) I plan of care resulting from the initial health appraisal
included reference to scheduling of a chronic care appointment; however, an appointment
was not scheduled and MEJIA was not seen for chrnnic care follow up.
Tuesday, June 6, 2017
Detainee MEJIA was scheduled for nursing sick call pursuant to a sick call request submitted
June 5, 2017. The request stated in Spanish, "I would like to see the doctor, because I have
fever." However, prior to the sick call appointment, a 10:35 a.m. General Note entry by �1\�1:
l<b){6); (b){?)(C)
documents detainee MEJIA presented to medical with left elbow pain resulting
from a fall in the shower the previous day. She stated during interview that she was able to
complete the encounter because she speaks "a bit of Spanish and [MEJIA] spoke a little
English." She rep01ted MEJIA was able to communicate his complaint, indicating the fall
occurred the day before, gesturing that he became dizzy and hit his elbow when he fell. In her
note, she documented swelling and redness of the elbow were observed and described him as
alert, fully oriented, and not in acute distress. Temperature and respirations were within normal
limits; blood pressure and pulse were abnormally elevated at 160/90 and 102, respectively. On
examination he was found to have limited range of motion in the left arm. fb)(6); (b)(7)(C)
documented MEJIA was referred to a provider, but on interview, stated she specifically referred
him tofb>(5); (b)(? )(C)
IHCDCR's part-time orthopedic 11 physician, because he was the only
provider available at the time.

I

I

Note: rb)(5); (b)(?)(C)

ldid not document a pain level.

Note: A blood pressure of 160/90 falls within the range classified as stage-two
hypertension per parameters set by the American Heait Association. The fact that his
temperature was normal signifies that the high pulse rate was not caused by a fever.
When asked if the abnormally high blood pressure and pulse were verbally reported to
rb)(6); (b )(7)(C) lfb)(6); (b)(7)(C) !stated she assumed they were related to pain and believed her
referral for an appointment was adequate. She also stated it was the physician's
responsibility to "check everything" and note the blood pressure.

11 Related to the skeletal {bone) system.

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 Time Unknown
Detainee MEJIA was seen byfb)(6): (b)(?)(C)I His entry documents the detainee injured his elbow the
day before and presented with some swelling, redness, and increased temperature of skin. His
assessment and plan was to rule out cellulitis 12• Detainee MEJIA was placed on the antibiotics
clindam cin 300 mg, one daily and Bactrim DS, one tab twice daily. He was to follow up with
the following day.
�!}�!ir- ,
Note: Detainee MEJIA was not seen by\�/\�/;",
on June 7, 2017. �()�(ir:,
stated
during interview that he did not receive the refen-al, and b)(6); (b)(7)(C) confirmed fbl(6ll
lCb)(6); I did not correctly schedule the appointment.
11:02 a.m.
(b)(6); (b)(?)(C) entered orders for an x-ray of the elbow, a complete blood count (CBC) with
differential 13, an eight-test chemistry panel 14, and a diabetes panel. He was prescribed enteric­
coated naproxen, one tablet twice daily for pain.
Note: According to verbal report of!(b)( 6); (b)(7)(C) !, the x-ray was com leted upon verbal
order ofl(b)(6); (b)(7)(C) I If the x-ray was done er verbal order o b)C5); (b)(?)(C) he did not enter
a corresponding written order. b)(5); (b)(?)(C) said that as MEJIA was exiting the x-ray
I asked what happened, then said to perfo1m the lab tests. (b)(6); (b)(7)(C)
room, !Cb)(6); _
said she did not bring the detainee's elevated blood pressure to b)(6); (b)(?)(C) attention but
mentioned MEJIA was diabetic.
Note: ,�1\�L,
on (b)(6); (b)( ?)(C)
hypertension.

did not conduct an in-person assessment of detainee MEJIA and based
account, did not review the record. He was unaware of the detainee's

Note: ��{�{;,--,
!reviewed and signed the urinalysis results at 3:42 p.m. the next day,
following the medical emergency described below. The urinalysis was normal with the
exception of a moderate amount of blood in his u1ine. The remaining laboratory studies
were not completed due to clotting of the samples. ��/\�L,
!stated during interview that
the new samples should have been collected and speculated a clerk did not notify a
provider when notified that the tests were not completed.
11:17 a.m.
Per Mobilex radiology report, the x-ray showed the elbow joint was intact with no fracture or
dislocation.

12 Cellulitis is a potentially serious bacterial skin infection.
13 Part of a complete blood count which looks at the various subtypes of blood cells for greater diagnostic ability.
14 A comprehensive group of blood tests to assess various physical and chemical processes in the body.

DETAINEE DEATH REVIEW: Carlos MEJIA-Bonilla
Compliance Review

February 12, 2018

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 Thursday, June 8, 2017
4:30 a.m. - 4:43 a.m.
Note: As detailed below, June 8, 2017 was the date of the medical emergency and
detainee MEJIA' s hospitalization. The following describes events shown on video taken
on cameras in the housing unit and sallyport, logged by fbl(6); (b)(?)(C)
and
documented in the medical record. The described events begin as cells of detainees
scheduled for court and for diabetic checks were unsecured after overnight lockdown.
The video was viewed during the site visit on a HCDCR laptop computer only, because
required software could not be downloaded on the government-issued or reviewer's
personal computers. The reviewer notes the video timestamps were consistent between
cameras.

I

The video shows two detainees exiting their cells at approximately 4:30 a.m., then sitting at a
table in the dayroom in close proximity to MEJIA's cell. At 4:33 a.m., MEJIA exits bis cell
and appears to stumble as he closes the door. The two detainees seated at the table nm to MEJIA
and catch him before he falls. Together, they move toward the table as an officer, identified as
I approaches. They appear to speak as a second officer 15 approaches, then MEJIA
l(b)(6); (b)(7)(C)
is moved to the table where he is seated, placing his head in his arms on the tabletop. This
lheads back to bis desk where he appears to pick up his
occurs at 4:35 a.m. as l(b)(6); (b)( 7)(C)
I
1 16 inKb)(6); (b)(7)(C)
radio, then makes a note. A sergeant, identified as!(bl(6J; (bl(7)(Cl
incident report, enters at 4:37 a.m. and proceeds to the table where MEJIA was seated. Detainee
According to the A3West logbook and
MEJIA appears to speak to the sergeant.
Infirmary/Medical log, Code White was called at 4:38 a.m. Dming interview of fbl(6); (b)(?)(C)
I
he confirmed MEJIA was "wobbly" when he came out his cell, and recalled the detainee spoke
to him in Spanish. According to !(b)(6); (b)(?)(C)
I incident report, MEJIA said he was diabetic
and did not feel well.
Note: Code White was called m approximately five minutes after detainee MEJIA
stumbled upon exiting his cell.
The video shows the first medical staff person, identified as i(b)(6); (b)(7)(C) !arriving at 4:39:06 a.m.
Within seven seconds, two additional medical staff arrive with an inmate worker and urney.
l(b)(6); (b)(7)(C)
report
lwas one of the two staff; the second was identified in (b)(5); (b)(?)(C)
6
7
)(C)
(b)(
(b)(
)
;
as lrh\ln\ lh\17\rc:\ I Also responding wasl
I who stated during interview that he
observed MEJIA was shaking and appeared disoliented. Duling interview of fb)(6); (b)( 7)(C) and
!lb\16t lb\17\IC \ I both stated a provider does not typically respond to a medical emergency. Kb)(6)I
l<b)(6); __ !stated RNs typically respond on their own and if deternlined necessary, have the patient
brought to the clinic for provider assessment. Because she had not toured the facility as of this
date, l(b)(6); (b)(7)(C) !decided to respond with the RN to the medical emergency to see the housing

I

15 The second officer could not be positively identified.
was not available during the site visit due to illness.
(b)(7)(C)

16 kb)(6);

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 unit design. The video shows both medical staff at the table where MEJIA was seated at 4:39:47
a.m. During interview, 1/b\/6Ub\/7\/C\ I stated she asked him what was going on, indicating she "was
able to communicate just enough between her Spanish and his English." She recalled MEJIA
said he "didn't feel good", and that another detainee offered that had not been eating. In her
medical record entry describing the response, l<bl(6l; (bl(7)(Cl I elaborated, stating MEJIA
complained of feeling weak, dizzy, and pale, stating be had diarrhea earlier and that he ate little
breakfast due to not liking the food. l(b)(6); (b)(l)(C) !decided moving him to medical was necessary.
The video shows attempts to lift the gurney started at 4:40 a.m. and continued until 4:42 a.m.
At that time, one of the RNs approaches MEJIA, he stands, then walks to the gurney and lays
down. Kb)(6); (b)(7)(C) l:locumented in her medical record entry that he was able to ambulate slowly
to the stretcher, with assistance. The video shows the gurney starts moving at 4:43:11 and exits
the housing unit at 4:43:51.

I

Note; �b)(6); (b)(l)(C) provided slightly different times in her medical record entry. She
documented the emergency code was announced at 4:40 a.m. and that she anived on the
unit at 4:43 a.m. Time of departure from the unit was not documented.
4:46 a.m. - 6:20 a.m.
Note: The following describes events shown on video taken on two cameras in the
medical area and documented in the medical record and vehicle sallyport log.
The video shows the team ente1ing medical with the gurney bearing detainee MEJIA at 4:46
a.m. The gurney is then positioned in the clinic hallway where!(b)( 6); (b)(7)(C) I is seen looking at
MEJIA's wristband for identification purposes. She then departs the scene. During interview,
lrb\/6\: /b\(7)/Cl I said detainees brought to the clinic pursuant to a Code White call are kept in the
hallway because of the proximity to the provider's office. She also stated that when asked, the
detainee said he felt weak and was depressed; also, that he had not felt well for the past few days.
In her medical record entry summarizing events, she documented that detainee MEJIA was
brought to medical via stretcher with complaints of dizziness, poor appetite, one bout of diarrhea,
and generalized weakness of two days duration. He was awake, alert, and able to communicate,
but he appeared very weak and pale with a slow steady gait. He denied chest pain, palpitations 17,
shortness of breath, or nausea and vomiting. Intravenous (IV) fluids were started. The video
shows MEJIA' s vital signs were taken by nurses after �b)(5); (b)(?)(C) I left the scene. In kb)(6I
!(bl(6l; (bl(7l(Clhnedical record entry, she noted MEJIA's temperature, respirations, and pulse oxygen
were within normal limits, his blood pressure was abnormally low at 80/50, his pulse was
irregular and elevated at 108, and his blood sugar was elevated at 146. tb)(6); (b)(7)(C) documented
he was able to drink a small amount of Gatorade, and an intravenous line (IV) was started with
normal saline. She said the goal was to stabilize his vital signs.

I

17 A sensation that the heart is racing, pounding, fluttering, or skipping beats.

DETAINEE DEATH REVIEW: Carlos MEJIA-Bonilla
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 The video shows the next events of significance started at 5:42 a.m. whenfb)( 6); (b)( ?)(C) lis seen at
MEJIA's side. Prior to this time, nurses periodically checked the IV line. At 5:42 a.m.. !(b){!
!(b)(6);
l111oves the gurney's guard rail and motions for the detainee to move. He then swings his
legs over the side, stands, moves toward the head of the gurney, and at 5:43:11 a.m., starts to
topple. !(b)(6); (b)(7)(C) I stops his fall and appears to call for help. Other medical staff an-ive and at
5:44:03 a.m., MEJIA is helped into a seated position on the gurney. As he lies down, a pool of a
dark substance is visible on the floor.
During interview oHb)(6); (b)(7)(C) L she stated she left her office to go to the gurney when she heard
MEJIA call out, asking to go to the bathroom. She said MEJIA answered yes when asked if he
had to urinate and if he was able to walk. Because she wanted to see him walk to "see how he
was doing," she moved the guardrail and watched as he got up. !(b)( 6); (b)(7)(C) I stated be
immediately started bleeding from the rectum and started to fall. She called for help and when
other nurses responded, directed that 911 be called. During interview ofkb)(6); (b)(7)(C) l she said
she had gone to retrieve a urinal before!(b)(6 ); (b)(7)(C) I aITived at MEJIA's side, returning to witness
MEJIA stand and falter. She said she immediately noticed melena 18 mixed with blood on the
floor. In her medical record entry, tbl(6); (b)(7)(C) I wrote that MEJIA urinated a small amount,
followed by expelling dark clotted blood from his rectum. He was placed on oxygen via
cannula 19, and 911 emergency response was called for transport of the detainee to Jersey City
Medical Center (JCMC). Consistent with her report to the review team, kb)( 6); (b)(7)(C) I medical
record entry documents MEJIA was noted to have melena expelled from the rectum while being
assisted to stand. He appeared to be in mild distress. The documented diagnoses were dizziness,
weakness, hypotension 20, and gastrointestinal bleed. An electrocardiogram 21 (EKG) was ordered
stat, and he was to be transferred to the hospital for evaluation and management. l(b l(6); (b)(?)(C)
later added an order for a mental health referral. She stated during interview that she referred
MEJIA for mental health evaluation because he said he was depressed and in anticipation of his
return from the hospital.
Note: The time of the 911 call was not documented. l<blf6): fbl(7)/Cl I stated she made the
call when directed by l(b)(6), (b)(7)(C) I and notified the officer. According to ��/\�k... ,
l(b)(6); (b)(7)(C) I medical staff typically place 911 calls, although security supervisors are
authorized to do so when necessary. He said the requirement to document the call to 911
verbal
is the responsibility of the staff person who places it. Based on l(b)(5); (b)(7)(C)
report to the review team, the call was likely made at approximately 5:45 a.m., roughly
an hour after he an-ived in medical and 65 minutes after he exited his cell.

I

18 Melena is dark, black, tarry stool.
19 A tube placed inside the nostrils.

20 Low blood pressure
21 A test which shows the electrical function of the heart.

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I

 Note: There is no documentation the EKG ordered byKb)( B); (b)(7)(C) lwas completed during
the hour medical staff were waiting for MEJIA's vital signs to stabilize.

I

Note: The entries o�(b)(B); (b)(?)(C) and Kb)(6); (b)(7)(C) I as described above were the last in the
medical record. There are no entries documenting MEJIA's admission to the hospital,
communication with hospital personnel thereafter, and his death.

I

� b)(B), (b)(?)(C)
was assigned to the medical clinic at the time. He said durin interview
that medical staff were surrounding the gurne when he a roached the scene. (b)(B); (b)(?)(C)
l(b)(B); I stated he was in Central Control when (b)(B); (b)(?)(C)
called and said, "I really need a
reported to medical and
supervisor here; nurses just called for an ambulance." tb)(B); (b)(?)(C)
asked nurses if they needed anything. They confirmed 911 was called and said they needed a
partition, which the video shows was placed around the gurney at 5:50 a.m. l(b)(B); (b)(?)(C)
I
stated that before the pa1tition arrived, he leaned over the gurney and said, "Buddy, are you
alright?" Detainee MEJIA shook his head. The sergeant observed nurses "doing something"
around the lower part of his body. tb)(6); (b)(7)(C) �tated nurses were cleaning blood and when the
!said that
privacy partition was placed, changed MEJIA into a clean uniform. l(b)(6); (b)(7)(C)
when he left the scene, he notified l(b)(6); (b)(7)(C)
I that two officers were needed to
!documented in her incident report that !(b)(B); I
accompany MEJIA to the hospital. l(b)(6); (b)(7)(C)
2
!(b)(6): (b)(7 )(C)
! was assigned to ride in the ambulance andl (b)(6); (b)(7)(C)
r was assigned
to follow in the chase vehicle.

I

The Vehicle sallyport logbook documents the ambulance anived at 5:58 a.m. and Emergency
Medical Technicians (EMT)l(b)(B); (b)(?)(C)
fJ were escorted to medical.
Note: According to fbl(B); (b)(?)(C) I her requests for the ambulance repo11 were denied.
Note: Ambulance arrival at 5 :58 a.m. was 13 minutes after the estimated time 911 was
calJed.
Video from the medical area camera shows the EMTs arriving at the scene at 5:59:45 a.m. At
6:01:49 a.m., detainee MEJIA is moved to a wheelchair and at 6:03:49 a.m., is moved out of
camera range. The vehicle sallyport logbook documents the EMTs returned with MEJIA,
accompanied by Kb)(6); (b)(7)(C)
I at 6:12 a.m. and left at 6:20 a.m.
Note: Departure from the facility was 35 minutes after the estimated time 911 was
called.
Note: The Infirmary/Medical log documents the EMTs mTived on post at 6: 10 a.m. and
departed at 6: 18 a.m. These times are inconsistent with the video and entries in the
22 kh\/RI· /h\/7111.\ lfirst name is unknown.
23 The first names of EMTs b)(6); (b)(7)(C)
f

ere unknown.

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 vehicle sallypmt log and are believed to be inaccmate. The inaccuracy may be explained
by the common practice of officers using personal timepieces which may or may not be
in sync with times shown on facility computers and clocks.
During interview ofKb)(6); (b)(7)(C)
I he stated detainee MEJIA was alert during the trip to the
hospital and spoke to the EMT in Spanish. The detainee remained alert once in the emergency
!observed blood
room, "talking, calm, watching TV, and using the remote." Kbl(6); (b)(7)(C)
on the sheets while emergency room staff attended to MEJIA and by his count, nine transfusions
were given. He reported MEJIA lost consciousness and was moved to the intensive care unit
(ICU) where intubated.

I

Note: fbH6); (b)(?)(C)
inf01med the review team that officers who transport and
supervise detainees at the hospital do not maintain a logbook. Consequently, information
shared by !(bl(6l: (bl(7)(C)
I is not documented, including time of arrival at JCMC,
detainee MEJIA's admission to the hospital, and placement in the ICU.
11:25 p.m.
According to an Incident Report written by l(b)(6); (b}( 7)(C)
I at 11 :55 p.m., he was notified
that detainee MEJIA was not expected to live through the night. The information was reported
by the officer supervising the detainee at the time, !(b)(6l: (bl(7l(Cl( through l(b}(6); (b)(7)(C)
I
l(b)(6); (b)(7)(C)
!contacted fbl(5); (b)(?)(C) I who reported the prognosis was provided by
hospital personnel; also, that they informed him MEJIA was in medical distress and bleeding
internally. Kbl(6); (b)(7)(C)
!documented he notified HCDCR Assistant Director Kb)(6);
I
and directed that a lieutenant notify Assistant Field Office Director (AFOD)Kb)(6); (b)(7)(C) I Per
the repmt, fbl(6); (b)(?)(C) I said the medical staff notified him earlier in the day that detainee
MEJIA was taken to the hospital, and that "NY ICE" would make necessary notifications.
June 9 and 10, 2017
l(b}(6); (b)(7)(C)
I reported to the review team than he was assigned hospital duty on these dates.
He said he observed MEJIA' s abdomen "kept getting bigger and bigger."
June 10, 2017
11:13 p.m.
According to an Incident Rep01t written by Kb)(6); (b}( 7)(C)
I he was infonned byl(b)(6); I
l/bl(6l: (bl(7l( Cl I that detainee MEJIA was pronounced dead at 11: 12 p.m. by fbl(6); (b)(?)(C)
I
The report states he instructedKb)(6); (b)(?)(C)
Ito retrieve "proper paperwork" from the coroner's
office before leaving the hospital, and then attempted to contactfb)(6); (b)(7)(C) � fbl(6); (b)(7)(C)
"did not answer and his mail box was full", so he proceeded to contact !(b)(6); (b)(7)(C)
I
who directed that he continue to make proper notifications and file a report. He then notified
lof the death.
j(b)(6); (b)(7)(C)

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 June 11, 2017
l(b)(6); (b)(7)(C) lfiled an incident report stating that at l :52 a.m., the New Jersey Regional Medical
Examiner's (ME) Office arrived at the hospital to take custody of the body of the detainee. His
request for a release form was denied, so upon authorization from Kb)(6J; (b){7){C)
I received
at 2:09 a.m., he turned custody of the body over to the ME and returned to HCDCR.
!/bl/6): /bl/7l/C l ladded a note to!(bl(6l: (bl(7)(Cl
!report indicating he confirmed that the ME does not
issue a release form and that he authorized the officer's return to the facility.

I\�/\�/;�, I

Summary of Hospital Records
The record of the JCMC Emergency Department notes the service date was June 8, 2017 at 6:42
a.m. According to the attending physician, "Patient seen immediately on anival because of high
possibility of imminent or life threatening deterioration in patient's condition." The patient
reported the onset of rectal bleeding since overnight, accompanied by a dull lower mild
abdominal pain. He reported a history of gastrointestinal bleeding in January requiring blood
transfusions.
Note: A history of gastrointestinal bleeding with blood transfusions was not documented
in the HCDCR medical record. MEJIA may not have reported the information; or,
communication may have been impeded by his poor English language proficiency.
His vital signs were normal, with the exception of a critically low blood pressure of 65/29 and
rapid pulse rate of 103. Following the initial assessment and laboratory studies, he was admitted
to the intensive care unit at 9:08 a.m. with diagnosis of upper gastrointestinal bleed. His blood
presslll·e continued to drop, recorded at 53/47 and associated with dizziness. He was given a
total of 13 blood transfusions, but episodes of significant blood loss in his stool continued. The
bleeding was suspected to be a variceal 24 bleed, related to advanced liver cin-hosis. An
endoscopy 25 done at the bedside showed blood clots in the esophagus with a significant
collection of blood. The bleed remained active, and his liver tests were observed to be
worsening, suggesting liver shock 26 . MEJIA was declared dead at 11:22 p.m. on June 10, 2017.
The preliminary cause of death was upper gastrointestinal bleed and hemonhagic shock 27.
Certificate of Death
The Certificate of death was dated July 26, 2017 and signed byl(b)(5): (b)( ?)(C)
I State Registrar,
Office of Vital Statistics and Registry. The immediate cause of death as gastro-intestinal
24 Abnormal veins in the esophagus.
25 A procedure in which an instrument is introduced into the body to give a view of its internal parts.

26

An acute liver injury caused by lack of blood and oxygen to the liver, usually due to low blood pressure,
A life-threatening condition resulting from the loss of more than 20% of the body's blood or fluid supply. This
severe fluid loss makes it impossible for the heart to pump a sufficient amount of blood to the body.
27

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 ) (6J'""'
; (b lf7l(C l ________.lan autopsy was
hemorrhage due to chronic alcoholism. According to ._kb-""....,. --;;-"'--'
not ordered.

After Action Review
I stated after action reviews of deaths are conducted by medical personnel.
A multi-disciplinary review is conducted only if directed by the HCDCR Deputy Director. In
this case, a multi-disciplinary after action review was not conducted, although incident reports
describing events were written by some security personnel.

K b)(6); (b)(7)(C)

Reviewers were provided with a Co1Tective Action Plan developed by CFG listing the following
goals:
•
•
•
•
•
•
•

Medication verification is to be completed within 24 to 72 hours.
Nurses are to fully document sick call encounters.
Nurses are to review the medical record to determine third-time requests for the same or
similar complaint and ensure the detainee is seen by a provider.
Nurses are to make appropriate referrals to providers.
Providers are to order chronic care visits and appropriate lab tests for new intakes.
The provider who orders the tests will review the results. Test results will be reviewed
byl\�/\�/;�,
lif lab work was ordered by an as-needed provider.
All staff will accurately document Code White response.

In addition, reviewers were provided with a memorandum dated July 3, 2017 from
j(b)(6); (b)(7)(C)
l to the Clinical Director listing the following:

(b)(6);

fh\/7\fr''

1. "All new intakes' medical charts will be cross-referenced with the ERM to ensure all
information is accurate and consistent.
2. "The EMR will be modified to send alerts to the provider whenever medication or refen-als
need to be ordered.
3. "The medical chart of all new intakes referred for medical/psychological appointments wiJl be
reviewed to ensure that they are scheduled for speedy follow-up examination.
4. "The medical charts of inmates/detainees currently housed at the HCOC&R who are
classified as 'Chronic Care' will be reviewed to ensure continuity of care.
5. "ICE officials will be notified immediately of all new detainees that are identified as 'Chronic
Care'. The date, time and name of the ICE official to whom the notification was made shall be
recorded in the detainee' s medical chart.

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 6. "There wiJI be regular communication with ICE officials to discuss all 'Chronic Care' and
clinical detainee cases.
7. "Representatives from ICE will be invited to attend all [Medical Audit Committee]
meetings."

CONCLUSIONS
Medical
MEJIA's medical intake screening was conducted promptly upon his arrival, and appropriately
resulted in referral to a provider on an urgent basis due to his high blood sugar level and need for
diabetes medication. Diabetes was the only chronic condition identified by the screening nurse,
although during the initial health appraisal, cin-hosis, anemia and hypertension were also
It cannot be determined whether MEJIA's limited English language proficiency
reported.
interfered with completion of a thorough, accurate intake screening.
l who conducted the initial health appraisal, included diabetes, cirrhosis, hypertension
and anemia on the list of MEJIA's medical conditions resulting from her examination; however,
her plan of care addressed only diabetes. She did not take the critical step of ordering diagnostic
testing for establishment of a treatment plan, nor did she take the very basic step of ordering
blood pressure monitoring to determine if anti-hypertensive medication was called for. She
directed that MEJIA's medications be verified with his pharmacy; however, neither she nor
another medical provider reviewed the list of medications when received five days following the
detainee's admission. Included on the list from the pharmacy were medications for the treatment
of anemia, hypertension, liver disease, and diabetes. Only diabetes medication was given during
the ten week detention period.

l(b)(6) ; (b)(?)(C)

I referred MEJIA for mental health evaluation because he reported he was depressed,
and for a chronic care appointment. Neither the mental health evaluation nor a chronic care
appointment were completed. The HSA stated Kb)(6); (b)(7)(C) I failed to schedule the mental health
appointment, and routine chronic care appointments are not scheduled for 90 days per policy.

Kb}{B); (b)(?)(C)

Detainee MEJIA submitted seven sick call requests. He was seen by RNs, none of whom
documented need for or use of interpretation assistance. In two requests submitted within two
weeks of arrival, he referenced the fact that he was on blood pressure medication and iron
supplements prior to admission and requested that his blood pressure and blood sugar be checked
because he was not feeling well. Other requests included complaints of sleeplessness, cough
and cold symptoms, feeling weak, "weak blood," and dizziness. Despite the requests wherein
he tried to bring to his chrnnic conditions to attention of the medical department-- conditions
already documented in the medical record and for which medications were verified-- nurses
failed to refer him to a provider for assessment.
DETAINEE DEATH REVIEW: Carlos MEJIA-Bonilla
Compliance Review

February 12, 2018

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 Other than the initial health appraisal, MEJIA's only encounter with a provider was on June 5,
2017, three days before the medical emergency that resulted in his hospitalization. He was
brought to medical after reporting he became dizzy and fell in the shower the day before, hurting
his elbow. The RN refen-ed him to the orthopedic physician but did not report that MEJIA's
blood pressure was elevated at 160/90. An x-ray found the elbow was not fractured or displaced,
I An appointment was not scheduled
and the physician referred him staff physician Kb)(6); �and MEJIA was not seen.
On the day of the medical emergency, Code White was called within an estimated five minutes
after MEJIA was observed in medical distress as he exited his cell. Medical staff arrived quickly
thereafter, and !(b)(6); (b)(7)(C) I determined moving the detainee to the medical clinic was necessary.
The responders strnggled with the gurney for two minutes before MEJIA was moved from the
housing unit to medical. For the next hour, he remained on gurney while IV fluids were
administered. While attempting to stand to go to the restroom, MEJIA faltered and expelled
bloody stool. Medical staff called 911 but did not document the time. Security personnel
expedited the arrival and departure of the EMS responders.
The medical file terminates with entries describing responding to the Code White, actions taken
once the detainee arrived in medical, and call to 911. There were no entries documenting
contact with the hospital for updates on MEJIA's condition, and no entry documenting his death.

Compliance Findings
Creative Corrections cites the following deficiencies in the ICE 2008 PBNDS:
Medical Care, sections (V)(A), which states, "Every facility shall directly or contractually
provide its detainee population initial medical, mental health, and dental screening, primary
medical and dental care, emergency care, specialty healthcare, timely responses, mental health
care, and hospitalization as needed within the local community."
•

Despite MEJIA's report of anemia, hypertension, diabetes, and cirrhosis, the provider
who conducted the initial health appraisal did not order blood pressure monitoring or
laboratory studies to determine treatment needs.

•

The list of medications provided by MEJIA' s pharmacy on April 6, 2017 was not
reviewed by a provider. Consequently, medications for anemia, hypertension, and liver
disease were not ordered, creating a break in continuity of chronic disease treatment.

•

In four of MEJIA' s seven sick call requests, he referenced conditions for which he was
taking medications before he was detained. On April 10, he said he was feeling weak
and was taking iron and blood pressure medications at home; on April 11, he asked that

DETAINEE DEATH REVIEW: Carlos MEJIA-Bonilla
Compliance Review

February 12, 2018

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 his blood pressme and blood sugar be checked because he was feeling sick; on April 23,
he requested an iron supplement; and on May 18, he complained of dizziness related to
anemia. Despite his reported history of anemia, high blood pressure and cirrhosis, and
confirmation of medications by his pharmacy, RNs did not refer him to a provider for
assessment. When he was seen for sick call on May 18, 2017, he was told he would be
seen by a provider; however, no appointment was scheduled.
•

On April 14, 2017, an eye examination showing significant vision deficits did not result
in referral to a provider or eye doctor.

•

On May 11, 2017, the RN did not examine MEJIA's throat when assessing him for
complaint of sore throat.

•

On May 30, 2017, a provider rewrote an order for diabetic medication without
conducting a chronic care evaluation.

•

An appointment with\�(\�?:�,
physician on June 7, 2017.

•

An appointment with a mental health professional was not scheduled following referral
by l(b)(6 t (b)(?�(C) l consequently, detainee MEJIA was never evaluated for depression
reported during the initial health appraisal.

was not scheduled following referral by the orthopedic

Medical Care, sections (V)(C)(2), which states, "All new arrivals shall receive TB screening
within 12 hours of intake and using methods in accordance with CDC guidelines for non­
minimal risk detention facilities."
•

A chest x-ray for tuberculosis clearance was completed on April 3, 2017. Detainee
MEJIA was admitted during the evening hours of April 1, 2017.

Medical Care, sections (V)(l)(l), which states, "The clinical medical authority shall be
responsible for review of all health screening forms within 24 hours or next business day to
assess the priority for treatment (for example, Urgent, Today, or Routine)."
•

The intake screening was signed by a psychologist rather than the Clinical Director or
designated medical provider.

Medical Care, sections (V)(l)(l), which states, "Non-English speaking detainees and detainees
who are deaf or hard of hearing will be provided interpretation or translation services or other
assistance as needed for medical care activities. Language assistance may be provided by another

DETAINEE DEATH REVIEW: Carlos MEJIA-Bonilla
Compliance Review
February 12, 2018
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 staff member competent in the language or by a professional service, such as a telephone
translation service.
•

Based on available information, MEJIA had limited English language proficiency.
Providers and nurses did not document need for or use of interpretation assistance, and
documents signed by MEJIA are in English. The language barrier likely impeded
communications during medical encounters, and his comprehension of information on the
documents he was required to sign, without interpretation, is highly questionable.

Medical Care, sections (V)(J), which states, "The clinical medical authority shall be responsible
for review of all health appraisals to assess the priority for treatment."
•

The clinical medical authority or other physician did not review and sign the initial health
appraisal. Review by a physician may have resulted in identification of diagnostic and
treatment omissions by 1Cb)(6); (b)(?)(C) I and development of an appropriate plan of care early
in the detention period.

Medical Care, sections (V)(K)(4), which states, "Any detainee referred for mental health
treatment shall receive a comprehensive evaluation by a licensed mental health provider as
clinically necessary, but no later than 14 days of the referral."
•

Although MEJIA reported depression dming the initial health appraisal, a mental health
assessment was not conducted during the detention period.

Medical Care, sections (V)(M), which states, "An initial dental screening exam shall be
performed within 14 days of the detainee' s a.tTival. If no on-site dentist is available, the initial
dental screening may be performed by a physician, physician assistant, nurse practitioner,
registered dental hygienist, or registered nurse."
•

A dental examination was not completed.

Medical Care, section (V)(T), which states, "Informed consent standards of the jurisdiction
shall be observed, and consent forms shall either be in a language understood by the detainee or
translation assistance shall be provided and documented on the form."
•

The informed consent form signed by detainee MEJIA was in English. There is no
evidence he understood written or spoken English.

Areas of Note
Creative Conections cites the following additional concerns:

DETAINEE DEATH REVIEW: Carlos MEJIA-Bonilla
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February 12, 2018
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 •

•

•
•

•
•

The HSA exhibited a lack of knowledge of the ICE 2008 detention standards. She stated
she was not aware of the Clinical Medical Autholity' s responsibility to ensure intake
screenings and initial health appraisals are reviewed for determination of p1iority for care.
Reviewers recommend that the HSA familiarize herself with the standards.
fb)(6); (b)(?)(C) I andkbl(6l: (bl(7l(Cl !documented refenal of MEJIA for evaluation/follow up by
other providers. kb)(6); (b)(?)(C) !stated neither took the necessary step of scheduling the
appointments; therefore, they were not conducted. Reviewers recommend that the HSA
ensure appointment scheduling procedures are understood and followed.
The medical team responding to the Code White struggled with the gurney for two
minutes. Reviewers recommend testing of the gurney and drills involving its use to
assure preparedness in the event of an emergency.
It is understood that during a medical emergency, health care professionals are not
focused on the time events occur. However, because calling for EMS is a clitical part of
an emergency response, the reviewers recommend that the time be noted and
documented.
Although MEJIA remained an ICE detainee, his medical record ended with his transfer to
the hospital. Updates on his status were not documented in the medical record and there
was no entry documenting his death.
As noted in the above compliance findings, language interpretation assistance was not
used in any medical encounter. Given MEJIA's limited English language proficiency,
conducting medical assessments without assuring he understood the questions and in
tum, was understood by the health care professional, was likely an impediment to care.
A related concern is the facility's practice of requiring a non-English speaking detainee to
sign fonns acknowledging receipt and understanding of information communicated in
English, including consent for treatment.

Security
Although the intake officer documented detainee MEJIA's primary language was Spanish and
that he required interpretation assistance, none was provided during the admission process. The
forms he signed were all in English. MEJIA was assigned to a pre-classification housing unit
approximately 12 hours after arrival, then to a low custody unit approximately 58 hours later.
The classification was applied by facility staff on the second day after arrival.
At approximately 4:33 a.m. on June 8, 2017, MEJIA exited his cell and was observed in medical
distress. The officer called Code White within an estimated five minutes. Security and medical
staff responded quickly and moved the detainee to the clinic. At 5:45 a.m. (estimated) medical
staff called 911 after MEJIA bled through his rectum upon standing. Security personnel
provided appropriate support to medical staff, and facilitated the entry and exit of EMS from the
facility.
Officers assigned to hospital transport and vigil are not required to maintain a log documenting
DETAINEE DEATH REVIEW: Carlos MEJIA-Bonilla
Compliance Review
February 12, 2018
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 actions and events.
No after action review of security personnel's involvement in the medical emergency was
conducted, although incident reports were collected by some involved staff. Based on written
and verbal reports, security personnel exercised due diligence in notifying ERO and attempting
to secme a body receipt from the medical examiner.

Compliance Findings
Creative Corrections cites the following violations of the ICE 2008 PBNDS governing safety and
security.
Admission and Release, section (V)(A), which states, "Each detainee's identification
documents shall be secured in the detainee's A-file."
•

Confiscated identification documents were not turned over to ERO for inclusion in
MEJIA's A-file.

Classification System, section (V)(B), which states, "Detainees shall be processed for housing
assignments within twelve (12) homs of arrival at the facility. Ordinarily, the initial assessment
process shall be completed within twelve (12) hours of admission to the facility. If the process
takes longer, documentation will be maintained as to what delayed the process and the detainee
will be housed appropriately."
•

Detainee MEJIA was moved to pre-classification housing within approximately 12 hours
of aiTival on April 1, 2017. The initial classification was not completed until April 3,
2017, and he was not moved to a general population housing unit until late in the
afternoon of April 4, 2017.

Areas of Note
•
•
•

As noted in the discussion of medical concerns, non-English speaking detainees should
not be required to sign forms acknowledging receipt and understanding of information
provided in English, only.
The second officer in the housing unit when MEJIA exited his cell on June 8, 2017, did
not write an incident report and could not be identified. Whereas he witnessed critical
events, his observations should have been documented in a rep01t.
There is no requirement in the ICE PBNDS for maintenance of a log by hospital
transportation or vigil officers. However, because a log provides a record of events as
they occur, maintaining a log supports accountability and assures information otherwise
unavailable is documented. The reviewer recommends that the facility consider
instituting a log for hospital transportation details.

DETAINEE DEATH REVIEW: Carlos MEJIA-Bonilla
Compliance Review

February 12, 2018

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 •

The PBNDS also does not require completion of a multi-disciplinary after action review
following a death. However, because security personnel often play an integral role, the
reviewer recommends that after action reviews include analysis of actions taken by
officers. After action reviews allow detennination of adherence to or non-compliance
with policy and post orders, and identification of training needs.

DETAINEE DEATH REVIEW: Carlos MEJIA-Bonilla
Compliance Review
February 12, 2018
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 APPENDIX

Vital Signs
DATE

TEMPERATURE

4/1/2017

98.2

PULSE

74
98.1
4/14/2017
97
67
4/25/2017
5/3/2017
76
98
76
5/11/2017
5/18/2017
76
98
6/6/2017
102
98.8
97.0
6/8/2017
108*
6/8/2017
108
97.3
* Pulse was documented as irregular.

RESPIRATIONS

BLOOD
PRESSURE

PULSE
OXYGEN

BLOOD
SUGAR

WEIGHT

18

100/66

99

178

16
16
16
16
16
16
18
20

134/83
109/60
120/60
125/67
120/67
160/90
80/50
86/50

99

253

DETAINEE DEATH REVIEW: Carlos MEJIA-Bonilla
Compliance Review
February 12, 2018
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97.3

178

146

Page 27

 Co of Hudson Dept of Corrections

30-35 Hackensack Avenue Kearny, NJ 07032
Phone: (201) 395-5600

ROLANDO MEZA

DOB: 10/24/1970

LOC:

&

Rehabilitation

June 9, 2017
Page 1

COMMITMENT#: 09313619 S81 # 46 Years Old
Race: Hispanic Gender: Male HLCN: HCCC

04/01/2017 - Nurse Intake: Nurse Intake
Provider: Kb)(6); (b)(7)(C)
I
Location of Care: Co of Hudson Dept of Corrections & Rehabilitation

Encounter Context

Facility at time of evaluation: Co of Hudson Dept of Corrections & Rehabilitation
Age at Time: 46 Years Old
Does the inmate agree to medical screening? Agreed
Is the Inmate a Veteran?: No

Interpretation Services

Does the inmate need an interpreter? No

Arresting Injuries

Did you sustain arresting injuries?: Denies

International Travel

Have you traveled outside of the United States in the last 30 days? No
Have you been in contact with anyone that has traveled outside of the US within the last 30 days?
No

Physical Limitations

Does inmate have any medical limitations or disabilities? Denies

Allergies

Does inmate have any allergies? Denies
Medications
Are you currently taking or should be taking any type of prescription medications?Yes

Medication Verification (Meds in the Community)

Medications as reported by inmate during admission to facility If inmate does not know the name(s) of the
medication, write the type in the indication column, and complete the form after the med is verified. E.g.
Blood Pressure Pill.

Medication #1
Medication Verified: No (Verify Later}
Pharmacy/Source: brantwood pharm
Address: long island
Medication/Description: metformen, Recurrent Rx

 Co of Hudson Dept of Corrections & Rehabilitation

30-35 Hackensack Avenue Kearny, NJ 07032
Phone: {201) 395-5600

ROLANDO MEZA

DOB: 10/24/1970

LOC:

June 9, 2017
Page 3

COMMITMENT#: 09313619 SBI # 46 Years Old
Race: Hispanic Gender: Male HLCN: HCCC

3. Family member or significant other has attempted or committed suicide (spouse, parent,
sibling, close friend or lover)? No
4. Expresses current thoughts about killing self or has suicide plan? No
5. First time EVER incarcerated? No
6. Is this inmate acting in a significantly strange or bizarre manner (Not due to withdrawal or
intoxication)? No
7. Is this inmate disoriented to time, place and person (Not due to withdrawal or intoxication)? No
8. Is the person unresponsive to questioning or withdrawn (NOT due to withdrawal or
intoxication)? No
9. Holds a position of respect in community (i.e. professional or public official) and/or alleged
crime is shocking in nature? Expresses feelings of embarrassment and shame.Yes
10. History of psychiatric hospitalization? No
11. Shows signs of depression (crying, emotional flatness, negative thinking)? No
12. Expresses that there is nothing to look forward to in the future (helplessness, hopelessness)?
No
13. Shows signs of excessive anxiety (agitated, fearful, panic)? No
14. Currently treated by a psychiatrist/psychologist? No
15. Previously treated by a psychiatrist/psychologist? No
16. History of violent behavior/aggression? No
17. Have you been a victim of sexual abuse? No
18. Have you been a victim of criminal violence? No
19. Have you experienced a significant loss in the past 6 months? No
20. Have you ever been placed in a special education setting? No
21. Are you worried about any major problems? (not legal or criminal) No

Review of Systems

GENERAL SYSTEM: Denies Any Sx Related to System.
EYES: Denies Any Sx Related to System.
E/Nfr: Denies Any Sx Related to System.
CARDIAC: Denies Any Sx Related to System.
PULMONARY: Denies Any Sx Related to System.
GASTROINTESTINAL: Denies Any Sx Related to System.
GENITOURINARY: Denies Any Sx Related to System.
MUSCULOSKELETAL: Denies Any Sx Related to System.
SKIN: Denies Any Sx Related to System.
NEUROLOGIC: Denies Any Sx Related to System.
PSYCHIATRIC: Denies Any Sx Related to System.
ENDOCRINE: Denies Any Sx Related to System.
HEME/LYMPHATIC: Denies Any Sx Related to System.
ALLERGIC/IMMUNOLOGIC: Denies Any Sx Related to System.
Dental: Oral hygiene status? Fair
Large asymmetrical facial swelling? No
Inability to close teeth evenly? No

Alcohol Use
Have you ever used alcohol? Denies

 Co of Hudson Dept of Corrections & Rehabilitation
30-35 Hackensack Avenue Kearny, NJ 07032
Phone: (201) 395-5600
ROLANDO MEZA

DOB: 10/24/1970

COMMITMENT#: 09313619 SBl # 46 Years Old
LOC: Race: Hispanic Gender: Male
HI-CN: HCCC

management. Yes
Intake Summary: REFER TO NP

Added Medications

)(__
6);__
c__
) __...--__.on 04/01/2017 at 8:15 PM
)(7)__
Electronically signed by,_(b__
(b.....
__(
on 04/04/2017 at 9:41 AM
Electronically signed by(b )(6); (b)(7)(C)

June 9, 2017
Page 5

 Co of Hudson Dept of Corrections

&

30-35 Hackensack Avenue Kearny, NJ 07032
Phone: (201) 395-5600

Rehabilitation

June 9, 2017
Page 1

ROLANDO MEZA

DOB: 10/24/1970

COMMITMENT#: 09313619 SBI # 46 Years Old
LOC: Race: Hispanic
Gender: Male
HLCN: HCCC

04/01/2017 - Provider Intake: Provider Intake

I

Provider: kb)(6); (b)(?)(C)
Location of Care: Co of Hudson Dept of Corrections & Rehabilitation

Encounter Context
Facility at time of evaluation: Co of Hudson Dept of Corrections & Rehabilitation
Age at Time: 46 Years Old

Provider Initial Medical Screening

Does the inmate agree to medical screening? Agreed
Reason for Priority: hx; DM BS 253 MG/DL, NEED PM DOSE OF METFORMEN (04/01/2017 7:58:28
PM)

Questionnaire Scores and Alerts:
Last PREA Score: 0 (04/01/2017 7:58:28 PM)
Precautions: None (04/01/2017 7:58:28 PM)
Disposition: General Population (04/01/2017 7:58:28 PM)
Positive Symptoms/Problems from Nursing Intake
Handicaps
Pain Scale
Inmate Stated Medications
Medical History

Stated Medical Problems:

DIABETES TYPE 2:
(04/01/2017 7:58:28 PM)
Review of Systems

Social History
Substance Use Tx?: Denies (04/01/2017 7:58:28 PM)
Allergies, Medications and Problems

Active Medications: : GLUCOPHAGE 500 MG ORAL TABS 1 by mouth twice daily.
Problems: Anemia (ICD-285.9) (ICD10-O64.9), Depression (ICD-311) (ICD10-F32.9), Cirrhosis (ICD571.5) (ICD10-K74.60), HTN (ICD-401.9) (ICD10-110), OM, uncomplicated, type II (ICD-250.00) (ICD10E11.9).
Additional NotesReports h/o depression, OM type 2, cirrhosis of the liver and anemia. Does not remeber
the name of all of his medications. uses brantwood pharmacy in islip, NY

Current Vital Signs

Previous Height: 57 (04/01/2017 7:58:28 PM)

Previous Weight: 178 (04/01/2017 7:58:28 PM)

 Co of Hudson Dept of Corrections & Rehabilitation
30-35 Hackensack Avenue Kearny, NJ 07032
Phone: (201) 395-5600

ROLANDO MEZA

POB: 10/24/1970

LOC:

June 9, 2017
Page 3

COMMITMENT#: 09313619 SBI # 46 Years Old
Race: Hispanic Gender: Male HLCN: HCCC

Pedal Pulses: WNL
Periph. Circulation: WNL
Gastrointestinal
Abdomen: WNL
Liver & Spleen: WNL
Male Genitourinary
Scrotum: WNL
Penis: WNL
Prostate: WNL
Lymphatic
Rectal
Neck: WNL
Axillae: WNL
Groin: WNL
Misc. Lymph Nodes: WNL
Musculoskeletal
Gait & Station: WNL
Digits & Nails: WNL
Head & Neck: WNL
Spine, Ribs & Pelvis: WNL
RUE: WNL
RLE: WNL
LUE: WNL
LLE: WNL
Neurological
Cranial nerves: WNL
Reflexes: WNL
Sensation: WNL
Mental Status
Judgement & Insight: WNL
Orientation: WNL
Memory: WNL
Mood & Affect: WNL

Practitioner Assessment & Plan
New Problems:
Anemia (ICD-285.9) (ICD10-O64.9), Depression (ICD-311) (ICD10-F32.9), Cirrhosis (ICD-571.5) (ICD10K74.60), HTN (ICD-401.9) (ICD10-110), OM, uncomplicated, type II (ICD-250.00) (ICD10-E11.9).
Assessment Comments: OM type 2
Cirrhosis
New Medications:
GLUCOPHAGE 500 MG ORAL TABS 1 by mouth twice daily.
New Orders:
2200 Diabetic/Calorie Controlled [2200OM].

 Co of Hudson Dept of Corrections & Rehabilitation
30-35 Hackensack Avenue Kearny, NJ 07032
Phone: (201) 395-5600
ROLANDO MEZA

DOB: 10/24/1970

LOC:

COMMITMENT#: 09313619 SBI # 46 Years Old
Race: Hispanic Gender: Male HLCN: HCCC

04/01/2017 - Internal Correspondence: Handout Printed
Provider: kb)( 6); (b)(7)(C)
I
Location of Care: Co of Hudson Dept of Corrections & Rehabilitation

Printed Handout:

- Informed Consent to Medical Services

on 04/01/2017 at 8: 15 PM
>
Electronically signed by <l b)(_ 6) _; (b )(7_ )cc
._ _ _ _ _ ________,Jl

June 9, 2017
Page 1

 lMMIGRATION AND CUST MS ENFORCEMENT
Detainee Classification System-Prin�•rv As.w.ssment Form
Event#:
FINS#:

Sub"ertlD:

(b)(6); (b)(7)(C)

NAME:
COUNTRY OF cmzENs

0.0.B.
CLASSIFIED BY:
DATE:

Field
Location:
(b)(7)(E)

ly/43/ I J

LANGUAGE: (ENGLISH Y /N) 0

�

(b)(6);
"-' (b)(7)(C)

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Office ofEnforcement Removal Operations

U.S. Department of Homeland Security
Immigration and Customs Enforcement

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""'a�C,;,.i.i:�

•

(b)(6);
,w,
201 Vanek Street th117
New York, NY 10014
l(b )(6); (b )(7)(C)

Fax (212)620-3441

CRIMINAL HISTORY REPORT

A

DETAINEE NME:
DETAINEE A#:

Meza Espinoza, Rolando

l(b)(7)(E)

DEl'AINEE SBI #:

CRIMINAL ffiSTORY:
1)
2)
3)
4)
5)
6)

Driving Under Influence Liquor

I

 Em-:ORCE Applicati�n SuiteR�A Summary
RCA

Page 1 of I

· -· 1

Person 10: h\/7\/F ex: M DOB: 10/2411970 Current Age: 46 COB: HONOU COC: HONOU
•
-· -•····
• Su ect 10 : 358380317 Processing Disposition: B ag and Baggage······· ··•··•· ··
• bj
·
· case #k )(7)(E Case Celogory: BC Oockel: VRK • Unassigned Dockal -----•-- •· --••--•• ·-- --- ••
b
Status: Custody Classification Level Supervisory Appr oval Complolo

!

lnilialiZeed On: 04101/2017
Last Decision Dato: 04/01/2017
Special Vulnerab.UUes: Nono

Man Del StaVAlleg: NIA
Risk lo Public Safety: High
Risk or Flight Low

Current I Active
Alerts

Custody Decision: Dotalnod by the
Department or Homeland Security
Custody Class.: Medium/ High

:.::..J

I

Priority 1

j

In Custody

j

F.O. or Removal

(

Crlmlnal

Meza Espinoza, Rolando�b><5>; (b)C7 ><c>

Summary
Status: Custody Classification Level Supervisory Approval Complete
Initiated on: 04/01/2017

Applied to encounter: 358380317

Last submitted for supervisory approval on: 04/01/2017

Last submitted for supervisory approval by: Keane, J 6577

Special vulnerabilities: None
Mandatory detention per statutes and allegations: N/A
Risk to public safety: High
Risk of flight: Low
Detain I release decision: Detained by the Department of Homeland Security
Supervisory approval on: 04/01/2017

Supervisory approval bvllh\/R\· /h\/7\/r.l

Custody classification level: Medium / High
Supervisory approval on: 04/01/2017

Supervisory approval byj(b )(6); (b ) (7)(C )

t iSSSWl'

111 lt

651K

PB

ss

United States Department or Homeland Security (OHS). U.S. lmmlgralion and Customs Enforcement (ICE), Enforcement and Removal Operations (ERO)

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Release EARM 5.30

b
7 E
--[ ) ( ) ( )
..:._ ..:._

..:._

..:._

_____________________....J-------------4./1 /?()17

 RECEIVING ROOM ID

HUDSONC�Y

CORRECTIONAL CENTER
NAME:

MEZA, ROLANDO
COMMITMENT#: 09 313619

INS#: Kb){6);

)

AGE:46
DATE ENTERED: 04 01 2017

MEZA, ROLANDO
COMMITMENT#: 09 313619
AGE:46
DATE ENTERED: 04 01 2017

LOCATION: _____
I. [
2. [
3. [
4. [
5. [
6. [
7. [

-

- - - • • --·�· -� .......,, • ru

] Protective Custody
] Psychologicallmpainnent
] Mental Deficiency
] Suicide Risk
] Serious Violence Threat
] K nown Gang Affiliation
] Sut!tance Abuse Program

r1:- I

IV l

I

1

I
I
I

C.

OVERRIDEOFS CALE CUSTODY IS R ECOMMENDED:

D.

RECOMMENDED CUSTODY LEVEL:

.
IF YES ' GIVE RATIO NALE(Requ1r ed)

]High

[

] Medium/High

A.
B.

S UPERVISORY APP ROVALOF OVERRIDE

I

Dat e:

I
D

1
.
FINAL CUSTODY LEVEL (lfoverndd
e 1Sapproved).................i ... ..
) High

[ ]2 NO

/
]Low

RECO MMEND ED CUSTODY LEVEL
(

{ ]IYES

(b)(6); (b)(7)(C)

Classification Agent Signature: _
SECTIONill.

nt.:> Ut. I AINEE: (mark with X)
. [ ] Known Management Problem
[ ] Suspected Drug/A6en Trafficker
• [ ] Suicide Risk
. [ ] Meclical Problem (PHS Form J-794)
• [ ] Physical l mpainnent (PHS For m J-794)
. [ ] Other (Specify)
[ ]Ter rori!t Threatfferrorist (Auto. L-3)

_j:/ L_/_L________
3

( ] DISAPPROVED

[ ] Medium/Low I

[ ]Meclium!High

Rationale (required ifdifferent from recommendation):.___________________
�

SE CTION IV.

HOUSI NG ASSIGNMENT

Final Classification and Housing assignment are:
[ ]High

[

] Medi wn/High

STEA SIGNATURE:

[ ] M

(b)(6); (b)(7)(C)

--------1

] Ad min. Segregation(Memo req.)

DATE: ____Cj_· _�j_!_______________

 �

...,

��

•

STATE FILE NUMBER

NEW JERSEY DEPARTMENT OF HEALTH

20170034594

CERTIFICATE OF DEATH

1a. Legal Nome of Occedonl (First, Middle, Last. Suffix)

LIMB
0NL1

Carlos Armando Bonilla

1b. Also Known As (AKA), If Any (First, Middle, Last, Sufflx)
Rolando Arnolfo Meza

2. Sox
,3. Sod�l Sccuritv Number
Malo
Lth\/R\
6. Birthplace (City & State/Foreign Country)
la Union, El Salvador
7a. Residence .Slate
1 7b. Counly
Suffolk
New York
7d Stteet and Number
12 Linda Lane
If Yes. Name of War:
Ba. Ever In US Armed Forces?

lab.

9. Domestic Status at Time ol Death
SlnnlefNever Married
11. Father's Nemo (First. Middle, Last)

No

,n,11:.,-

1 4a.Age
43 Yoars
170. Apl No,

15. Dalo of Birth (Mo/Day/Yr)
09/23/1973

7c. MunlCtpality/City
Contral lslln
,71. Zip Codo
11722
8c. War Service Dates (From/To):

110. Nomo of Surviving Spouse/Portner (Namo given at bfrlh or on bir1h certificate)

12. Molher's Name Prior to Flr,1 Marriage (First, Middle, Lest)

1•·

lh\lg\-

...

I

13b. Rclallonshlp 10 Decedent
Dauahter

on,

1'.k. Maillnn Address IStmet and Number. City, Stats, Zip Code)

(b)(6);

14. Method of Olsposlllon
fh\f�\- fh\17\fr\

Burlal

I

15. Placo of Disposition /name of cemotery. crematory, othe�
Queen of All Saints Cemetery

17. Nome end Complete Address of Funeral Facility
Grant Funeral Homes Inc. 571 Sulfolk Ave., Brentwood NY 11717
18, E�ttonic Signature of Funeral DlfCClor

<Donna IIJustamantc

16. Location- Cily & Slale/Forelgn Count,y
1
Central Islip, New York United St�tc1
1

21. Decodenl of Hispanic Origin?
1
Other Hispanic: Salvadorian

20, Decedent Educ.:iUon

9th through 12th grade; no dlploma

23. Occupation of Decedcnl (Typo of work done most of ffe, even if retired) 124, Kind of 8uslnessnndus1,y
Construcllon
Mason
25. Name and Address of Los! Employer
M and B Long Island Construction,•, Brentwood, NY 11717
28. Name of Person Pronouncing Death
26. Dote Pronounced Dead (Mo/Day/Y"
1
06/1012017
27. Time Pronounced Dead (24•hrJ
2312
31. Dato ol Oealh (MOIDay/Yf)
Approx--0611012017

710. Inside Cfty Llmlls?
Yes

19. NJ Ucenso Number
23JP00509800

22. Dceedcnt Raco
White

<Dliruv 'llasa11t

1

J 29. License Number
Medical Resident
32.
of Dealh /24-hr)

nme

2312

130. Dale Signed (Mo/Day/Yr)
06110/2017
34. Place of Oealh
33. Was Modlcal Examiner Conlacted?
1
1
Hospital: Inpatient
Yes

35a, Facility Name (ff not lnsritutkm, give sheet and num�r)
Jersey City Medical Cenlor
35c. County
35b. Municlpahty
Hudson
Jorsov Citv
36a.
PART
I
•
IMMEDIATE
CAUSE·
final
disease
or
condition
resulllng
In doalh. SubscquenUy list conditions,If any, leading to
CAUSE OF DEATH: 1
· lhe cause listed on line a, Enter !he UNDERLYING CAUSE {disease or lnlurv that initiated the events rcsull.in" in death\ LAST.
Interval Between Onsel and Deolh
Immediate Cause
3 days
a. Gast,o,intesllnal hemorrrhage

Duo to (or as a consequence of):
b. Chronic. alcoholism
Due to (or as a consequence of);

unknown years

Due to (or as a consequence of):
d.
3Gb. PART II • Enter other sigrnficant conditions contnbuting to deolh but not resulllng In
undcr1ying cause given in PART I.
C.

39. Dale or Injury (Mo/Day/Yrj
Reeo<d
Contoms
Amendment

□

37. Was an Autopsy Performed?
No
38. wc,e Autopsy Findings Available 1 0 Complete Causo o f
Doalh?
Not A ppllcnble
142. Injury at work?
140. Time of Injury (24•hQ 141. Pl.ace of Injury (e.g. home, conltruction site, resu,urant)

46. Manner of Death

Natural
50. Certifier Typo

Medical Eumlner

52. Electronlc Signature of Certifier

'Etftfy J £ifavois

143d. S!alo

143c. County

]43b. Municipality

438. LocaUon of Injury (Number and Street, Zip Code)

44. Describe How Injury Occurred

1

•s. If TransportaUon Injury:

47. Did Ooccdcnt •B. Old Tobacco Uso 49. If Fcmoro, Pregnancy Slate
IHave Oiabc\cs? 1 Cont,,buto lo Death?
Unknown
Not applicable
Yes
151. Nomo. Address, and Zip Codo of Certifier
Eddy J Lllavols, M.O,
325 Norfolk St, No,wark, NJ 07103
53. License Number
25MA06385200

56. Dl!:ltiCl No.

55 Eleclt'on!c Signt,.turo of l�I Rog1stmr

V0236

£aura 'Frencfi

DATE ISSUED: July 26, 2017

,54.

57. Dote Recolvcd
1
06/19/2017

ISSUED BY:

Jersey City, Room 118
Tamika Harmon, Alternate Deputy Registrar
Th i s i s to cert ify that the above i s correctly copied
from a record on file in my office.
•
Certified copy not valid unless the raised Great
('\
Seal of the State of New Jersey or the seal of the
-.....>v�
issuing municipality or county, is affixed hereon. ---='--- _ _
V_ _ A..:.._rr--'
i nce_nt_ .:..T_
isi -=-.:....:=:::......State Regi strar
Off i ce of Vital Stat i st i cs and Reg i stry

\J

Cole Certified (Mo/Day/Y1

l . l...Jvv:::::

-f

0611412017

Casa 10 Number
1924401

 This NJ certificate document Is printed with a Custom "NJ Vital Records"
watermark. Please HOLD at a light to verify its authenticity.
Additional security features Include but are not limited to the following:
multi-colored background with enhanced VOID pantograph, micro-line
prinllng, bright fluorescent orange numbering, Invisible fibers and other
security features.

 DETAINEE DEATH REVIEW -Carlos Armando METIA-Bonilla
TICMS #201708095
SYNOPSIS
On June 10, 2017, Carlos Armando MEJIA-Bonilla, a forty-three-year-old citizen of El Salvador
died while in the custody of U.S. Immigration and Customs Enforcement (ICE) at the Jersey City
Medical Center (JCMC), in Jersey City, New Jersey (NJ). 1 The New Jersey Department of
Health Certificate of Death documented MEJIA' s cause of death as gastrointestinal hemorrhage
due to chronic alcoholism. 2
MEJIA was detained at the Hudson County Department of Correctiona1 Rehabilitation
(HCDCR), in Kearny, NJ, from April 1, 2017 to June 10, 2017. HCDCR is governed under an
Intergovernmental Service Agreement (IGSA) and is owned and operated by the Hudson County
Department of Corrections. HCDCR is contractually obligated to comply with the ICE
Perfo1mance Based National Detention Standards (PBNDS) 2008. Medical care at HCDCR is
provided by Hudson County and supported by Center for Family Guidance (CFO), a contract
company. At the time of MEJIA's death, HCDCR housed approximately 591 male and 43
female detainees of all classification levels for periods in excess of 72 hours.
DETAILS OF REVIEW
From August 8 to 10, 2017, ICE Office of Professional Responsibility, External Reviews and
Analysis Unit (ERAU) staff visited HCDCR to review the circumstances smTounding MEJIA's
death. ERAU was assisted in its review by contract subject matter experts (SME) in correctional
healthcare and security. ERAU's contract SMEs are employed by Creative CoITections, a
national management and consulting fim1. 3 As part of its review, ERAU reviewed immigration,
medical, and detention records pertaining to MEJIA, in addition to conducting in-person
interviews of individuals employed by HCDCR, CFO, and the local field office of ICE's Office
of Enforcement and Removal Operations (ERO).
During the review, the ERAU review team took note of any deficiencies they observed in the
facility's compliance with the detention standards as they related to the care and custody of the
deceased detainee and documented those deficiencies herein for informational purposes only.
Their inclusion in this repo1t should not be construed in any way as indicating the deficiencies
identified conu·ibuted to the detainee's death. ERAU dete1mined the following timeline of
events, from the time of MEJIA's apprehension by U.S. Border Patrol (USBP), through his
detention at HCDCR, and eventual death at JCMC.
IMMIGRATION AND CRIMINAL HISTORY
On August 20, 1993, MEJIA unlawfully entered the United States near Douglas, Arizona.4
1 MEflA entered ICE custody under the false identity of Rolando Arnulfo MEZA-Espinoza. This report refers to the
detainee by his verified true identity, Carlos Armando METTA-Bonilla.
2 Gastrointestinal hemorrhage refers generally to bleeding in the gastrointestinal tract, from the mouth to rectum.
3
See Exhibit 1: Creative Corrections Security and Medical Compliance Review.
4
See INS Form 1-221, Order to Show Cause and Notice of Hearing, dated August 21, 1993.

1

 DETAINEE DEATH REVIEW -Carlos Armando METIA-Bonilla
TICMS #201708095
On August 21, 1993, USBP encountered MEJIA near Indio, California and served him with an
Order to Show Cause and Notice of Hearing, charging him with inadmissibility pursuant to
Section 241(a)(l )(B) of the Immigration and Nationality Act (INA or the Act), as amended, for
entry to the United States without inspection. 5 That same day, USBP released MEJIA on his
own recognizance, citing a lack of detention space. 6
On March 15, 1999, MEJIA applied for Temporary Protected Status (TPS) under the alias
Rolando Arnulfo Meza-Espinoza of Honduras. 7
On February 5, 2001, the U.S. Immigration and Naturalization Service (INS) denied MEJIA's
TPS application on the basis that he previously presented his identity to an immigration officer
as Carlos Armando MEJIA-Bonilla of El Salvador and was therefore ineligible for TPS status as
a Honduran national. 8 On July 30, 2001, MEJIA appealed this decision. 9
On January 10, 2002, INS granted MEJIA TPS under the alias Rolando Arnulfo Meza­
Espinoza. 10
On October 6, 2009, the Suffolk County Court of the State of New York convicted MEJIA
(under the alias Meza) of driving under the influence of alcohol and sentenced him to three years
of alcohol treatment and a fine. 11
On November 25, 2014, the Suffolk County Court convicted MEJIA (under the alias Meza) of
aggravated driving while under the influence of alcohol, and sentenced him to three years
conditional discharge, 18 months with a suspended driver's license, and a fine. 12
On April 1, 2015, U.S. Citizenship and Inunigration Services (USCIS) withdrew MEJIA's TPS
approval, citing his felony conviction. 13

5
See INS Form I-213, Record ofDeportable/Inadmissible Alien, dated August 21, 1993; see INS Form I-221, Order
to Show Cause and Notice of Hearing, dated August 21, 1993.
6
See INS Form I-213, Record of Deportable/foadmissible Alien, dated August 21, 1993; see USBP Memorandum to
File, dated August 21, 1993.
7
See INS Form I-821, Application for Temporary Protected Status, dated March 15, 1999.
8 See Form M-344, TPS Notice (denial), dated February 2, 2001.
9
See Form I-290B, Notice of Appeal or Motion, dated July 30, 200 l.
10 See ICE Significant Incident Notification, dated June 10, 2017; See INS Form I-821, Application for Temporary
Protected Status, stamped January 10, 2002.
11
See ICE ENFORCE Alien Removal Module (EARM) C1ime Log, accessed December 20, 2017; See U.S,
Citizenship and Immigration Services Decision letter, dated Ap1il 1, 2015; see ICE Significant Incident Notification,
dated June 10, 2017.
12
See County Court of the State of New York, Suffolk County, Certificate of Disposition indictment, dated January
13, 2015.
13 See USClS Decision letter, dated Apri.1 l , 2015.

2

 DETAINEE DEATH REVIEW -Carlos Armando METIA-Bonilla
TICMS #201708095
On April 1, 2017, ICE ERO New York arrested MEJIA in Central Islip, New York (NY) (under
the alias Meza). 14 MEJIA was processed at the Varick Street Processing Center and booked into
HCDCR (under the alias of Meza) that same date. 15
On May 4, 2017, ICE ERO New York served MEJIA a Notice to Appear charging him as
inadmissible pursuant to Section 212(a)(7)(A)(i)(I) of the INA. 16 MEJIA remained in removal
proceedings, and the Executive Office for Jmmjgration Review scheduled his hearing before an
immigration judge for June 15, 2017. 17
NARRATIVE
On April 1, 2017, at 6:45 p.m., MEJIA arrived at HCDCR. 18 fb)(6); (b)(7)(C)
!conducted
the detainee's intake processing and documented MEJIA denied any medical problems or taking
any prescribed medication. 19 Although l(b)(6); (b)(?)(C) !documented MEJIA' s primary language
was Spanish and that he required an interpreter, 20 !<bl!6l: lbl/7\/Cl � stated he conducted MEJIA's
intake in English and did not use language interpretation assistance. 21
tb>(5); (b)(?)(C)

!inventoried and receipted MEJIA' s funds and personal property. 22 According to
the valuables receipt, MEJIA mTived with a New York identification card which was secured
with his personal property, rather than provided to ERO for inclusion in hjs alien file as required
by the PBNDS 2008. 23 ERAU notes the property and valuables receipts Kbl(6); (b)(7)(C) !provided
MEJIA to sign were written and completed in English rather than the detainee' s reported
language of Spanish. ERAU notes that although all available documentation and interviews with
HCDCR staff indicate MEJIA had limited English language proficiency, all written
communications he received from facility staff were in English.
At 8: 15 p.m., MEJIA signed an English version of the Informed Consent to Medical Services
form, 24 and HCDCR l(b)(6); (b)(7)(C)
I completed MEJIA' s medical and
25
mental health intake screening and documented the following:

See ICE Significant lnc.ident Notification, dated June I 0, 2017; see ICE Form T-213, Record of
Deportable/Inadmissible Alien, dated April I, 2017.
15
See ICE Significant Incident Notification, dated June 10, 2017; see ICE Form T-213, Record of
Deportable/Inadmissible Alien, dated April I, 2017.
16
See ICE Significant Incident Notification, dated June 10, 2017.
17
See ICE Significant Incident Notification, dated June 10, 2017.
18
See New Jersey County Correction Information System (NJCCIS) Inmate Information, accessed August 8, 2017.
19 The Intake Risk Assessment is a standard set of seven questions relating to medical, mental health, and security,
asked by the intake officer. See NJCCIS Intake Risk Assessment, dated April I, 2017.
20 See NJCCIS Background Information, accessed August 8, 2017.
,.,,..,...,.""'"....,,..,...,="".,.,
21 ERAU
interview withKb)(6); (b)(7)(C)
i August 8, 2017; t(b)(6): (b)(7)(C)!stated he occasionally uses Spanishspeaking coworkers for interpretation assistance, but he did not remember whether a coworker assisted him with
MEJIA.
22 See Hudson County Correction Center Property Receipt, dated April 1, 2017; see Hudson County Correctional
Center Property (Valuables) Receipt, dated April 1, 2017.
23 See Hudson County Correctional Center Property (Valuables) Receipt, dated April 1, 2017.
24
See HCDCR Informed Consent to Med.ical Services, dated April 1, 2017.
25 See Exhibit 2: HCDCR Nurse Intake Encounter, dated April 1, 2017.
14

3

 DETAINEE DEATH REVIEW -Carlos Armando METIA-Bonilla
TICMS #201708095
•
•
•
•

MEJIA's vital signs were within normal limits 26 with the exception of an abnormally
high blood sugar level of 253.
MEJIA did not require an interpreter. 27
MEJIA's mental health and suicide risk assessments were no1mal.
MEJIA reported a history of type 2 diabetes for which he took prescription metformin,28
normally filled at the Brentwood Pharmacy in Long Island, NY.

As a result of the detainee's history of diabetes, his elevated blood sugar level, and his need for
an evening dose of metformin, �b)( 6); (b)( ?)(C) referred MEJIA to a provider as an urgent priority.
A provider saw him approximately one hour later. 29

I

ERAU notes CFG's Clinical Care Guidelines require nursing staff to verify and confirm a
patient's medication with the dispensing pharmacy or the prescribing practitioner and complete a
medication verification form at the time of intake. 30 Although MEJIA informed l{b}{6); (b}(7)(C) of
the pharmacy dispensing his diabetes medication, f bl(6); (b)( ?)(C) �id not verify the detainee' s
medication during his intake screening and did not complete the medication verification form. 31
As a result, medical staff did not request MEJIA's medication records untill(b)(6); (b)( ?)(C)
j(b)(6); (b)(7)(C)
!instructed an RN to do so on April 3, 2017.32

I

I

MEJIA's intake screening was not signed by j(b)(6); (b)(7)(C)
iHCDCR' s Clinical Director,
nor her designee, in contravention of the PBNDS 2008. On April 4, 2017, at 9:41 a.m.,l(b)(6);�·
l<bl/6l
I HCDCR's psychologist, reviewed and signed MEJIA's intake screening for mental
health screening. 33

At 9:24 p.m.,l(b)(6); (b)(?)(C) pompleted MEJIA' s initial health appraisal and documented the
following: 34

26 Normal temperature is 98.6; normal range for pulse is 60 to 100 beats per minute; normal range for respirations is
12 to 20 breaths per minute; and, nmmal blood pressure is 120/80, with 90/60 to 139/89 considered within normal
range.
27
During her interview with ERAU on August 8, 2017,Kb)(6);
stated she is not fluent in Spanish and
conducted the screening in English. She could not recall MEJLA's English language proficiency level but surmised
the detainee must have spoken some English for her to not use an interpreter.
28
Metformin is a prescription medication for diabetes.
29 At HCDCR, a nurse who refers a detainee to a provider is responsible for scheduling that detainee for the provider
appointment.
30
See CFG Clinical Care Guidelines 2016.
31
See HCDCR Nurse Intake Encounter, dated April I, 2017; ERAU interview witbl(b)(6); (b)(7)(C)
August
8, 2017.
32
did not recall which RNl(b)(6); �I August 8, 2017. j(b)(6);
ERAU interview with l(b)(6); (b)(7)(C)
instructed to request the records, andKb)(6); (b)( 7)(C)
lwas terminated prior to ERAU's onsite review and was
unavailable for interview.
33
!/ b)/6):
!was not identified as a designee forl(b)( 6); _.
34 See Exhibit 3: HCDCR Provider Intake Encounter, dated April l, 2017.

I

I

I

I

4

 DETAINEE DEATH REVIEW -Carlos Armando METIA-Bonilla
TICMS #201708095
•
•
•
•
•

MEJIA reported a history of depression, type 2 diabetes, 35 cirrhosis of the liver, 36 and
anemia. 37
MEJIA reported taking medication but could not remember the names of his medications.
MEJIA's physical examination yielded no1mal results.
MEJIA reported a history of anemia, depression, cirrhosis, hypertension, and diabetes. 38
fb)(6); (b)(7)(C) ordered Glucophage 39 500 mg twice daily, and a 2200-calorie diabetic diet.

I

Although fb)(6); (b)(?)(C) !included depression on MEJIA 's problem list and noted he required
referra] for a mental health assessment, she did not schedule the mental health appointment. As
a result, MEJIA was never evaluated or treated for his reported depression. Additionally, as
noted by Creative CoITections, fbl(B); (b)(?)(C) practitioner plan of care did not address MEJIA's
stated
reported conditions of hypertension, anemia, and cirrhosis. CFG physician!(b)(6); (b)(?)(C)
CI bl (6J; (b)(7)(C) I should have ordered blood pressure monitoring, a low sodium diet, and diagnostic
testing, including testing to determine iron and liver function blood levels. 4° Creative
Co1Tections notes that although fb)(6); (b)(?)(C) appropriately identified MEJIA as a chronic care
patient, she failed to schedule him for a chronic care appointment.j(b)(6); (b)(7)(C) lalso did not
document if language interpretation assistance necessary or utilized during the encounter.

I

I

I

I

Neither ICb)(B); _.
nor her designee reviewed and signed the initial health appraisal. During her
stated
interview with ERAU, l(b)(6); (b)(?)(C)
she was unaware of the PBNDS 2008 requirement for the clinical medical authority to review all
intake screenings and initial health appraisals to determine care priority. 41

I

MEJIA's Medication Administration Records (MAR) show that he received his first dose of
metformin the evening of April 1, 2017 and received all required subsequent doses during his
detention at HCDCR.42

On April 2, 2017, at 6:24 a.m., HCDCR transfen-ed MEJIA to housing unit Alpha 300 East, cell
414 while he awaited custody classification.43 HCDCR designates this unit for pre-classification
detainees.

I

On April 3, 2017, Classification Agent�b)(B); (b)(?)(C)
completed MEJIA' s initial custody
classification and appropriately assigned him low custody based on the severity of his most

35

Type two diabetes is a chronic condition where the body is resistant to insulin.
Cirrhosis is a condition whereby chronic Liver cell damage leads to scarring and liver failure.
37 Anemia is a medical condition wherein the blood does not contain a sufficient number of healthy red blood cells.
38
ERAU notes METIA never recieved medication to address his hypertension, anemia, or liver disease during his
detention at HCDCR.
39
Glucophage is a brand of metformin.
40
ERAU interview with (b)(6); (b)(?)(C) August 8, 2017.
41
ERAU interview with (b)(6); (b)(?)(C)
August 8, 2017.
42
See Medication Administration Record, April-June, 2017
43
See NJCClS Cell Assignment, accessed August 8, 2017; ERAU interview with Kb)(6); (b)(7)(C)
l August 10,
20[7.
36

5

 DETAINEE DEATH REVIEW -Carlos Armando METIA-Bonilla
TICMS #201708095
recent charge and conviction hjstory. 44 ERAU notes this classification was completed more than
24 hours after hls arrival at HCDCR, in contravention of the ICE PBNDS 2008.
At 8:24 a.m., HCDCR faxed MEJIA's Release of Information Authorization, signed by the
detainee on April 1, 2017, to Brentwood Phaimacy of Long Island, NY, for release of records to
review and verify the detainee's existing medications. 45
On this same date, MEJIA received a chest x-ray which showed no evidence of tuberculosis,
pulmonary edema, or heart disease. 46
On April 4, 2017, at 4:28 p.m., HCDCR transferred MEJIA from the pre-classification area to
general population housing unit Alpha 300 West, cell 307. 47
On April 6, 2017, HCDCR medical staff received MEJIA's medication list from Brentwood
Pharmacy which included the following prescriptions:48
•
•
•
•
•

Antihypertensive 49 medications spironolactone and lisinopril, once daily,
Iron supplement Ferosol, twice daily,
A multivitamin, once daily,
Vitamin thiamine, 50 once daily, and;
Metformin twice daily.

A provider did not review this information upon receipt.
On April 14, 2017, at approximately 11 :55 a.m., HCDCR Kb)(6); (b)(7)(C)
f 1 encountered
MEJIA in response to two sick call requests for a blood test and complaints of feeling weak and
needing eyeglasses to see, and documented the following: 52
•
•

MEJIA's vital signs were within normal limits, with the exception of a mildly-elevated
blood pressure of 134/83.
MEJIA reported experiencing nosebleeds.

44

See Exhibit 4: ICE Detainee Classification System - Primary Assessment Form, dated April 3, 2017. ERAU
notes this classification was completed more than 24 hours after his arrival at HCDCR, in contravention of the ICE
PBNDS 2008.
45 See CFG Health Systems, LLC Release of Information Authorization, dated April 3, 2017.
46
See Mobilex USA Radiology Report, dated April 3, 2017. ERAU notes the TB screening was completed more
than 12 hours after the detainee's arrival at HCDCR, in contravention of the PBNDS 2008.
47 See NJCCIS Cell Assignment, accessed August 8, 2017.
48 See HCDCR Nurse Sick CalJ Encounter, dated Aptil 14, 2017; See HCDCR Vision Exam Encounter, dated April
14, 2017.
49
Hypertension refers to high blood pressure.
so Thiamine is vitamin B1, which is often depleted in Iiver disease related to alcohol abuse.
51
Becausel/bl/6l: /b\(7)/Cl
!was no longer employed at HCDCR at the time of the site visit, ERAU was unable to
determine her level of proficiency in Spanish.
52 See HCDCR Nurse Sick Call Encounter, dated April 14, 2017.

6

 DETAINEE DEATH REVIEW -Carlos Armando METIA-Bonilla
TICMS #201708095
• fb)(6); (b)(7)(C) pssessed MEJIA's visual acuity using the Snellen eye test,53 and found
vision deficits of 20/50 in the left eye, 20/40 in the right eye, and 20/50 in both eyes.
o l(b)(6);(b)(7)(C) I noted MEJIA wore prescription glasses but did not note whether the
glasses were in the detainee's possession or worn dming the acuity testing.
ERAU notes eyeglasses were not listed on MEJIA's personal property inventory.
Despite the visual acuity findingsJb)(6); (b)(?)(C) I did not refer MEJIA for
examination by an optometrist. 54
• MEJIA reported a history of cataracts and vision changes in the past six months.
l(b)(6); (b)(?)(C)

I did not document use of an interpreter and did not refer MEJIA to a provider.
I

On April 25, 2017, at approximately 10:00 a.m., HCDCR �b)(6); (b)(?)(C)
encountered
MEJIA in response to his sick call request for cough medicine and iron for his anemia, and
documented the following: 55
• MEJIA complained of a cough and sore throat.
• MEJIA's vital signs were within no1mal limits.
• MEJIA reported no pain.
• tb)(6); (b)(7)(C) I ordered the following medication for MEJIA:
o Tylenol twice daily as needed for pain;
o Guaifenesin twice daily as needed for cough; and 56
o Chlorpheniramine maleate twice daily as needed for cold symptoms. 57
!(b)(6 ); (b)(7)(C) I did not document use of an interpreter, and did not address MEJIA' s request for an
iron supplement.
On May 3, 2017, at 12:55 p.m.. l(b)(6);(b)(7)(C) !encountered MEJIA in response to his sick call
request for cough medicine and complaint of constipation and feeling ill. 58 MEJIA's vital signs
were within normal limits and b)(6);(b)(7)(C) provided the detainee Tylenol for his pain and
guaifenesin for his cough. (b)(5); (b)(?)(C) did not address MEJIA's complaints of consti ation,
sleep difficulty, and stomach problems, nor did she refer him to a provider. b)(6); (b)(?)(C) did
not document use of an interpreter.
On May 11, 2017, at approximately 1:00 p.m.,!(b)(6);(b)(7)(C) !encountered MEJIA in response to
his sick call complaint of a chest and throat infection and an itchy rash, and documented the
following: 59
53

The Snellen test assesses vision by way of an eye chart.
The failure to refer METIA for examination by an optometrist is in contravention of the PBNDS 2008.
55 See HCDCR Nurse Sick CalJ Encounter, dated Ap1il 25, 2017. MEJIA submitted this sick call request on April
23, 2017; see HCDCR Medical Department Request Form, dated April 23, 2017.
56
Guaifenesin is a cold and cough medicine also known under the brand Mucinex.
57
Chlorpheniramine maleate is an antihistamine used to prevent allergy symptoms.
58 MEJIA submitted this sick call request on April 30, 2017; see also HCDCR Medical Department Request Form,
dated April 30, 2017 and HCDCR Nurse Sick Call Encounter, dated May 3, 2017.
59
MEJIA submitted this sick call request on May 8, 2017; see HCDCR Nurse Sick Call Encounter, dated May 11,
2017.

54

7

 DETAINEE DEATH REVIEW -Carlos Armando METIA-Bonilla
TICMS #201708095
•
•

MEJIA reported nasal congestion, a sore throat, and an itchy rash on his upper body.
MEJIA presented with skin dryness and pen-point size redness on his upper chest and
bilateral upper extremities.
• MEJIA's vital signs were within normal limits.
• tb)(6); (b)(?)(C) I ordered the following medication for MEJIA:
o Clotrimazole, an antifungal cream, appljed twice daily to rash area;
o Chlorphenirarnine maleate twice daily as needed for allergy symptoms; and,
o Tylenol twice daily as needed for pain.
l<b)(6); (b)(?)(C) I did not document if an interpreter was used for this encounter, 60 nor did she
document whether she examined MEJIA's throat for his complaint of pain.
On May 18, 2017, at 12:08 p.m., Kb)(6); (b)(?)(C) I encountered MEJIA in response to his sick call
complaint of recurring dizziness and documented the following.61
•
•
•
•

MEJIA's vital signs were within normal limits.
MEJIA reported no pain.
MEJIA reported a history of auemia 62 with recurring dizziness.
RN Bernardo encouraged MEJIA to drink fluids and told the detainee he would be seen
by a provider. ERAU notes i<b)(6); (b)(?J(C) I did not refer MEJIA to a provider for follow­
up.

i<b)(B); (b)(?)(C)

I did not document if an interpreter was used for this encounter.

On May 30, 2017. �b)(6); (b)(?)(C)
b-enewed MEJIA' s order of metformin twice daily. 63
i<b)(6);
!completed this order without evaluating MEJIA or his medical record. 64
On June 6, 2017, at 10:35 a.m., MEJIA arrived in the medical unit complaining of left elbow
pain resulting from a fall in the shower the previous day. 65 HCDCR !(b)(6) ; (b)(?)(C) I observed the
detainee' s elbow was red and swollen with limited range of motion. J(b)(6); (b)(?)(C) I did not
document MEJIA's pain level. kb)(6); (b)(?)(C) !also addressed MEJIA' s complaint of fever during
the encounter. She noted MEJIA's vital signs were within normal limits, with the exception of
an abnormally elevated blood pressure and pulse of 160/90 and 102, respectively. fb)(6); (b)(?)(C)
did not document use of an interpreter during this encounter.

ERAU was unable lo determine bow MEJIA communicated these detailed medical complaints to fb)(6); (b)(?)(C) I
given his 1.imited English proficiency and Kb)(6); (b)(?)(C) !omission of documentation of the language used during
this encounter.
61 See
HCDCR Nurse Sick Ca!J Encounter, dated May 18, 2017.
62 Conm10n symptoms of anemia include tiredness, fatigue, shortness of breath, rapid heartbeat, dizziness, and pale
skin.
63
See HCDCR Chart Maintenance note, dated May 30, 2017.
64 ERUA interview with l(b)(6) : (b) {?) {C)
I August 9, 2017.
65
See HCDCR General Note, dated June 6, 2017.
60

8

 DETAINEE DEATH REVIEW -Carlos Armando METIA-Bonilla
TICMS #201708095

I

Following the encounter, Kb)(6); (b)(7)(C) stated she refeITed MEJIA to l(b)(6); (b)(7)(C)
HCDCR's part-time orthopedic 66 physician, as he was the available provider at the time.67
! examined MEJIA's elbow and observed some swelling, redness, and increased skin
l(b)(6);
temperature. To prevent the possible development of cellulitis, 68 I<�)(�);___
jplaced MEJIA on
!noted
the antibiotics clindamycin 300 mg, once daily, and Bactrim DS, twice daily. 69 Kbl(6);_
�b)(6);
ltbe following day, but he did not
MEJIA should receive a follow-up assessment with
did
not
examine
MEJIA the following day. 70
schedule an appointment, and therefore��(��(;,._,
l
Later that morning, when,�?\�?;,.,,
arrived for his shift, (b)(6); (bl(7)(C)
riefed him on MEJIA's
5
)(C)
(b)(
(
(b
general health. After the conversation with l ); ?
,�!\�L, ordered an elbow x-ray and
blood tests for MEJIA, and prescribed the detainee enteric-coated naproxen twice daily for
pain.71 [�!\�L,
I received the blood test results the following day and noted they were
inconclusive because the samples contained clots and could not be processed. 72
At 11: 17 a.m., MEJIA received the x-ray which showed the detainee's left elbow joint was intact
and without any fracture or dislocation. 73

June 8, 2017, Day of Medical Emergency
At approximately 4:30 a.m., detainees in Alpha 300 West scheduled for court and diabetic
medical checks began exiting their cells to the unit's dayroom to await escort from an officer. 74
As MEJIA exited his cell, at approximately 4:33 a.m., he stumbled and had difficulty walking.
As two nearby detainees assisted MEJIA to a table in the dayroom, housin unit !(b)(6); (b)(7)(C)
ICb)(6); . !observed and approached the table. 75 MEJIA info1med (b)(6); (bl(7)(C)
in Spanish he was
diabetic and did not feel well. 76

Orthopedics is a medical discipline focused on the skeletal (bone) system.
ERAU interview with!(b)/6): (b)(7)/C)
!August 8, 2017.
68
Cellulitis is a potentially serious bacterial skin infection.
69
See HCDCR Orthopedic Practitioner Exam, dated June 6, 2017.
70
�b)(6);
ERAU interview with l(b)(6); (b)(7)(C)
I August 8, 2017; during her interview with ERAU, �--�
�id not correctly schedule the intended appointment.
confirmedl(b)(6);
71
See HCDCR Chart Maintenance: LABS, dated June 6, 2017; Naproxen is also known by the bra11d name AJeve.
Blood tests ordered were a complete blood count (CBC) with differential (part of a complete blood count which
looks at the various subtypes of blood cells for greater diagnostic ability), an eight-test chemistry panel (a
comprehensive group of blood tests to assess various physical and chemical processes in the body), and a diabetes
panel.
7
2 kb)(6);
I received and reviewed the blood test results the morning following the lab order, after MEJIA was
transferred to the hospital on June 8, 2017.
73
See Mobilex USA Radiology Report, dated June 6, 2017.
74
See video surveillance footage, June 8, 2017. ERAU viewed HCDCR's video surveillance footage during the
onsite review.
15
See video surveillance footage, June 8, 2017.
76 See!(b)(6); (b)(7)(C)
!Incident Report, dated June 8, 2017. kb)(6); (b)(7)(C) !speaks and understands Spanish.
66

67

9

 DETAINEE DEATH REVIEW -Carlos Armando METIA-Bonilla
TICMS #201708095
At 4:38 a.m., �b)(6); (b)(7)(C)

!called a Code White (medical emergency) via radio. 77

At 4:39 a.m., HCDCRkb)(6); (b)(7)(C)
!arrived in the unit, followed seconds later by CFG
l(b)(6); (b)(7)(C)
and
HCDCR
kbl(6l
(bl/7)/Cl
lwho brought a gurney, 78 andkb)(6); (b)(7)(C) I
I
!lbl/6\:
I who observed MEJIA appeared shaky and disoriented.79 As evidenced in the video
surveillance footage, the medical responders had difficulty lifting and securing the gurney into
place, but at 4:42 a.m., they assisted MEJIA onto the gurney, and at 4:43 a.m., medical staff
exited the housing unit with MEJIA.
At 4:46 a.m., the medical responders entered the medical unit with MEJIA. so Medical staff took
MEJIA's vital signs, provided him Gatorade to drink, and started an intravenous (IV) line. 81 l(b)(6)I
l(b)(6);
!documented the following:82
•
•
•
•
•

Upon response to the Code White, MEJIA appeared weak and pale and moved with a
slow steady gait.
MEJIA denied chest pain, palpitations, 83 shortness of breath, or nausea and vomiting.
Medical staff provided MEJIA with intravenous (IV) fluids.
MEJIA's vital signs were within n01ma] limits with the exception of an abnormally low
blood pressure of 80/50, an elevated and in-egular pulse of 108, and an elevated blood
sugar level of 146.
Medical staff provided MEJIA with supplemental oxygen via cannula. 84

At 5:42 a.m.JbH6): (b)(7)(C) I attended to MEJIA after he requested to use the bathroom to urinate
and stated he could walk there. 85 At 5:43 a.m.,l(b)(6); (b)(7)(C) attempted to help MEJIA off of the
gurney into a standing position but had to support the detainee to prevent him from collapsing.86
!(b)(6); (b)(7)(C) I noticed MEJIA was bleeding from his rectum, called out for assistance, and directed
nurses to call 911.87 At 5:44 a.m., other medical staff responded and assisted MEJIA into a
seated position on the gurney. 88 l(b)(6); (b)(7)(C) lone of the responding nurses, stated she
immediately noticed a bloody melena 89 substance on the floor next to the gurney. 90 At
prder. 91
approximately 5:45 a.m.Jbl(6); (b)(?)(C) lcalled 911 perfb)(6); (b)(7)(C)

I

I

BRAU interview withl(b)(6); (b)(7)(C)
!August 9, 2017. l(b)(6); (b)(7)(C) did not recall what accounted for the
delay in calling a medical emergency.
78
!Incident Report, dated June 8, 2017.
See video sw·veillance footage, June 8, 2017; see alsokbl/6): (b)(7)(C)
79
ERAU interview withl(b)(6); (b)(7)(C)
!August 9, 2017.80 See video sw·veiJlance footage, June 8, 2017.
80 See video sw·veiJlance footage, June 8, 2017.
81
See HCDCR Progress Note, dated June 8, 2017.
82
See HCDCR Progress Note, dated June 8, 2017.
83
A sensation that the heart is racing, pounding, fluttering, or skipping beats.
84 A cannula is a thin tube placed inside the nostriJs to administer supplementaJ oxygen.
85 ERAU interview with!lbl/6\: /bl/7\/C\
I August 9, 2017; see video surveillance footage, June 8, 2017.
86 See video surveillance footage, June 8, 2017.
87
ERAU interview with l(b)(6); (b)(7)(C)
!August 9, 2017.
88 See video surveillance footage, June 8, 2017.
89
Melena is dark, black, tarry stool.
90
ERAU interview with !(b)(6); (b)(7 )(C)
I August 9, 2017.
77

91

See id.

10

 DETAINEE DEATH REVIEW -Carlos Armando METIA-Bonilla
TICMS #201708095
!(b)(6); (b)(7)(C)
!was assigned to the medical unjt during this time and upon hearing the
2
nurses call for an ambulance, be alerted shift supervisor l(b)(6); (b)(7)(C)
!
f Kb)(6);
!(b)(6); lnotifiedl(b)(6); (b)(7)(C)
L the assigned transportation supervisor, that two officers
were needed to accompany MEJIA to the hospital.93 l<b)(6); (b)(7)(C) !assigned i<b)(6); (b)(l)(C)
!Cb)(6); (b)(7)(C) Ito ride in the ambulance and fb)(6); (b)(7)(C)
I to follow in the
chase vehicle. 94

I

At 5:58 a.m., an ambulance arrived at HCDCR. At 5:59 a.m., Emergency Medical Technicians
I anived in the medical unit.95 At 6:01 a.m.,
(EMT)fbl(6), (b)(?)(C)
medical staff assisted MEJIA into a wheelchair, and fbl(6); (b)(7)(C)
escorted the detainee and
96
EMTs to the ambulance.
The EMTs placed MEJIA in the ambulance, and at 6:20 a.m., the
ambulance departed HCDCR en route to JCMC.

I

!officers who transport and supervise detainees at the
According tcl,bl(5); (b)(l)(C)
hospital do not maintain a logbook. 97 Further, HCDCR medical staff did not obtain hospital
updates from JCMC regarding MEJIA's condition. Consequently, information related to events
after MEJIA departed HCDCR and while admjtted at JCMC is documented only in the JCMC
emergency department record. 98 During hls interview with ERAU Jb)(6); (b)(7)(C)
I stated
MEJIA was alert during the transport to JCMC and remained so while in the emergency room. 99
At approximately 9:08 a.m., JCMC admitted MEJIA to the intensive care unit (ICU) with an
upper gastrointestinal bleed. 100
At approximately 11:25 p.m., !Cb)(6); (b)(7)(C)
!(assigned to MEJIA's hospital post) notified
101
ICb)(6); (b)(7)(C)
I that hospital staff did not expect MEJIA to live through the night.
!(b)(6); (b)(7)(C) lalso mentioned MEJIA was in medical distress and bleeding internally. ��,?-!\�-\--.�1
l(b)(6); (b)(7)(C) !notified HCDCR fbl(6l; (bl(7l(Cl
l and ordered kbl(6l; (bl(7l(Cl
ICb)(B); (b)(l)(C)
� to notify ICE. At approximately 11 :45 p.m., fbl(6l; (bl(7)(Cl
!spoke with ICE
ICb)(6); (b)(7)(C)
land informed him of the detainee's
condition.
Between the time of his admission to the ICU and hls death on June 10, 2017, MEJIA' s blood
pressure continued to fall, and he received a total of 13 blood transfusions as episodic blood loss
in his stool persisted. 102 JCMC medical staff suspected the bleeding was the result of a
ERAU interview witlfb)(6) (b)(7)(C)
I August LO, 2017.
ERAU interview withj(b)(6), (b)(7)(C)
IAugnst 8, 2017.
94
!Incident Report, dated June 8, 2017.
See Sergeant fbH6):
95
See Intake Control Logbook, dated June 8, 2017; see also video surveillance footage, June 8, 20 I 7.
96 See Intake Control Lo ook, dated June 8, 2017; see also video surveillance footage, June 8, 2017.
r
97
ERAU interview withib)(6); (b)(7)(C)
L August 9, 2017.
98 HCDCR medical staff also failed to document the 911 call and eventual death in MEflA's medical record.
99 ERAU mterview with !(b)(6); (b)(7)(C)
IAugust 10, 2017.
100
See JCMC Emergency Department record, received June 12, 2017.
101
!Lncident Report, dated June 8, 2017.
See!(b)(6); (b)(7)(C)
102
See JCMC Emergency Department record, received June 12, 2017.
92

93

11

 DETAINEE DEATH REVIEW -Carlos Armando METIA-Bonilla
TICMS #201708095
variceal 103 bleed related to advanced ljver cirrhosis. 104 JCMC also performed an endoscopy 105
which showed MEJIA bad blood clots in hls esophagus, and that the bleeding was active. Liver
function tests inilicated MEJIA was experiencing liver shock. 106
!pronounced MEJIA
On June 10, 2017, at 11:12 p.m., JCMC physician!(b)(6);(b)(7)(C)
who
was
assigned
to
MEJIA
at
the
hospital
at the time, called
dead. 107 l(b)(6); (b)(?)(C)
I
8
(b)(7)(C)
!(b)(6); (b)(7)(Cl
!notified
land informed him of the detainee' s death.10 !(b)(6J;
l(b)(6); (b)(7 )(C)
lof
MEJIA'S death. 109
On June 11, 2017, at 2:09 a.m., the New Jersey Regional Medical Examiner's (ME) Office
accepted custody of MEJIA' s body.110
On July 26, 2017, the New Jersey Department of Health issued a Certificate of Death
documenting MEJIA' s cause of death as gastrointestinal hemorrhage due to chronic alcoholfam
and the manner of death to be natural.111 An autopsy was not performed.
After Action Review
Following MEJIA's death, CFO conducted an after-action review and developed a corrective
action plan addressing practice and procedures in several areas, including intake, sick calls,
refenals, medication verification, test orders and review, and documentation. 112 The conective
actions were implemented on an ongoing basis, beginning in June 2017.
!issued a memorandum to CFO Medical Director�b)(6ll
On July 3, 2017, l(b)(�); (b�(?)(C)
l\�/�L, I proviiling the following procedural updates regarding chronic care inmates and
detainees, effective immediately:113
1. Medical staff will cross-reference all new intakes' medical charts with the [Electronic
Medical Record] to ensure all information is accurate and consistent.
2. CFO will modify the [Electrnnic Medical Record] to send alerts to the provider whenever
medication or referrals need to be ordered.

3

Variceal refers to abnormal veins in the esophagus.
See JCMC Emergency Department record, received June 12, 2017.
105 An endoscopy is a procedure in which an instrument is introduced into the body to give a view of its internal
parts.
106 Liver shock is an acute liver injury caused by lack of blood and oxygen to the liver, usually due to low blood
pressure.
107
cidentReport, dated June 11, 2017.
See
108 See
cidentReport, dated June 11, 2017.
109
cidentReport, dated June 11, 2017.
See
110 See
tReport, dated June 11, 2017.
111
See Exhibit 5: Certificate of Death, New Jersey Department of Health, dated July 26, 2017.
112
See HCDCRICFG Corrective Action Plan, not dated.
113
See Chronic Care inmates/Detainees Memorandum, dated July 3, 2017.
10

104

12

 DETAINEE DEATH REVIEW -Carlos Armando METIA-Bonilla
TICMS #201708095
3. Medical staff will review the medical cha1ts of all new intakes referred for
medical/psychological appointments to ensure that they are scheduled for speedy follow­
up examination.
4. Medical staff will review the medical chaits of inmates/detainees cuITently housed at the
HCDCR who are classified as 'Chronic Care' to ensure continuity of care.
5. CFG will immediately notify ICE officials of all new detainees that are identified as
'Chronic Care' and will record the date, time and naine of the ICE official to whom the
notification was made in the detainee' s medical chart.
6. CFG will regularly communicate with ICE officials to discuss all 'Chronic Care' and
clinical detainee cases.
7. CFG will invite representatives from ICE to attend all Medical Audit Committee
meetings.
During his interview with ERAU.Kb)(6); (b)(?)(C)
I stated that when deemed appropriate and
ordered by the HCDCR Deputy Di.rector, the facility also conducts multi-disciplinary reviews
including both medical and security personnel. 114 l(b)(6); (b)(?)(C)
I did not order a
multi-disciplinary review in MEJIA's case.
MEDICAL CARE AND SECURITY REVIEW
ERAU reviewed the medical care HCDCR provided MEJIA, as well as the facility's efforts to
ensure that he was safe and secure while detained at the facility. ERAU found deficiencies in
HCDCR's compliance with certain requirements of the ICE PBNDS 2008: 115
1. ICE PBNDS 2008, Medical Care, section (V)(A) states, "Every facility shall directly or
contractually provide its detainee population: initial medical, mental health, and dental
screening, primary medical and dental care, emergency care, specialty healthcare, timely
responses, mental health care, and hospitalization as needed within the local community."
•
•
•
•
•

114
115

Despite MEJIA's repmt of anemia, hypertension, diabetes, and cirrhosis, the provider
conducting the initial health appraisal did not order blood pressure monitoring or
laboratory studies to determine treatment needs.
A provider did not review the list of medications received from MEJIA's outside
pharmacy. As a result, MEJIA was not ordered medication for anemia, hypertension,
and liver disease, creating a break in the continuity of his chronic disease treatment.
MEJIA submitted four sick call requests referencing his medical history of anemia,
high blood pressure, and cirrhosis, but RNs never referred him to a provider for
assessment.
On April 14, 2017, MEJIA's eye examination showed significant vision deficits but
l(b)(6); (b)(?)(C) ldid not refer him to a provider or eye doctor.
On May 11, 2017, l(b)(G); (b)(?)(C) I did not examine MEJIA's throat despite his
complaint of throat pain.

ERAU interview with!(b)(6); (b)( ?)(C )
I August 9, 2017.
See Exhibit l: Creative Corrections Security and Medical Compliance Review.
13

 DETAINEE DEATH REVIEW -Carlos Armando METIA-Bonilla
TICMS #201708095
•

On June 6, 2017, ��!\�!:�,
I noted MEJIA should receive a follow-up assessment
with b)(�); _
e following day, but �b)(6); (b)(7)(C) �id not schedule the appointment and
therefore (�\\�\;r1
did not examine MEJIA on June 7, 2017.

2. ICE PBNDS 2008, Medical Care, section (V)(C)(2) states, "All new arrivals shall receive
TB screening within 12 hours of intake and using methods in accordance with CDC
guidelines for non-minimal risk detention facilities."
•

MEJIA received a chest x-ray for tuberculosis clearance on April 3, 2017, more than
12 hours after his admission to HCDCR.

3. ICE PBNDS 2008, Medical Care, section (V)(I)(l) states, "The clinical medical authority
shall be responsible for review of all health screening forms within 24 hours or next
business day to assess the p1iority for treatment (for example, Urgent, Today, or
Routine)."
•

MEJIA'S medical intake screening was signed by a psychologist rather than the
Clinical Director or designated medical provider.

4. ICE PBNDS 2008, Medical Care, section (V)(I)(l) states, "Non-English speaking
detainees and detainees who are deaf or hard of hearing will be provided interpretation or
translation services or other assistance as needed for medical care activities. Language
assistance may be provided by another staff member competent in the language or by a
professional service, such as a telephone translation service."
•

Available documentation and interviews conducted by ERAU indicate MEJIA had
lin1ited English language proficiency. However, there was no documentation
evidencing that language interpretation assistance was used during any medical
encounter.

5. ICE PBNDS 2008, Medical Care, section (V)(J) states, "The clinical medical authority
shall be responsible for review of all health appraisals to assess the priority for
treatment."
•

The clinical medical authority or designee did not review and sign MEJIA' s initial
health appraisal.

6. ICE PNBDS 2008, Medical Care, section (V)(K)(4) states, "Any detainee referred for
mental health treatment shall receive a comprehensive evaluation by a licensed mental
health provider as clinically necessary, but no later than 14 days of the referral."
•

MEJIA reported depression during his initial health appraisal but he did not receive a
mental health assessment during his detention.

7. ICE PBNDS 2008, Medical Care, section (V)(M) states, "An initial dental screening
14

 DETAINEE DEATH REVIEW -Carlos Armando METIA-Bonilla
TICMS #201708095
exam shall be perlonned within 14 days of the detainee's arrival. If no on-site dentist is
available, the initial dental screening may be performed by a physician, physician
assistant, nurse practitioner, registered dental hygienist, or registered nurse."
•

MEJIA did not receive a dental examination.

8. ICE PBNDS 2008, Medical Care, section (V)(T) states, "Informed consent standards of
the jurisdiction shall be observed, and consent forms shall either be in a language
understood by the detainee or translation assistance shall be provided and documented on
the form."
•

HCDCR provided MEJIA the informed consent form in English. The medical record
does not contain documentation that medical staff translated the form for the detainee.

9. ICE PBNDS 2008, Admission and Release, section (V)(A) states, "Each detainee's
identification documents shall be secured in the detainee's A-file."
•

HCDCR secured MEJIA's identification documents in his personal property rather
than provide them to ERO for inclusion in the detainee's A-file.

10. ICE PBNDS 2008, Class�fication System, section (V)(B) states, "Detainees shall be
processed for housing assignments within twelve (12) hours of a1Tival at the facility.
Ordinarily, the initial assessment process shall be completed within twelve (12) hours of
admission to the facility. If the process takes longer, documentation will be maintained
as to what delayed the process and the detainee will be housed appropriately."
•

MEJIA anived at HCDCR on April 1, 2017, but HCDCR completed his initial
classification on April 3, 2017, more than 12 hours after his a1Tival and without
documenting what delayed the process. He was transfe1Ted to a general population
housing unit on April 4, 2017.

AREAS OF CONCERN
ERAU noted the following generalized concerns regarding MEJIA's medical care:
•

The HSA did not exhibit knowledge of specific ICE PBNDS 2008 medical care
standards, e.g. the HSA was not aware of the Clinical Medical Authority's
responsibility to ensure intake screenings and initial health appraisals are reviewed to
determine care priority.
• l(b)(6); (b)(7)(C) I andl\�/\�L.
I independently refe1Ted MEJIA to providers for evaluation,
but neither scheduled the appointments; consequently, they were not conducted.
• The medical staff who responded to the Code White struggled with the gurney for
two minutes. 116

116

HCDCR medical staff could not identify the cause or explanation for staffs difficulty with the g11rney.

15

 DETAINEE DEATH REVIEW -Carlos Armando METIA-Bonilla
TICMS #201708095
ERAU noted the following concerns related to documentation:
•
•

MEJIA's medical record ended with his transfer to JCMC. HCDCR medical staff did
not document in the medical record any hospital updates from JCMC, his death, or
the time 911 was called at HCDCR.
Although not required by the ICE PBNDS 2008, accountability and assurance of
events is supported by transport and vigil officers maintaining a log.

ERAU noted the following concern related to after-action reviews:
•

Although not required by the ICE PBNDS 2008, ERAU recommends HCDCR
conduct multi-disciplinary after-action reviews following a death, as both medical
and security staff play integral roles in the care and custody of detainees. After­
action reviews allow determination of adherence to or non-compliance with policy
and post orders, and identification of training needs.

16

 DETAINEE DEATH REVIEW -Carlos Armando METIA-Bonilla
TICMS #201708095
EXHIBITS
1.
2.
3.
4.
5.

Creative Conections Security and Medical Compliance Review.
HCDCR Nurse Intake Encounter, dated April 1, 2017.
HCDCR Provider Intake Encounter, dated April 1, 2017
ICE Detainee Classification System - Primary Assessment Form, dated April 3, 2017.
Certificate of Death, New Jersey Depa.rtment of Health, dated July 26, 2017.

17

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Office of Enforcemenr and Removal Operations
ICE Health Service Co,ps

U.S. Department of Homeland Security

500 12th Street, SW
Washington, D.C. 20536

U.S. Immigration
and Customs
Enforcement
March 1, 2018
MEMORANDUM FOR:

l(b)(6); (b)(?)(C)

FROM:

l/b)/6): (b)/7)/C)

Assistant Director
ICE Health Service Corps
Deputy Assistant Director of Clinical Services/Medical Director
ICE Health Service Corps

l<b)(6); (b)(7)(C)

Medical Executive Officer
ICE Health Service Corps

l(b)(6); (b)(7)(C)

Program Manager
ICE Health Service Corps

l(b)(6); (b)(7)(C)

Senior Investigator
ICE Health Service Corps

l (b)(6); (b)( ?)(C )

Investigator
ICE Health Service Corps

j(b)(6); (b)( ?)(C)

Regional Nurse Consultant-Eastern
ICE Health Service Corps

l (b)(6); (b)(7)(C)

IHSC Investigations Unit Chief
ICE Health Service Corps

cument contains pre-decisional and/or deliberative process ·11
o
.
,
mandatory disclosure under the Freedom o
. Do not release without prior
,
·
Customs Enforcement, ICE Health Service Cmps.
www.icc.gov

 M01tality Review: Carlos Armando MEJIA-BonillaJb)( 5); (b)(?)(C)
Page 2 of 19
SUBJECT:

Mortality Review - 2017SIR0014441 =
Carlos Armando MEJIA-Bonilla,�l(b- )(6-);-(b-)( 7)-(C- ) -�
(aka Rolando Arnulfo MEZA-Espinoza)

Executive Summarv:
Mr. Carlos Armando MEJIA-Bonilla, a 43-year-old El Salvadorian male, was in U.S.
Immigration and Customs Enforcement (ICE) custody from April 1, 2017 to June 10, 2017. Prior
to ICE custody, he had a history of diabetes mellitus- type II, liver cirrhosis, anemia, and
depression. During the course of his custody, he was treated for diabetes mellitus- type II, cold
symptoms, and rash. On June 8, 2017, Hudson County Department of Corrections and
Rehabilitation (HCDCR) medical staff responded to an emergency code in the dormitory. Upon
arrival, Mr. MEJIA was found reporting generalized weakness, dizziness, and an episode of
diarrhea. Medical staff transported Mr. MEJIA to the medical clinic for further evaluation. While
in medical, intravenous fluids (NF) were initiated. Mr. MEJIA had a high pulse (108) and a low
blood pressure (80/50) and staff noticed dark colored, tarry, clotted blood from his rectum.
Subsequently, HCDCR medical staff referred Mr. MEJIA via ambulance to Jersey City Medical
Center (JCMC) emergency depaitment. JCMC admitted Mr. MEJIA as an inpatient. After two
days, Mr. MEJIA was pronounced dead on June 10, 2017 at 11: 12 p.m. with a preliminary cause
of death as upper gastrointestinal bleed (GI) and hemorrhagic shock (a condition of reduced
blood volume, resulting in inadequate delivery of oxygen and nutrients essential for cell
function, which leads to organ damage and death).
Mortality finding: Based on the overall findings of this review, Mr. MEJIA's progressively
worsening physical status warranted a timely referral to a higher level of care for continuity and
appropriate management of his medical care. Although it is reasonable to monitor a patient with
multiple chronic conditions at HCDCR, Mr. MEJIA's symptoms were not addressed timely by a
higher level of care (i.e., advanced practice provider (APP) or physician). Therefore, it would
have been best practice to ensure processes were in place to initiate, refer, and manage Mr.
MEJIA's chronic conditions without delay.
The following is a summary of health care delivery/program weaknesses found during the course
of this review:
1. Timely access to necessary and appropriate medical care.
•

Throughout the course of Mr. MEJIA 's HCDCR detention, he submitted seven sick call
requests (April 10, 11, 23, 30, May 9, 17, and June 5, 2017) indicating he needed his
medications, blood work, and that his condition was becoming progressively worse.
Despite the frequent sick call requests, Mr. MEJIA was not referred to a higher level of
care for timely and necessary medical care.

2. Timely medical follow up for chronic conditions.
o

·-

re-decisional and/or deliberative process i,
.
o not release without prior

 M01tality Review: Carlos Armando MEJIA-BonillaJb)(6); (b)(7)(C)
Page 3 of 19
•

Although, Mr. METTA was identified with a chronic condition during intake screening
and the physical health assessment, the provider did not initiate the appropriate follow-up
process.

3. Patients with special health needs.
•
•
•
•

The APP did not complete an initial assessment for a chronic disease or special needs.
An individualized treatment plan addressing all of Mr. MEJIA' s reported conditions was
not developed.
Mr. MEJIA was not listed on the chronic disease or the special needs log.
Mr. MEJIA's special needs treatment plan was not filed in his medical record.

4. Communication regarding appropriate notification of a patient with special health
needs.
•

During the initial health assessment, the APP did not complete the medical-psychiatric
alert that initiates the notification process to the health services administrator, clinical
medical authority, facility administrator, and ICE, nor was a medical-psychiatric alert
documented in Mr. MEITA's medical record.

5. Prescribing continuity medications.
•

A qualified health care professional (physician, APP, or nurses) did not review and or
continue medications, in accordance with safe medication reconciliation practices.

6. Language access.
•

Based on the intake and sick call documentation of numerous nurses, it appears that Mr.
MEJIA had limited English proficiency (LEP). It was incumbent upon the nurse to
communicate with Mr. MEJIA in a language that he understood during "vital" times in
his care, e.g., sick call or assessments. The HCDCR nursing staff generally did not
communicate with Mr. MEJIA in Spanish; therefore, they did not communicate with Mr.
MEJIA in a manner which ensured be understood and could fully participate in his
nursmg care.

7. Nonemergency health care requests and services.
•

Mr. MEJIA was seen numerous times during nurse sick call and requested to be seen
by a provider; he was not referred to a higher level of care in a timely manner.

•

Per HCDCR guidance, detainees should be seen within 24 hours after the submission
of a sick call request. Mr. MEJIA was seen up to four days after submission of sick
call requests.

8. Policy guidance.
or
ocument contains pre-decisional and/or deliberative process in or
.
o not release without prior
mandatory disclosure under the Free om o
ugratlon and Customs Enforcement, ICE Health Service

 M01tality Review: Carlos Armando MEJIA-Bonilldb)(6); (b)(7)(C)
Page 4 of 19
•

HCDCR's medical unit policies do not include clinical care guidelines or nursing
protocols addressing management of GI disorders and comprehensive alcohol/drug
screening questions.

9. Documentation.
•
•

The provider did not document vital signs or obtain a comprehensive history of Mr.
MEJIA's reported chronic conditions.
There was no documentation of the time that emergency medical services (EMS)
called arrival to and departure from the facility.

The following is a summary of the mortality review committee's recommendations:
•

Forward these findings via appropriate communication channels to the HCDCR
administrator and health authority for review and create a corrective action plan (CAP)
for each of the individual findings.

•

Forward these findings and recommendations to ICE and HCDCR for review. ICE and
HCDCR should ensure that the HCDCR CAP is implemented and sustained.

Mortality Review Detailed Report:
On June 11, 2017, ICE Health Service Corps (IHSC) received notification of the death of ICE
I Mr. MEJIA, a 43-year old El
detainee Carlos Annando MEJIA-Bonilla, Kb)(6); (b)(7)(C)
Salvadorian male, was in ICE custody from Ap1il 1, 2017 to June l 0, 2017, and assigned to
HCDCR, Kearny, New Jersey (NJ), on the date of his death. Mr. MEJIA passed away at JCMC
on June 10, 2017.
The IHSC Assistant Director requested a mo1tality review to learn from Mr. MEJIA's death by
reviewing the care provided and the circumstances leading up to his death. The goal of the
mortality review is to determine the appropriateness of clinical care; ascertain whether changes
to policies, procedures, or practices are warranted; and identify issues that require fmther study.
The following report is based on the fmdings and recommendations of the m01tality peer review
committee, which convened on November 7, 2017. The review was based on the following
information: 1) Mr. MEJIA's HCDCR medical records, EMS, and community hospital records;
2) incident and notification repo1ts; 3) ICE ENFORCE Removal Module (EARM) and ICE
ENFORCE Alien Detention Module (EADM) database records; 4) Mr. MEJIA's death certificate
and autopsy report; 5) an on-site review and staff interviews conducted by fact-finder, l(b)(6); I
i(b)(6); (b)(7)(C) l at HCDCR on August 18-20, 2017; and 6) applicable HCDCR and ICE Detention
Standards.
Observations and Recommendations
or
c.
nt contains pre-decisional and/or deliberative process in orn :
.
mandatory disclosure under the Freedom o 'In o ·
. o not release without prior
ustoms Enforcement, ICE Health Service Cmps.

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Page 5 of 19
Sequence ofEvents
On April 1, 2017, Mr. MEJIA entered ICE Enforcement and Removal Operations (ERO)
custody and was held at the Varick Staging Facility (VSF), New York (NY).
On the same day, Mr. MEJIA was transferred to HCDCR. During HCDCR's custody intake risk
assessment, Mr. MEJIA reported a history of health problems and taking prescribed medications.
A registered nurse (RN) performed Mr. MEJIA's medical intake screening. During this
encounter, Mr. MEJIA denied having medical, mental health, or dental conditions; however, he
did report use of prescribed medications for blood pressure, but did not know the name of the
medication, and reported taking metformin. Mr. MEJIA was assigned priority and refened to a
provider due to his blood sugar of 253. His intake screening was otherwise unremarkable.
An APP completed Mr. MEJIA's health assessment examination. Mr. MEJIA repo1ted a history
of depression, diabetes mellitus-type II, hypertension, liver cirrhosis, and anemia. Mr. MEJIA
could not recall the names of his medications, but stated the phannacy he used was "Brentwood
Pharmacy in Islip, NY." The examination was otherwise unremarkable. Mr. METTA was
prescribed metformin 500 mg, one tablet, twice daily, and ordered a 2200-calorie American
Diabetic Association (ADA) diet. Although, the documented individualized treatment plan,
orders, or follow up appointments were not entered into the system.
On April 6, 2017, Mr. MEJIA's list of medications was received from Brentwood Pharmacy.
Prior to Mr. MEilA's arrest, his current medications were: thiamine (B l vitamin supplement)
100 mg- one tablet, daily; multi-vitamin (MVI)- one capsule, daily; spironolactone (diuretic) 25
mg- four tablets, daily; lisinopril (anti-hypertensive) lOmg- one tablet, daily; ferosul (iron
supplement) 325mg- one tablet, twice daily; omeprazole (decreases gastric acid ) 40mg- one
tablet, daily; docusate sodium (stool softener) I 00 mg- one tablet, three times daily; metformin
500 mg- one tablet, daily; lactulose (laxative) 10 grn/15ml solution- 15 milliliters, four times,
daily; and aspirin 81 mg- one tablet, daily. A medical provider did not review this list.
On April 10, 2017, Mr. MEJIA submitted a sick call request stating he needed to have a blood
test done, because he takes pills for anemia, hypertension, and "sugar." He also repo1ted feeling
weak and needing glasses. A nurse received the medical request on April 12, 2017.
On April 10, 2017, Mr. MEJIA submitted an additional sick call request stating "I need my
blood examined, because I take pills for my pressure and sugar." "My blood levels are high." "I
feel weak and I use glasses to see." Medical received the sick call request on April 12, 2017.
On April 11, 2017, Mr. MEJIA submitted a sick call slip stating, he needed to see a doctor to
check his blood pressure and "sugar," because he is a diabetic and he feels very bad. An RN
reviewed the sick call request on April 12, 2017. Medical staffs response to Mr. MEJIA was
"your request will be reviewed and you will be scheduled accordingly."
For
1c1
.ment contains pre-decisional and/or deliberative rocess :
.
mandatory disclosure under the Freedom o
) (5). Do not release without prior
,
ugratlon and Customs Enforcement, ICE Health Service Cmps.

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Page 6 of 19
On April 14, 2017, an RN saw Mr. MEJIA face-to-face for a nose bleed. His vital signs (VS)
were: temperature (T) 98.1, pulse (P) 74, respirations (R) 16, blood pressure (BP) 134/83, and
oxygen saturation (SaO2) 99%. The Snellen eye test results were: OS (left) 20/50, OD (right)
20/40, OU (both) 20/50. Mr. MEJIA repo1ted a two-year history of cataracts and, prior to his
arrest, he wore prescription eye glasses. Mr. MEJIA reported changes in his vision within the
past six months. [Investigator's note: No referral was submitted to a medical provider for follow
up.]
On April 23, 2017, Mr. MEJIA submitted a sick call request stating, "I need medicine for cough
and iron pills for anemia."
On April 25, 2017, an RN saw and evaluated Mr. MEJIA for complaints of nasal congestion,
sore throat, and a non-productive cough. Mr. MEJIA requested his blood work to be done.
During this encounter, the RN treated Mr. MEJIA with the following: guaifenesin 200 mg, one
tablet, daily, as needed for cough; allergy 4 mg, one tablet, as needed for congestion, and;
acetaminophen 325 mg, one tablet, as needed for pain.
On April 30, 2017, Mr. MEJIA submjtted a sick call request stating "I need to see you very
badly," "I am not sleeping well," and "I have constipation and my stomach hurts." Medical staff
reviewed the sick call request on May 3, 2017, and Mr. MEJIA was scheduled for nurse sick call.
On May 9, 2017, Mr. MEJIA submitted a sick call request stating, "I need to see the doctor,
because I have an infection in my chest and throat, and I am itching." Medical received the sick
call request on May 10, 2017.
On May 11, 2017, an RN saw and evaluated Mr. MEJIA for complaints of sore throat, nasal
congestion, and rash/itching. The examination revealed: scattered, pinpoint size redness on his
upper chest and bilateral upper extremities, and dry skin. The nurse treated Mr. MEJIA with
vitamin E/A&D ointment to apply at bedtime; clotrimazole 1% ointment to apply, twice daily, as
needed; allergy 4 mg- one tablet, twice daily, as needed; and acetaminophen 325 mg- one tablet,
twice daily, as needed. [Investigator's note: The RN did not refer Mr. MEJIA to a medical
provider.]
On May 17, 2017, Mr. MEJIA submitted a sick call request stating, "I need something for sleep,
and I am dizzy." "I have anemia."
On June 6, 2017, Mr. MEJIA submitted a sick call request stating, "I would like to see the
doctor, because I have a fever." Medical reviewed the sick call request on June 6, 2017. Medical
staffs response to Mr. MEJIA was, "Your request will be reviewed, and you will be scheduled
accordingly."
On June 6, 2017, an RN saw and evaluated Mr. MEJIA for complaints of pain with swelling and
.
is document contains pre-decisional and/or deliberative rocess ·,
mandatory disclosure under the ree o · .
5). Do not release without prior

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Page 7 of 19
redness to his left elbow. Mr. MEJIA reported he bad fallen in the shower yesterday and bit his
elbow. VS were: T 98.8, P 102, R 16, and BP 160/90. Exam: limited range of motion to the
affected extremity. Mr. MEJIA was referred to a medical provider.
On the same day, an on-site orthopedic physician saw and evaluated Mr. MEJIA. Exam: some
swelling, redness, increased skin temperature, and range of motion- good. X-ray of left
extremity: elbow joint intact, ossification pattern normal, no fracture, no dislocation. Clinical
impression: rule out cellulitis. The orthopedic medical doctor (MD) ordered Mr. MEJIA the
following treatment: clindamycin (antibiotic) 300 mg, one capsule, twice daily, and
sulfamethoxazole/trimethoprim DS (antibiotic) 800/160 mg, one capsule, twice daily, and
referred Mr. MEJIA for an urgent follow up with the primary care provider (PCP) the next day.
On the same day, the PCP ordered the following laboratory tests: complete blood count (CBC)
with differential, chemistry-8 and a diabetic panel. The PCP also ordered naproxen (enteric
coated) 500 mg, one capsule, twice daily, as needed. [Investigator's note: The PCP did not
conduct a/ace-to-face encounter/evaluation with Mr. MEJIA prior to submitting orders.]
On June 8, 2017, medical staff (licensed practical nurse (LPN), RN, and APP) responded to an
emergency code white called by the dormitory custody officer stating, "Mr. MEJIA was feeling
weak and dizzy." Medical staff responded with emergency equipment and the stretcher. Upon
arrival to the donnitory, Mr. MEJIA was sitting in the chair in the general area. Mr. MEJIA
reported feeling dizzy, weak, one episode of diarrhea earlier and he had not eaten. Medical staff
obtained his VS (BP 80/50, P 108). Mr. MEJIA was transported to medical for further
evaluation.
The APP completed an assessment and initiated one liter (L) IVF of 0.9% normal saline and
ordered the following: finger stick blood sugar (146); maalox 30 cc, now; and, ibuprofen 600
mg, one tablet, now. The APP stated Mr. MEJIA reported feeling better after the first L of IVF
and requested to use the bathroom. As Mr. MEJIA was assisted to a standing position, he became
incontinent of urine, followed by a large amount of dark colored clotted blood from the rectum
and appeared to be in mild distress. Oxygen was applied via nasal cannula at 3L/minute and 911
was called. Upon EMS arrival, Mr. MEJIA was assessed and transported to JCMC.
[Investigator's note: During the time frame ofMr. MEJIA's arrival to the medical clinic, he was
on the stretcher in the medical clinic hallway outside the APP 's office].
Cause of death
•

GI hemorrhage due to chronic alcoholism.

Manner of death
•

Natural.

o
_ .· document contains pre-decisional and/or deliberative rocess :,
mandatory disclosure under the Free om o
). Do not release without prior
. ra 10n ana Customs Enforcement, ICE Health Service 01p..

 M01tality Review: Carlos Armando MEJIA-BonillaJb)(6); (b)(7)(C)
Page 8 of 19
Strengths and Best Practices
During the course of this review, it was readily apparent that the HCDCR health care staff are
earnest and dedicated professionals. After Mr. MEJIA's death and p1ior to this review, additional
program strengths included, a local administrative review of all detainee records within the past
three months to identify any detainees with chronic conditions that may have been missed, and
the implementation of a process study to determine and/or identify any problematic areas related
to chronic care services and continuity of care. Another strength identified during this review,
was the responsiveness of custody staff in notifying medical of Mr. MEJIA's deteriorating
condition on June 8, 2017. Finally, and most important, the HCDCR medical staff were very
receptive to this review process and looked forward to receiving constructive feedback.
Weakness, Lessons Learned, and Process Improvement Recommendations
A review of Mr. MEJIA's HCDCR medical records revealed care and health services issues were
delivered outside the safe limits of practice, which either directly or indirectly contlibuted to his
death.
Mortality finding: Based on the overall findings of this review, Mr. MEJIA's progressively
worsening physical status warranted a timely referral to a higher level of care for continuity and
appropriate management of his medical care. Although it is reasonable to monitor a patient with
multiple chronic conditions at HCDCR, a higher level of care (i.e., APP or physician) did not
address Mr. MEJIA's symptoms timely. Therefore, it would have been best practice to ensure
processes were in place to initiate, refer, and manage Mr. MEJIA' s chronic conditions without
delay.
ICE detention standard used for this review: ICE Performance-Based National Detention
Standards (PBNDS), 2008.
1. Timely access to necessary and appropriate medical care.
Throughout the course of Mr. MEJIA's HCDCR detention, he submitted seven sick call
requests (April 10, 11, 23, 30, May 10, 17, and June 5, 2017), in Spanish, with multiple
complaints to include, requesting his medications, blood work, and progressively worsening
of his condition. Despite the frequent sick call requests, Mr. MEJIA was not referred to a
higher level provider for appropriate level of care.
•

On April 10, 2017, Mr. MEJIA submitted a sick call request stating "I need my blood
examined because I take pills for my pressure and sugar" "My levels are high, I feel
weak" and "I use glasses to see." The RN did not appropriately triage the sick call
request. The RN saw Mr. MEJIA on April 14, 2017, and all complaints were not
addressed, and Mr. MEJIA was not referred to a higher level of care.

nt contains pre-decisional and/or deliberative process in or
mandatory disclosure under the Freedom o
7
. o not release without prior
·· 1grat1on and Customs Enforcement, ICE Health Service Cmps.

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Page 9 of 19
•

On May 18, 2017, Mr. MEJIA was seen for dizziness, decreased blood pressure, and
anemia; however, the nurse instructed Mr. MEJIA to increase fluids and did not refer him
to a provider.

•

On June 6, 2017, Mr. MEJIA complained of pain with swelling and redness to his left
elbow. He was seen by the on-site orthopedic physician who provided antibiotic
treatment and referred him to the PCP for an urgent, next-day follow-up. The PCP
ordered laboratory tests and pain medication, but did not evaluate or assess Mr. MEJIA.

[Investigator's note: During the interview, the PCP stated "after reviewing Mr. MEJIA's
problem list, he requested the nurse to puil his laborato,y results, but the laboratory tests
had not been ordered. The PCP ordered the laboratory tests and anticipated seeing Mr.
MEJIA the next day per the orthopedic physician's referral.]
Applicable standards of care for this finding:
•

PBNDS 2008: Part 4 Medical Care, section V, Expected Practices, states "every
facility shall directly or contractually provide its detainee population: initial medical,
mental health and dental screening; primary medical and dental care; emergency care;
specialty health care; timely responses, mental health care, and hospitalization as
needed within the local community."

•

National Commission on Correctional Health Care (NCCHC): Standards for Health
Services in Jails, 2014: J-A-01: Access to care, states "inmates have access to care to
meet their serious medical, dental, and mental health needs."

Findings:
Throughout the course of Mr. MEJIA's HCDCR detention, he repeatedly requested, via sick
call, to be seen by a doctor for evaluation of his condition. Despite Mr. METIA 's repeated
requests and worsening symptoms, HCDCR failed to provide Mr. MEJIA with timely access
and appropriate medical care.
Before reviewing the medical record or evaluating Mr. MEJIA, the PCP ordered laboratory
tests and medication for pain without an appropriate assessment.
Recommendations:
1. Forward these findings via appropriate communication channels to the HCDCR
administrator and health authority for review and to create a co1Tective action plan
(CAP). The CAP should ensure that: 1) HCDCR nursing staff have sufficient knowledge
and competency to recognize when detainees require referral to a higher level of care
provider; and 2) all nurses should review and acknowledge competency of all nursing
protocols.
·
·s document contains pre-decisional and/or deliberative process in orm
or
.
·
o not release without prior
mandatory disclosure under the Free om

 M01tality Review: Carlos Armando MEJIA-Bonilla, fbl(6); (bl(7l(C)
Page 10 of 19
2. Forward these findings and recommendations to ICE and HCDCR for review. ICE and
HCDCR should ensure that the HCDCR CAP is implemented and sustained.
2. Timely medical follow up for chronic conditions.
On April 1, 2017, an APP performed Mr. MEJIA's initial health assessment;
however, the APP did not appropriately enroll Mr. MEJIA in a chronic care program
to appropriately manage his care, in accordance with PBNDS 2008 and HCDCR
policy and procedures.
The APP documented a treatment plan for diabetes in Mr. MEJIA's medical record;
however, the treatment plan did not address Mr. MEJIA's reported depression, hypertension,
and anemia. Mr. MEJIA was never entered on the chronic disease log, and therefore, was not
scheduled or evaluated for a chronic care baseline evaluation.
The responsible physician (medical director) is required to review the medical record when a
detainee has been added to the chronic disease log and assures the patient is tracked for
adequate follow up and monitoring. The APP failed to enter Mr. MEJIA on the chronic
disease log; therefore, the responsible physician was not able to review and monitor Mr.
MEJIA's medical conditions.
Applicable standard of care for this finding:
•

PBNDS 2008: Part 4 Medical Care, section R, Special Needs and Close Medical
Supervision, states "when a detainee requires close medical supervision, including
chronic and convalescent care, a written treatment plan that includes access to health
care and other personnel regarding care and supervision, shall be developed and
approved by the appropriate physician, dentist, or mental health practitioner, in
consultation with the patient, with periodic review."

•

PBNDS 2008: Part 4 Medical Care, section S, Continuity of Care, states "the facility
administrative health authority must ensure that a plan is developed that provides for
continuity of medical care in the event of a change in detention placement or status."

•

HCDCR Policy: G-01, Chronic Disease Services, states "when individuals are
identified as having medical conditions requiring close supervision and/or long term
chronic care will be entered on the chronic disease log, and followed through
regularly scheduled chronic care clinics. A clinician will do the initial baseline
evaluation in the chronic care clinic within 30 days of admission to the facility."

Findings:
Mr. MEJIA was not seen in the chronic care clinic within 30 days of admission for an initial
baseline evaluation.
·
or
ocument contains pre-decisional and/or deliberative 1
1p . rom
mandatory disclosure under the Free m .
2(b) (5). Do not release without prior
· mgratlon and Customs Enforcement, ICE Health Service 01ps.

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Page 11 of 19
During the initial health assessment, the APP failed to enter Mr. MEJIA on to the chronic
disease log, which initiates the process for initial and follow up chronic care clinic
appointments, laboratory tests, and the responsible physician's review of the medical record.
HCDCR failed to provide Mr. MEJIA with a timely follow-up for his chronic conditions.
Recommendations:
a. Forward these findings via appropriate communication channels to the HCDCR
administrator and health authority for review and to create a CAP. The CAP should
ensure that: l ) HCDCR initiates a quality assurance process to confirm detainees with
chronic conditions are added to the chronic disease log and have appropriate orders and
scheduled follow up appointments entered into the system, and 2) HCDCR medical
authority will review and confirm all detainees with a chronic condition have appropriate
orders and scheduled follow up appointments.
b. Forward these findings and recommendations to ICE and HCDCR for review. ICE and
HCDCR should ensure that the HCDCR CAP is implemented and sustained.:.
3. Patients with special health needs.
On April l , 2017, the APP documented Mr. MEITA's cmrent problems as: anemia, depression,
cirrhosis, hypertension, and diabetes type II-uncomplicated. There was no documentation that
Mr. MEJIA was included in the special needs clinic.
Applicable standard for this finding:
•

PBNDS 2008: Part 4 Medical Care, section V.R., Special Needs and Close Medical
Supervision, states "when a detainee requires close medical supervision, including
chronic and convalescent care, a written treatment plan that includes access to health care
and other personnel regarding care and supervision, shall be developed and approved by
the appropriate physician, dentist, or mental health practitioner, in consultation with the
patient, with periodic review. The written treatment plan will conform to NCCHC
requirements."

•

HCDCR Policy: G-02, Patients with Special Health Needs, states ''inmates' special needs
are met with special health conditions requiring close medical supervision or
multidisciplinary care, including developmental deficits and chronic and convalescent
care are met. The special needs clinic should include, but is not limited to: mental health,
chronic conditions, and other needs, i.e., developmentally disabled, terminally ill, frail,
elderly, pregnant and physically handicapped. The initial assessment for a chronic disease
or special needs will be performed by a medical provider. Assignments are made to a
special needs clinic at HCDCR by the treating clinician."

·or
is document contains pre-decisional and/or deliberat'v.
1p . rom
mandatory disclosure under the ·
. 552(b) (5). Do not release without prior
.

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Page 12 of 19
•

HCDCR Policy: H-01, Health Records, states "special needs treatment plans will be filed
in the inmate patient's health care record."

Findings:
The APP did not complete an initial chronic disease or special needs assessment. An
individualized treatment plan addressing all of Mr. MEJIA's reported conditions was not
developed, and Mr. MEJIA was not listed on the chronic disease or the special needs log, nor
was a special needs treatment plan filed in Mr. MEJIA's patient's medical record.
Recommendations:
a. Forward these findings via appropriate communication channels to the HCDCR
administrator and health authority for review and to create a CAP. The CAP should
include processes to ensure: 1) all clinicians have the knowledge and competency to
identify detainees requiting special needs; 2) all clinicians complete the initial
assessment for special needs accordingly, and; 3) all detainees meetii1g the criteria are
adequately monitored.
b. Forward these findings and recommendations to ICE and HCDCR for review. ICE and
HCDCR should ensure that the HCDCR CAP is implemented and sustained
4. Communication regarding appropriate notification of a patient with special health
needs.
On April 1, 2017, during the health assessment, the APP documented Mr. MEJIA's current
problems as: anemia, depression, cirrhosis, hypertension, and diabetes type II-uncomplicated.
Applicable policies for this finding:
•

PBNDS 2008: Part 4 Medical Care, section 4.a, Medical/Psychiatric alert, states
"medical staff shall notify the facility administrator in writing, when they determine
that a detainee's medical or psychiatric condition requires: clearance by the medical
staff prior to release or transfer, or medical escort during removal, deportation or
transfer."

•

PBNDS 2008: Part 4 Medical Care, section V.R, Special Needs and Close Medical
Supervision, states "the health administrative authority for each facility must have a
plan to notify ICE for any detamee with special needs. The written notification must
become part of the detainee's health record file."

Findings:
During the initial health assessment, the APP did not complete the medical-psychiatric alert
that mitiates the notification process to the health services adminish·ator, clinical medical
For
zeta
nt contains pre-decisional and/or deliberativ
p . rom
5 . Do not release without prior
,
mandatory disclosure under the Free.
.
. . mmzgration and Customs Enforcement, ICE Health Service Cmps.

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Page 13 of 19
authority, facility administrator, and ICE. A medical-psychiatric alert was not documented in
Mr. MEJIA's medical record.
Recommendations:
a. Forward these findings via appropriate communication channels to the HCDCR
administrator and health authority for review and to create a CAP. The CAP should
ensure that: 1) HCDCR clinicians have sufficient knowledge and competency regarding
the identification and notification process of detainees with chronic diseases and special
needs, and 2) HCDCR clinicians will appropriately identify detainees requiring a
medical-psychiatric alert in accordance with PBNDS 2008: Part 4 Medical Care, section
4.a, Medical/Psychiatric alert.
b. Forward these findings and recommendations to ICE and HCDCR for review. ICE and
HCDCR should ensure that the HCDCR CAP is implemented and sustained.
5. Prescribing continuity of medications
On April 1, 2017, during Mr. MEJIA's intake and health assessment, he reported taking
current medications, but did not remember the name. However, he did state the name of the
pharmacy he used prior to his arrest. The APP prescribed metformin 500 mg, one tablet,
twice daily, due to a blood sugar of 253, and requested Mr. MEJIA's medication list from the
pharmacy. On April 6, 2017, HCDCR received Mr. MEJIA's list of medications from the
Brentwood Pharmacy. There is no documentation indicating that a provider reviewed the
medication list.
Applicable standards of care for this finding:
•

PBNDS 2008: 4.3 Medical Care; section II, Expected Outcomes, states "detainees
will have access to a continuum of health care services, including prevention, health
education, diagnosis and treatment."

•

PBNDS 2008: 4.3 Medical Care; section V.S, Continuity of Care, states "the facility
administrative health authority must ensure that a plan is developed that provides for
continuity of medical care in the event of a change in detention placement or status."

•

NCCHC: Standards for Health Services in Jails, 2014: J-D-02: Medication Services,
states "medication services are clinically appropriate and provided in a timely, safe,
and sufficient manner. . .Inrnates being admitted who report taking medications
cutTently, or who bring the medications with them is to continue their medication
unless there is a clinical reason to alter or discontinue the medication."

Findings:

mandatory disclosure under the Freedom
. Do not release without prior
,
ugration and Customs Enforcement, ICE Health Service Cmps.

 M01tality Review: Carlos Armando MEJIA-Bonilla, kb)(6); (b)(7)(C)
Page 14 of 19
On April 6, 2017, HCDCR' s medical staff received Mr. MEJIA' s list of medications. The
APP did not review the list of medications or conduct medication reconciliation with Mr.
MEJIA, in accordance with safe medication reconciliation practices.
Recommendations:
a. Forward these findings via appropriate communication channels to the HCDCR
administrator and health authority for review and to create a CAP. The CAP should
ensure that: 1) a safe medication reconciliation process is established and proper training
implemented, 2) HCDCR providers will review and sign all applicable medication related
documents from outside entities, and 3) HCDR providers will reconcile medications with
feedback from the patient in accordance with the appropriate guidance for prescribing
continuity medication for new admissions.
b. Forward these findings and recommendations to ICE and HCDCR for review. ICE and
HCDCR should ensure that the HCDCR CAP is implemented and sustained.
6. Language access.
During the intake screening, the RN documented that an interpreter was not needed. There
was no additional supporting documentation, i.e., preferred language, nurse speaks Spanish.
Multiple nurses reported using "Google" translation during encounters instead of the required
language lines. During interviews, multiple nurses stated "telephone translation services are
available, but Google translation was used because it was much quicker." The medical
administrators stated Google translation was not approved for use during patient encounters.
It is well described in research that "adverse effects affect LEP patients more frequently, are
often caused by communication problems, and are more likely to result in serious harm
compared to those that affect English-speaking patients. Effective provider-patient
communication is vital, especially in areas as critical as medication reconciliation, hospital
discharge, informed consent, and surgical care." Agency for Health Care Research and
Quality [(AHRQ), 2012]
Applicable standard and reference for this finding:
•

PBNDS 2008: 4.3 Medical Care, section II.37, Expected Practices, states "non­
English speaking detainees and/or detainees who are deaf and/or hard at bearing will
be provided interpretation/translation services or other assistance as needed for
medical care activities."

•

Umbdenstock, Rich, "Improving Patient Safety Systems for Patients with Limited
English Proficiency," Agencyfor Health care Research and Quality (AHRQ),

or
:� document contains pre-decisional and/or deliberative process in ormat ·
.
·
mandatory disclosure under the Free om
o not release without prior

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Page 15 of 19
publication 12-0041 (2012).Accessed January 30, 2018, website:

Findings:
Based on the sick call documentation of numerous nurses, it appears that Mr. MEJIA had, or
may have had, LEP. It was incumbent upon the nurse to communicate with Mr. MEJIA in a
language that he understood dming "vital" times in his care, e.g., intake, sick call,
assessments. The HCDCR nursing staff generally did not communicate with Mr. MEJIA in
Spanish, and therefore, did not communicate with Mr. MEJIA in a manner which ensured he
understood and could fully participate in his nursing care.
Recommendations:
a. Forward these findings via appropriate communication channels to the HCDCR
administrator and health authority for review and to create a CAP. The CAP should
ensure that: 1) HCDCR nmsing staff has sufficient knowledge and competency to
identify detainees with LEP; and 2) all nurses are required to communicate with detainees
with LEP in a language that they understand during "vital" health care encounters, e.g.,
intake screening, sick call, provider visits.
b. Forward these findings and recommendations to ICE and HCDCR for review. ICE and
HCDCR should ensure that the HCDCR CAP is implemented and sustained.
7. Nonemergency health care requests and services.
On April 23, 2017, Mr. MEJIA submitted a sick call request complaining of cough and
needing iron pills for his anemia.
On April 25, 2017, Mr. MEJIA was seen and treated for nasal congestion, sore throat, and
cough. Mr. MEJIA also requested blood work during this encounter.
On April 30, 2017, Mr. MEJIA submitted a sick call request complaining of problems
sleeping, constipation, and a stomachache. On May 3, 2017, an appointment was scheduled
for sick call and "cough" was added to problem list.
On May 9, 2017, Mr. MEJIA submitted a sick call request complaining of nasal congestion,
excessive sputum, and rash to upper chest. On May 11, 2017, Mr. MEJIA was seen and
treated for complaints.
On June 5, 2017, Mr. MEJIA submitted a sick call request complaining of a fever. On June 6,
2017, Mr. MEJIA was seen by the nurse. The nurse documented "patient came to medical c/o
[complaints of] pain, with swelling and redness on left elbow. Patient [Mr. MEJIA] claimed
he fell in shower, yesterday, and hit his elbow; Exam: alert and oriented x 3, not in distress;
_ . ·s document contains pre-decisional and/or deliberative process in or
or
.
·
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'.). Do not release without prior

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Page 16 of 19
limited range of motion on the affected side; VS: T 98.8, P 102, R 16, and BP 160/90. Mr.
MEJIA was referred to the provider."
Applicable standards for this fmding:
•

PBNDS 2008: Part 4 Medical Care, section V.N, Sick Cail, states "all facilities must
have an established procedure in place to ensure that all sick call requests are received
and triaged by appropriate medical personnel within 48 hours after the detainee
submits the request. Medical personnel shall review the request slips and determine
when the detainee will be seen."

•

NCCHC: Standards for Health Services in Jails, 2014: J-E-07: Nonemergency Health
Care Requests and Services, states "all inmates have the opportunity daily to request
health care. Their requests are documented and reviewed for immediacy of need and
the intervention required. Qualified health care professional respond to health
services requests and conduct clinicians' clinic on a timely basis and in a clinical
setting."
"A disposition is made and noted on the patient's request form or in a log or
appointment book. Not every nonemergency health services request requires an
appointment; however, when a medical, dental, or mental health request describes a
clinical symptom, a face-to-face encounter between the patient and a health care
professional is required."
"When indicated, refe1nl to the clinicians' clinic is made for the inmate to see a
physician or midlevel practitioner. In general, when a patient presents for
nonemergency health services more than two times with the same complaint and has
not seen a physician, he or she receives an appointment to do so."

•

HCDCR Policy: E-07, Nonemergency Health care Requests and Services, states "all
requests will be reviewed by the nurse and the date, time, and disposition of the
review, along with the initials of the nurse will be indicated on the sick call request."
"The sorted sick call slips will be given to the nurses for triage and disposition,
nursing versus physician sick call lists. The Director of Nursing (DON) or designee
will triage the slips and so1t out the "must-see AM", "must-see STAT", and note the
disposition on the sick call sheet. The sheet is returned to the charge nurse. The DON
will confer with the clinician regarding problem. The clinician will triage the slips
and s01t out those cases with chronic stable diseases, make note on the sick call slip
of the condition, refer to chronic care for evaluation and retmn the completed slip to
nursing to have the inmate patient appropriately logged out and scheduled for chronic
care clinic to be seen."
"Sick call requests will be screened by clinical personnel within 24 hours of receipt
and ptioritized in a timely manner according to acuity. The inmate with non-emergent

·
cument contains pre-decisional and/or deliberative process in orn
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comp]aints will be seen or a disposition rendered and the inmate notified with the
next 24 hours.
Findings:
•

On April 25, 2017, during the sick call encounter, Mr. MEJIA requested blood work;
the nurse did not refer him to a higher level of care for evaluation

•

On May 3, 2017, "cough" was added to the problem list, Mr. MEJIA was not seen by
the nurse and his complaint of constipation and stomachache was not addressed. This
was not in compliance with NCCHC J-E-07.

•

On June 6, 2017, Mr. MEJIA was seen for complaint of fever; however, the nmse
failed to address the following: BP 160/90, and P 102. During the interview, the nurse
stated there was no intervention because Mr. MEJIA' s elevated VS were related to
Mr. MEJIA experiencing pain.

•

During the course of detention, Mr. MEJIA was seen between one to four days after
submission of sick call requests. Per HCDCR guidance, detainees should be seen
within 24 hours after the submission of a sick call request.

•

Mr. MEJIA reported chronic conditions were documented on the problem list of his
medical record. Mr. MEJIA was given acetaminophen on April 25 and May 11, 2017.
The nursing sick call protocols (16) states, "If a patient is Hepatitis C-positive, has
chronic liver disease, has recently consumed alcohol, or is in the midst of withdrawal,
use only ibuprofen 200 mg, two tablets. Do not give acetaminophen."

•

Although Mr. MEJIA was seen numerous times dming nurse sick call and requested
to be seen by a provider, he was not referred to a higher level of care.

Recommendations:
a. Forward these findings via appropriate communication channels to the HCDCR
administrator and health authority for review and to create a CAP. The CAP should
ensure: 1) the HCDCR nurses appropriately assess and develop nursing care plans for all
significant clinical symptoms complaints made by detainees, and 2) HCDCR nmsing
staff has sufficient knowledge and competency to identify when a referral to the provider
is warranted, 3) HCDCR nursing staff review, triage and document sick call requests in a
timely manner, and 4) HCDCR nurses have a documented review all nmsing sick call
protocols.
b. Forward these findings and recommendations to ICE and IHSC for review. ICE and
IHSC should ensure that the HCDCR CAP is implemented and sustained.
8. Policy Guidance
For
zct
ocument contains pre-decisional and/or deliberative r
. om
mandatory disclosure under the Free or .
(b) (5). Do not release without prior
· rmgration and Customs Enforcement, ICE Health Service

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Page 18 of 19
On April 1, 2017, during the intake and health assessment encounter, Mr. MEJIA reported a
history of liver cirrhosis; although, he denied use of alcohol and substance abuse.
Upon receipt of Mr. MEJIA's medication list, it included omeprazole (decreases gastric
acid).
On April 30, 2017, Mr. MEJIA complained of GI symptoms, and he was scheduled for nurse
sick call.
Applicable standards for this finding:
•

NCCHC: Standards for Health Services in Jails, 2014: J-A-05, Policies and
Procedures, states "the facility has a manual or compilation of policies and defined
procedures regarding health care services that addresses each applicable standard in
the Standards for Health Services in Jails."
All aspects of the standard are addressed by written policy and defined procedures.

Findings:
•

On April 1, the nurse or the provider did not ask additional questions regarding Mr.
MEJIA alcohol/drug history.

•

On April 30, 2017, Mr. MEJIA complained of GI symptoms, but was never seen by the
nurse and his complaints were not addressed.

•

HCDCR's medical unit policies do not include clinical care guidelines, or nursing
protocols addressing management of GI disorders and comprehensive alcohol/drug
screening questions.

Recommendations:
a. Forward these findings via appropriate communication channels to the HCDCR
administrator and health authority for review and to create a CAP. The CAP should
ensure: I) HCDCR's medical policies include management of GI disorders, and 2)
HCDCR's medical policies include a comprehensive screening questionnaire for drug
and alcohol use when a detainee reports with a significant history, and 3) all HCDCR's
medical policies will be reviewed and updated accordingly.
b. Forward these findings and recommendations to ICE and IHSC for review. ICE and
IHSC should ensure that the HCDCR CAP is implemented and sustained.
9. Documentation

·

For
t
ocument contains pre-decisional and/or deliberative process in o
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·
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'.). Do not release without prior

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Page 19 of 19
On April 1, 2017, the APP completed Mr. MEJIA's initial health assessment. A health
history and physical examination was documented in the medical record.
On June 8, 2017, the APP completed an assessment and initiated one liter (L) IVF of 0.9%
normal saline and ordered the following: finger stick blood sugar (146); maalox 30 cc, now;
and, ibuprofen 600 mg, one tablet, now. The APP stated Mr. MEJIA repo1ted feeling better
after the first L of IVF and requested to use the bathroom. As Mr. MEJIA was assisted to a
standing position, he became incontinent of urine, followed by a large amount of dark
colored clotted blood from the rectum and appeared to be in mild distress. Oxygen was
applied via nasal cannula at 3L/minute and 911 was called. Upon EMS arrival, Mr. MEJIA
was assessed and transported to JCMC.
Applicable standards for this finding:
•

NCCHC: Standards for Health Services in Jails, 2014: J-E-04, Initial Health
Assessment, states "initial health assessments include, at a minimum, a qualified
health care professional recording of vital signs (including height and weight)."

•

HCDCR policy: E-04, Initial Health Assessment, states "The intake processing at
HCDCR will include, but not limited to, 1) the collection of additional data to
complete the medical, dental and mental health histories ...", and 2) recording of
height, weight, blood pressure, pulse, and temperature."

Findings:
The provider did not document vital signs or obtain a comprehensive history of Mr. MEJIA's
reported chronic conditions.
On June 8, 2017, EMS was called; however, there is no documentation of the time EMS was
called, arrival to and departure from the facility.
Recommendations:
a. Forward these findings via appropriate communication channels to the HCDCR
administrator and health authority for review and to create a CAP. The CAP should
ensure: I) all medical staff conduct thorough histories and assessments, accordingly, on
initial health assessments,2) all medical staff review HCDCR's initial health assessment
policy and document accordingly, and 3) ensure all staff are reminded to thoroughly
document EMS responses, accordingly .
b. Forward these findings and recommendations to ICE and IHSC for review. ICE and
IHSC should ensure that the HCDCR CAP is implemented and sustained.
End of report.
o
m

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ocess inform ·
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o not release without prior