ICE Internal Detainee Death Review for Efrain Romero De La Rosa

DETAINEE DEATH REVIEW - Efrain DE LA ROSA JICMS[™™ SYNOPSIS On July 10, 2018, Efrain DE LA ROSA (DE LA ROSA), a forty-year-old citizen of Mexico, died while in custody of U.S. Immigration and Customs Enforcement (ICE) at the Southwest Georgia Regional Medical Center (SGRMC) in Cuthbert, Georgia (GA). DE LA ROSA’s preliminary cause of death is self-induced strangulation. The Georgia Bureau of Investigation (GBI), Associate Medical Examiner, documented DE LA ROSA's cause of death as suicide by hanging." DE LA ROSA was detained at Stewart Detention Center (SDC) in Lumpkin, GA, from March 13,2018 until his death on July 10, 2018. SDC is a dedicated facility governed by an Intergovernmental Service Agreement, owned and operated by CoreCivic (CC), and is required to comply with the ICE Performance Based National Detention Standards (PBNDS) 2011. ICE Health Services Corp (IHSC) provides medical care at SDC and is supported by contract company InGenesis; InGenesis subcontracts with STG International, Maxim Healthcare Services, Prestige Healthcare, and Akahi Associates to ensure adequate levels of care are. provided at SDC. At the time of DE LA ROSA’s death, SDC housed approximately 1,835 male detainees of al classification levels for periods in excess of 72 hours. DETAILS OF REVIEW From August 14 to 16, 2018, ICE Office of Professional Responsibility (OPR), External Reviews and Analysis Unit (ERAU) staff visited SDC to review DE LA ROSA’s detention and the circumstances surrounding his death while in ICE custody. ERAU was assisted in its review by contract subject matter experts (SME) in correctional healthcare and security, who are employed by Creative Corrections, a national management and consulting firm.> As part of its review, ERAU reviewed immigration, medical, and detention records pertaining to DE LA ROSA, in addition to conducting in-person interviews of individuals employed by CoreCivic, IHSC, InGenesis (to include subcontractors), and ICE Office of Enforcement and Removal Operations (ERO) staff. During the review, the ERAU review team took note of any deficiencies observed in the facility's compliance with the relevant detention standards as they relate to the care and custody ofthe deceased detainee and documented those deficiencies herein for informational purposes only. Their inclusion in the report should not be construed in any way as indicating the deficiency contributed to the death of the detainee. ERAU determined the following timeline of events, from the time of DE LA ROSA's encounter with ERO, through his detention at SDC. and is eventual death at the SGRMC. 7 See Exhibit 1 Georgia Bureau of Investigation, Divison of Forensic Sciences Autopsy. Official Report, dad October 2,018 * See Exhibit 2: Creative Corections Dtsince Dest Review Healthcare and Security Analysis 1 o1 

DETAINEE DEATH REVIEW — Efrain DE LA ROSA JICMS [77] IMMIGRATION AND CRIMINAL HISTORY Inthe year 2000, at an unknown date and time, DE LA ROSA claimed to have illegally entered the United States nar the U.5.-Mexico border near Arizona, without being admitted or paroled by an immigration official.’ On July 8, 2004, the Circuit Court of Fairfax County, Virginia (VA), convicted DE LA ROSA of driving while intoxicated, sentenced him to 30 days’ confinement* and suspended his drivers license for 12 months. On July 22, 2004, the Circuit Court of the City of Alexandria, VA, convicted DE LA ROSA of possession of burglary tools and sentenced him to two years’ confinement, with the possibilty of one and one-half years suspended for good behavior, and two years’ probation.* On August 30, 2004, the Circuit Court of the City of Alexandria, VA, convicted DE LA ROSA of carjacking and sentenced him to 20 years’ confinement, with the possibility of 12 years suspended for good behavior, and five years’ probation.® On October 13, 2004, the Circuit Court of Fairfax County, VA, convicted DE LA ROSA of carjacking and sentenced him to 15 years” confinement, with the possibility of nine years and six ‘months suspended for good behavior, and five years’ probation.” On October 25, 2004, the Circuit Court of Fairfax County, VA, convicted DE LA ROSA of receiving stolen property, and sentenced him to six months’ confinement and six months” supervised probation.” On November 22, 2004, the Commonwealth of Virginia Department of Corrections (VADOC) booked DE LA ROSA into the Alexandria City Jail.” On December 6, 2004, the Fairfax County General District Court, Fairfax, VA, convicted DE LA ROSA of escape without force and sentenced him to 30 days’ confinement with 30 days suspended." 3 See Enforce Alien Removal Module (EARN Nari, dated May 10, 2017. initaly th Circuit Cort of Fairfax County Suspended sl 30 days of th il sence, contingent upon is good havior for one ses. On February 10,200, the Circuit Couto Fax County determined DE LA ROSA iol he ter of is release ad dered hi 0 crv the remind of i previous 30 days” confinement. See Cite Court of Fe County Final Onder, dtd February 10, 2005. Se Circuit Court ofthe City of Alexandria Sentencing Sunmiry, dated October 1, 2004 See Circuit Court of the City of Alexandra Sentencing Summary. dated Octobe 29, 2004 7 See Circuit Court of Fairfax County Sentencing Onder dated Janay 11, 2005 * Se Circuit Court of Fairfax County Sentencing Onder dated January 7. 2005. See Commonwealth of Virginia Deparment of Corrections DE LA ROSA Transfer Dates Report, dated November 22,2004 July 11, 2018 © See United States Deparment of Rstice Criminal Record, dated February 9, 2018, 2 02 

DETAINEE DEATH REVIEW - Efrain DE LA ROSA nemsP™ On January 11, 2005, VADOC transferred DE LA ROSA from Alexandria City Jail to Fairfax County Adult Detention Center. From this date through January 15, 2013, VADOC transferred DE LA ROSA to five separate facilities." On January 15, 2013, VADOC transferred DE LA ROSA to Marion Correctional Treatment Center (MCTC). On April 5, 2017, ERO Washington encountered DE LA ROSA at the Virginia Department of Behavioral Health and Developmental Service (DBHDS), MCTC, '* pursuant to a referral from the VADOC. The DBHDS detained DE LA ROSA at MCTC as he suffered from schizophrenia and was found to be mentally incompetent and was therefore unable to participate in his criminal proceedings." On August 29, 2017, ERO Washington issued DE LA ROSA a Notice to Appear, Form 1-862, charging removability pursuant to Sections 212(a)(6)(A)(i)."* 212()(2)(A)i)(1).¢ and 212(a)2)(B)"” of the Immigration and Nationality Act (INA).'® On September 8, 2017, ERO Washington lodged an Immigration Detainer ~ Notice of Action, Form 1-247A, with the MCTC:; however, on this same date, based on the recommendation of the Washington ICE Office of Chief Counsel (OCC), ERO Washington lifted the detainer pursuant 108 CFR 236.2(b)." On September 11, 2017, MCTC released DE LA ROSA. On February 9, 2018, a designated immigration officer (DIO) from the Wake County 287(g) program encountered DE LA ROSA at the Wake County Detention Center (WCDC) in Raleigh, North Carolina (NC), following his arrest for larceny. The DIO lodged a Form 1-247A with the wepe?! 7 Se Commonesth of Virginia Department of Cottons DE LA ROSA Transfer Dats Report dated November 23.2004 uly 11.2018. Now MTC is a behavioral health nit (BHU) lcs fr acu car, outpatient. and residential mental health services. It house mal offenders determined in nec of care ows the scope of services avalable in prisons. See EARM Narative, dated May 10,2017 See ICE Significant Icident Report. dsed July 11 2015. 5 Amalin present inthe nied States without bing admit o paroled or who rived nthe United Sats st any ime o lace thr than as designated by th Atorey General An then who has been convicted of, or who adits having commited. o who adits commiting acts which onsite the sential clement of a crime ivoling mora upitude (other than a purl political fens) or an malin who has bn convicted f two o more offnss other than url pola offenses) fo which he agregar eninces 1 concent wee five yeas or moe. E35 DHS Form 1-862 Notice fo Appt dated August 29. 2017 1 An ale confined dus 0 meal inability in an mtinaion sal no be accepted nt physical custody by he Service until am order of removal has bn entered. See ICE Significant Incident Report. dtd Jy 11, 2015. 2 See Commonwealth of Virginia Department of Corrections DE LA ROSA Transfer Dates Report, dated. November 22, 2004 - uly 11: 2015, See DHS Form 247A. Immigration Detain - Nie of Action, ded February , 2015. 3 03 

DETAINEE DEATH REVIEW — Efrain DE LA ROSA JCMS] On March 9, 2018, the Wake County District Court in Raleigh, NC, convicted DE LA ROSA of larceny and sentenced him to 28 days’ confinement with 28 days’ credit for time served. On March 12, 2018, WCDC released DE LA ROSA to the custody of ERO Atlanta.” On March 13, 2018, ERO Atlanta transferred DE LA ROSA to SDC. On March 22, 2018, the Atlanta OCC filed a motion with the Executive Office for Immigration Review (EOIR) to change the venue of DE LA ROSA’s removal proceedings from Arlington, VA, to Lumpkin, GA.2* On this same date, the ICE Office of the Principal Legal Advisor (OPLA) submitted a request for mental health reviews with IHSC. On April 18, 2018, EOIR granted the motion for a change of venue.” On June 28, 2018, IHSC provided OPLA with DE LA ROSA’ medical records, which indicated history of schizophrenia. On this same date, Atlanta OCC filed a motion for consideration of ‘medical/mental health records with EOIR. > On July 3, 2018, an Immigration Judge in Lumpkin, GA, ordered DE LA ROSA removed from the United States to Mexico.” NARRATIVE On March 13, 2018, at approximately 1:07 p.m.,* SDC admitted DE LA ROSA. Atan unknown time, Ofc ompleted DE LA ROSA’s initial ICE Custody Classification Worksheet and appropriately classified DE LA ROSA as high: a supervisor did not approve the classification until March 29, 2018.% AUI0:55 pm. “[IOIBII0 Registered Nurse (RN), completed DE LA ROSA's pre- screening and documented DE LA ROSA denied having any current health problems or taking any medications.” RN Po okiso noted that DE LA ROSA appeared alert, with normal 2 See Raleigh'Wake City-County Bureau of Identification Criminal Disposition Inquiry, dated March 11, 2018. See EARM Custody Actions & Decision, dated March 12, 2015, 4 See EARM Custody Actions & Decision, dad March 1, 2015, 3 See Department of Justice EOIR Immigration Court, Motion to Change Venue, dated March 22, 201, 3 See HSC OPLA Request for Medical Records. dated March 22, 201, = Sce ICE Significant Incident Report, dated July 11, 2018 3 Sce DHS Motion for Consideration of Medical Mental Healt Records, dated June 25, 2018 * See Onder ofthe Immigration Judge, July 3, 2015. Sec Inmate Information Shect, dted March 13, 2013. 0 Se ICE Casto Clsitcation Asm, dtd Marc 13,2013. ERAU nots ftir] any wes [07 oXNIC) regarding special vulnerabilities (i. mental illness) on the assessment form. adic) PRA sppreximated ming of medical svnts a beta possible. Medical ins catalogued within the report priorized based on ree indicated round tim. vial sigs. o lectronicall signed thir ne. * See eClinicalWorks (CW) Progress Note by R ed March 13, 2018. R! [Progress Sheet. 4 04 

DETAINEE DEATH REVIEW — Efrain DE LA ROSA JICMS behavior and appearance, and exhibited no noticeable restrictions or difficulties in movement or breathing. On March 14,2018, at 1:51 am. Officer PTT hooked DE LA ROSA into SDC. At2:45 am. RNP OC kompleted DE LA ROSA’s medical and mental health screening and documented the following: . i i the screening in the detainee’s native language of Spanish, although DEA ROSA reported he spoke fluent English. «DE LAROSA's vital signs were all within normal limits except for an elevated blood pressure of 119/80." + DE LA ROSA disclosed a history of drug (cocaine), alcohol, and tobacco use, with last consumption in January 2018, December 2017, and February 2018, respectively. «DE LA ROSA reported feeling good and denied pain, medical or dental problems, withdrawal or tuberculosis (TB) symptoms. + DE LA ROSA stated that while incarcerated in Virginia, the MCTC treated him for schizophrenia. DE LA ROSA also reported taking eight different medications but stated he ceased use approximately three months before he arrived at SDC because he. could not sleep. «In response o the question, “Do you ever hear voices that others do not hear?” DE LA ROSA responded he hears God talk to him. «In response to the question, “Do you believe someone can control your mind?” DE LA ROSA stated, “No, only God.” + DE LA ROSA appeared to have normal speech, comprehension, focus, physical characteristics, and emotional attributes. «DE LA ROSA arrived with a Transfer Summary* from WCDC, discussed below. torr hy en dad “It is unknown why the booking time differs from the March 13, 2018, 1:07 p.m. admission time noted on Inmate sion She I See tangs Commitment Summary deed March 19,2018, * See CW Progress Note by RN[—— dated March 14, 2018. 17 mom porate ons GSTET TT Tot normal rng or 8 pls i 60 10 100 bts por inue; the normal rang for esprions i 210 20 breaths po mint and poral pond rose 17080 oli. Aeon 16 Toe American Hear ASsocition (VHA) 14s blood ress readin ics sag on persion Suge nc yprension i chuscenzed by a ysl reading of 13010 139 or Gs adn of 30 0.85, sopra va cron mena) Bs disode ht affes how parson thks ols and behaves, often losing osch wip rely, Fs ciractenoed by Possible audver and val Wallcaions pparot perapion of Something not ren, dehtons (eit ht Fly mained dite bin contd b ea. depen, iho and hr fo hrs. SX Schioptvnia i cron mena esi disorder hat ffs how person inks, fs, and behaves, on sing Louch with aly i chiraciersed by possible audory and veal Ballcnations (appr percep of Something not ren, deitons (elit ht Fly mained despite bing Cond b ea. depen, Sitharm and farm to others, See WCDC Medical Summary (4 pages). reviewed by of 13,2018. s 05 

DETAINEE DEATH REVIEW — Efrain DE LA ROSA JICMS 1 According to the WCDC Transfer Summary, DE LA ROSA was not currently taking medication and per a purified protein derivative (PPD)! test completed on February 10, 2018, was negative for TB. The Problem List? included seven items: legible entries included a scar to the dorsal ® side of the right hand. prior incarceration in the VADOC. and schizophrenia. Based on her findings, RN [TP Jocumented the following: + The mental health screening was negative for suicidal or homicidal ideation. . RNP explained the TB test and chest x-ray to DE LA ROSA and completed the Process WI Appropriate shielding ** + AsDE LA ROSA had an abnormal intake screening, the RN referred him to a medical provider. . RNP tcarca DE LA ROSA for custody. ERAU notes that during DE LA ROSA’s first detention period at SDC, medical staff did not obtain a signed HSC Medical Consent Form for general treatment from DE LA ROSA. At4:50 am, Office Jomplccd arisk classification assessment and documented answers of "No 0 all questions. ® At 10:02 am., SDC assigned DE LA ROSA to general population unit 6, pod A, cell 110.7 On March 15, 2018, at 9:30 pr iil Practitioner (NP), conducted DE LA ROSA’s initial physical assessment, Tad documented the following: + DELAROSA’s vita signs were all within normal limits except for an elevated blood pressure of 13/80, «+ DE LA ROSA denied a history of chronic medical conditions and dental problems. «DE LA ROSA reported a history of schizophrenia and hospitalization for the disease in 2004 and 2010. + DE LA ROSA could not recall the names of his past medications and stated he ceased use of them after informing a doctor in NC that he could not sleep. “1d # APD skin testi solution nected into the ski to determine whether a person has been infected with wherculois. EA Problem List i runing ist of patien’s medical problems. Problem Lists are maintained inthe medical record to support contin of care during patient encounters © Dorsal refers to the top sid “ See CCW Progress Note by RN, dated March 14, 2018, ERAU nots the SDC medical record was void of a chest x ay report. Creative Corrections advised if completed, the reason is unclear as the WCDC Transfer Summary documented TB clearance through PPD testing just one month carlier and the ICE PENDS 2011 standard, Medical Car: TB Management sas, “For detainees tht have been in continuous aw enforcement custody, symptom screening plus documented TB screening within one year of arival may be accepted for intake Scrcning purposes.” €'See Assesment Questionnaire Form: Initial Screening Tool, dated March 14, 2015. The assessment questionnaire nx is utilized 0 screen for victimization nd predatory history risk, among other factors o be considered when vabuaing housing options for a detance See SDC Cellmate Housing History, dated March 13, 2018 - May 4, 2018, See cCOW Progress Nace Jil March 15, 2018 6 os 

DETAINEE DEATH REVIEW - Efrain DE LA ROSA JICMS 1 + DE LA ROSA again stated hearing voices from God, the last time in September 2017. - + DE LA ROSA denied suicidal or homicidal ideations. + DELA ROSA was not currently exhibiting symptoms of a serious mental disorder or Nel ied DE LA ROSA to continue daily activities even if he did not feel like it reguIarTy exercise, and nolify an officer or nurse if he started having thoughts oT Farming himself or others or hearing voices. Additionally, NP —Jeferred DE LA ROSA to mental health, Dr. [FOOE Clinical Director, co-ed the note on March 17, 2018. On March 16, 2018, at 5:25 p.m., IHSC Dr. psychologist, signed off on a ‘mental health assessment conducted pursuant to NP| feral and documented the following: + Dr. FTO ronducted the assessment in English + During discussion of his past schizophrenia diagnosis, DE LA ROSA adamantly denied suicidal or homicidal ideations, gestures, or plan. «DE LA ROSA mentioned God told him he would speak in the lands of Israel, Iraq, and “Arabia” and would go to Heaven in the future. + DELA ROSA reported a history of drugs and alcohol. + DE LA ROSA reported a conviction of driving under the influence of alcohol and going 0 prison in 2004, and then to a mental health prison years later «DE LA ROSA stated he had friends to talk to for support, including his brother, and that he speaks to God. + Dr[FOOVET Hescribed DE LA ROSA as appropriately dressed and future-oriented. + Dr. IE also noted DE LA ROSA showed no abnormalities in psychomotor activity or body movement and his affect, mood, speech, insight, thought content, and judgement were normal DrfPO BCT Jetermined there were no current symptoms of a serious mental disorder or condition, But n the treatment section of the noes, he listed treatment planning and supportive: psychotherapy intervention. ‘The plan included multiple elements that focused on DE LA ROSA’s general wellness, coping and stress management skills, and dircction/understanding that he would notify staff if he had any issues or felt unsafe with himself. Dr.[XO/ XC] documented discussing this plan with DE LA ROSA, who verbalized understanding and agreed to Tollow the plan an ee Errno meron meditation, and positive TRIE; DE LA ROSA stated he would use the techniques when necessary. DEE fu noted staff scheduled DE LA ROSA for a psychiatry evaluation and a mental heal ToTow-up. DE LA ROSA consented to receiving tele-psychiatry services. ATIC) “i 9 See CW Progress Note by DI Jdated March 16, 2018. 1 Affect refers tothe emotional RE TOR expresses, which can be appropriate o inappropriate in relationship to the situation. See IHSC Consent 0 Receive Tele-Psychiatry Services (Form 792), dated March 16, 2018, 7 [24 

DETAINEE DEATH REVIEW - Efrain DE LA ROSA Jems [70] On April 3, 2018, at 5:45 p.m. Officer TTT Jreported to Case CounselorfT0 O70] Bp boi Unit Manager[Xo BAC) that DE LA ROSA exhibited inappropriate TGF towards her. Security staf removed DE LA ROSA from the pod and Unit Manager Bg more him to stop making inappropriate comments to staff: however, DE LA regarding his actions after two officers TEPOEd To her that DE LA ROSA was being inappropriate. When DE LA ROSA failed to listen, Unit Manager, Instructed the. officers to submit their reports. ** i the second officer, Officer[PX® BNC [E,Jomcesdd to document hei separ emeions with DE LA ROSA OTice PO 7] “Completed an Incident of Prohibited Acts and Notice of Charges document and cited DE LA ROSA for Making Sexual Proposals or Threats. Subsequently, Shift Supervisor [X0 ©] ordered DE LA ROSA's placement in disciplinary segregation. At8:20 p.m [FTE |RN, completed DE LA ROSA’s segregation clearance assessment. RN[=_ documented DE LA ROSA’s vital signs were all within normal limits except for an eleva Blood pressure of 128789 RN{— _ noted that DE LA ROSA denied suicidal or homicidal ideations and visual or auditory Rallucinations. RNRoho noted DE LA ROSA did not appear to have any acute or unresolved medical conditions Which might worsen in segregation. RN Eoldueued DE LA ROSA on how to access medical, mental, and dental care while in seg SEATON and cleared him for housing. AUS:S2 pm, security staff placed DE LA ROSA into restricted housing unit (RHU)® Pod 7A, cell 205.0 Security staff created and accurately completed the Confinement Activity Record (CAR)®" and Confinement Watch Log (CWL)® for this date." AUI0:1S pam. umes a telephone encounter to the Mental Health Unit stating she cleared DE LA ROSA Tor housing in segregation. So eden ment Oto Ded Ape 3,013 A ERAU interview with Unit Maser — Hated August 15, 2018. 15 Se Inde Stent by Ofcom Thckdent Semen by Offi dad Apel 3, 2018, See Incident of Proibited Acts rk of Charges, dated April 3, 2018 See Confinement Record, dated Apel 3, 2015 3 Se SO rg et [SE ari. 2018. The SDC RHU is special marlS50heht unit (SMU) as defined in the ICE detention siandards. © See Cllmte Housing History Report, dated March 13, 2015 — May 4, 2015 The CAR i a multi-purpose form posted on a clipboard outside cach cll within segregation and details which meals, recreation, visits and other activities th detainee partook in that day. RNs also sgn this ecord during thee rounds Ax SDC docs ot Have an electronic system or recordin rounds, officers manually record the te oftheir rounds on the CWL. Additionally, cach shi supervisor required 0 sign the form. and RNs re required to document the time of thie rounds, a well as mornin, noon, andlor evening delivery of medication, when applicable. oo “PERAU notes during DE LA ROSA's placements in segregation, multiple CARS and CWLs were void of ties or Jocuments specifics regarding refused activities and meals recorded on DE LA ROSA's CARS during is Jacements i gregaton Be Telephone Encounter by RN [= Juan os 8 2) 

DETAINEE DEATH REVIEW - Efrain DE LA ROSA JICMS On AFI, 20183-1043 0.m., Sergeant (Sgt. initiated an investigation related to DE LA ROSA's offense.** Sg Jmerviewed DE LA ROSA, during which he admitted to the offenses charged. SetfPi%) JAoted referral to the Institution Disciplinary Panel (IDP).* At 10:48 am., SgfoX) issued DE LA ROSA his Detainee Rights at the IDP’ Hearing,” which DE LA ROSA $7gied as having received. Aul127 an fT] RN, completed an initial segregation round. For questions related to thoughts OF Swede, medical complaints or requests, and referral for health care won, Re no changes th pre-populated answers of “No.” Addiionaly, the pre-populated segregation evaluation template language remained unedited in the Examination section. Therefore, Re failed to include subjective findings reflecting an individualized assessment oF DELA ROSA. ERAU further notes that during DE LA ROSA’s multiple segregation placements, RNs ‘completed daily medical segregation rounds but al entries contained the same template language with no supplemental information reflecting an individualized assessment of the detainee.” A317 pan. [FTC Licensed Clinical Social Worker (LCSW), signed off on DE LA ROSA’s clinical segregation assessment pursuant to RNR Jreferral and documented the following: L + DELA ROSA’s thoughts, mood, and affect were consistent with previous reports. DE LA ROSA stated he was fine and adjusting well to being in segregation + DE LA ROSA denied having suicidal and homicidal ideations, intent, or plan. + DELAROSA’s dress was appropriate and his grooming and hygiene were adequate. ee Investigation Report, dated April 4, 2018 see Jones the investigation at 10:52 am. An DP is higher-level disciplinary panel tht ad SAE Hetine incident reports. The pane is comprised of 49) |_cther the individual appointed by th fcility administrator or one single disciplinary hearin officer. See Detsine Rights a the IDP Hering. dad April 4 2015 See Incident aT Prohibited Acts and Notice of Charges, dated April 3, 2018. 2 Sec cCW Progress Note by RN Jdated April 4, 2013. ERAU notes RNB id pot sign pis nr nit. Api 9, 201.2 523 am ve TET he round. Although ERAU id not meric RN. — Jegarding this din RBI BITC cin on vg 16,201 copa anc ivr Tres ne ound and ent Tea 7 cCW following return o the lnc. She futher sated. although nurses re expected to make allenic prior to the end of their shif, occasionally some ar missed per IHSC Directive 03-06, Health Evaluation of Detainees in Special Magen Unit, Section 5.2: On-going Medical Rounds in the SMU, “a) The RN or medical provider conducts daily rounds in the SMU: (5) The RN or medical provider queries ach individual regarding medical, dental and behavioral health concerns or requests Particular consideration i given to the possibilty of suicidal ideation or temps: and (©) The RN or medical provider documents the medical rounds in the SMU lo book and in the patents health record. The pogess not is in he SOAP (Subjective, Objective. Assessment, Plan) format and summarizes the patient's disposition (0 include whether the patient stable. has no medical or psychistric concerns voiced or homicidal or suicidal plan o nent; and ifthe patient will continue to recive monitoring daily while in the SMU) 7" Unles a significant event occurred related ta daly medical segregation ound, completion of medical segregation rounds and th usc of template language are not discussed futher within the report 7 See eCW Progress Note by LCSWIBRD Hated Apel 4, 2018 rei tilzed SOAP format within her EA " Ld 9 [3] 

. TE DETAINEE DEATH REVIEW - Efrain DE LA ROSA JICMS 1 + DE LA ROSA was receiving mental health treatment by way of tlk therapy.” © LCSW Josruced and reminded DE LA ROSA of th proces 0 request mena health Services if he had any issues. Leslie hoes ‘mental health providers were to follow up on a weekly basis, continue to monitor, and report any changes. LCS tetermined DE LA ROSA did not meet serious mental illness (SMI) criteria; therefore, he Was Stable enough to remain in segregation. HSC Licutenant (Lt) Commander (LCDR] LCSW, co-signed the note on April 19, 2013, concurring with LCSW, JooneTasions garding SMI and segregation. LCSW Cannon further recommended GORTIGIty of care needs as medically indicated to address coordination of chronic care management. SDC was unable 10 produce a CWL for this date On April §, 2018, at an unknown time, SDC sceurity staff issued DE LA ROSA a Notice of IDP "rT Hearing with a documented hearing date of April 6, 2018.7 On-April 6, 2018, at 12:42 p.m. the IDP conducted a disciplinary hearing at which DE LA ROSA again admitted inappropriate statements. ® The IDP sentenced DE LA ROSA 10.30 days of segregation; Shift Supervis firs name unknown) signed off on the sanction the same day.” Assistant Shift Supervisor __—] rst name unknown) delivered a copy of the IDP Report to DE LA ROSA three days Tater On April 10, 2018, at an unknown time, Officer PTT fompleted a special classification review using the ICE Custody Classification Worksheet.” Officer hdded Talk therapy, ho referred a psychotherapy, nlves an encounter by a mental beth professions 0 help tints cope ith thei felinge, problem sole, and change behavior pattern hat might contribute thie Symptoms. IHSC Directive 07-05, Serious Mental Disorders or Conditions, stats, “Detainees with SMI esd 0 be moritored closely to ensure consistent and adequate care. The Behavioral Health Unita IHSC Headquarters monitors ctinces with significant pychiaric impairmens. The Behavioral Health Provider (BHP) te ily completes and submits weekly report 1 BHU for otfiction and continued monitoring of thei seriously mentaly i etinces. SMI determination is basd on significant psychiatric impairment ofthe detainee. The detance must Incet one or more ofthe Following rtra based on th valuation compleied by the mental heslth cae provider: 6) One or more aciv psychiatric symploms: disorganization of thought or beavior, civ hallucinations o delusions. Catatonia, ever depressive sympioms, suicidal eaton. homicidal Keaton, sere exscesbtion of manic Symptons nd marked anxiety sn impulsivity: (5) History of mo than two psychic hospitalization in he past hrc months and ill presenting moderate 10 severe symptoms: (€) Prescatly taking pychiaric medication and ill presenting scive moderate 1 severe symptoms: (4) Continues to display harm 0 Sef or others in spite of yh neament andor pychistrc hospitalizations nd () Serious limitations i mental ctioning communicating, aking cae of activites of daily ling, social kill, ei) due o mental disability o severe medical conditions impaiing mental function. dementia o rumatic bran injury. See Notice of IDP Hearin, dated Apri 5. 2015, See IDP Report, dated April 6 2015. 7 1d: see also Disciplinary Segregation Orde, dated April 6, 2018. 7 See IDP Report, dated April. 2015. See ICE Custody Classification Assessment, dated Apel 10, 2013 10 10 

DETAINEE DEATH REVIEW — Efrain DE LA ROSA JICMS ™~ 1 two additional points for the disciplinary infraction, maintaining the current classification level of high; a supervisor approved the classification the next day. On April 11,2018, at 11:46 a.m., IHSC LUPO OTT LCSW, completed the weekly mental health segregation ound. LCSWPayc, JR TT she perceived DE LA ROSA to be can cooperative, nd wilh siidl on Fo ctl LESWELL os hoc Clinical Segregation Assessment checklist and determined DE LA ROSA did ot meet SMI criteria, LCSWIIO) Jco-signed the note on April 19, 2018, and noted concurrence with LCSWT,c, [fonctusions regarding SMI. On April 13,2018, in accordance with the ICE PBNDS 2011, a security supervisor or equivalent ‘was due to conduct an interview with DE LA ROSA as part of a seven-day review of his status. in disciplinary segregation. There is no record in DE LA ROSA’s detention file indicating the review occurred. On April 16, 2018, at approximately 12:00 pan. sew Jcumenct a mental health low ap. es ed hat DE LA ROSA deme amiony or visual halacinaions and stated he only 8 oice of God; he denied thoughts of self-harm and any content that was commanding, threatening or stressful in nature. DE LA ROSA also sated he began to hear voices in 2005 while in prison, and that the voices give him peace because they are there with him. DE LA ROSA refused evaluation for medication stating he did not need medication and signed a refusal form. The refusal form included standard language concerning the potential health consequences of refusing treatment or procedure and a hand-written note from LCSW [ific, Jexplaining the consequences of his refusal LCSW, Wetermined DE LA ROSA was not a danger to himself or others. ERAU notes LCSW219)_ did not utilize the ¢CW Clinical Segregation Assessment checklist; therefore, she did not COMPIEt the data checklist tha specifically addressed whether DE LA ROSA met SMI crt LCSWEEL, otc do id at nls ay chang 0 DE LA ROSA caret ramen plan Salas 25, 2013, DEP OOO Tiocumented confirmatory sign-off OF LCSW ote without ter comet SDC was unable to produce a CWL for April 17, 2018. On April 18,2018, at 10:58 am. LCSW{TLc, ined of on a mental health segregation round** and noted that DE LA ROSA presenied in a calm manner with no signs of ineffective coping or acute emotional distress. LCSW(2,¢, utilized the eCW Clinical Segregation Aesment checklist and determined DE LA ROSA dd not meet SM area. LCSW #779] © See CW Progress Note by LCSW) Fisted Apel 11,2008. ES RE LEVEE LA 630 on Lm sas eon April 17, 2018, but included comm ETT he encounter was ate ent SRT obeured on April 16, 2013 ERAU concluded th encounter occurred around 12:0 p.m. the refusal form documents this ie. = See Rfusal Form, ded April 16,2018 The form was signa by LCSW, fon wines by Les] Es No LES od A piri) n 1" 

DETAINEE DEATH REVIEW — Efrain DE LA ROSA JCMS] ‘made no change to DE LA ROSA’s assessment or treatment plan; there was no confirmatory sign-off by another provider on the note. At6:10 p.m., SDC transferred DE LA ROSA to general population unit 7B, cell 113% Neither the Confinement Record nor the Disciplinary Segregation Order forms provided specific reasoning as to why SDC released DE LA ROSA 15 days into his 30 days of disciplinary segregation.” According to the Confinement Record, which he signed two days later, Security Cher DE LA ROSA’ release from segregation, but no documentation provided supports that the facility administrator approved the carly release." Furthermore, security staf did not complete a special r-classification for DE LA ROSA within sag] y 24 hours prior to his release from segregation. On this date, DE LA ROSA’s medical record included an initial psychiatry appointment progress note by oe the contents of the note were blank.” Dr] — Jd not sign her notc until July T9, 2018, nine days after DE LA ROSA’s death. As discussed Tater in the report, the next time a prescribing mental health provider assessed DE LA ROSA was on April 24,2018, during an initial suicide risk assessment. On April 19, 2018, at 12:41 pam., SDC transferred DE LA ROSA to unit SB, cell 212, where he remained until facility staff placed him in protective custody on April 24, 2018.” On April 21, 2018, DE LA ROSA dated an incident statement, completed in Spanish with his name at the top bul unsigned, which requested transfer to another cell as he alleged his cellmate told him he was going to kill him.” There is no response or follow-up action from SDC documented on the form. According to the SDC Cellmate Housing History record, DE LA ROSA had one cellmate on this date, who SDC moved on April 23, 2018.7 *ERAU notes shhough the ICE PBNDS 2011 Standards and IHSC or SDC policy do not require confirmatory signoff by snothe provide in these instance, observations related 0 conimatory sign-of,o the ck of ne, Are detailed within the report for comity purpose. Furthermore, Creative Corrections advised that review and Sian-fTby another mental health professional supports quality mental heal nd suicide prevention management. See SDC Cellmate Housing History, dated March 13, 2015. May 3, 2013 See Confinement Record, dated Apel. 2018; See Disciplinary Sregation Order, atcd Api 6, 2015 See Confinment Record, ated Apel. 2018. In accord with the ICE PENDS 2011 Standard, Secury Management Unis, Scetion (VB). “The supervisor may recommend the detainees carly release from he SMU upon ding time in disciplinary Seer gation sno Jonge nesevary o regulate the detainees bebaviors an carly tease recommendation must have th Fly administrator’ approval before th detain may be etumed othe ic) general population.” lance with the ICE PBNDS 2011, Custody Classification System, Section (VHC), “Sta shall complet spec Tckssification within 2 hours before a detainee aves the SMU... ec rare ty Df — Jed apr 15, 2018 See SDC Cllmte Housing HITT March 1. 2018 - May 4, 2018, See nciden Statement, dated April 21. 2018. Multiple othe reason the form were void of information, to include answer to nur and medical questions. +See SDC Celmate Housing History, died March 13, 2018 May 4, 2018, 2 12 

DETAINEE DEATH REVIEW — Efiain DE LA ROSA JICMS[T™ | - On April 24, 2018, at 10:23 a.m, SDC re-assigned DE LA ROSA to RHU pod 7A, cell 201, nding investigation for protective custody.” At approximately 10:51 a.m. * Commander Psychiatric Mental Health Nurse Practitioner (PMIHNP), conducted a mental Thea assessment and noted the reason for the assessment was auditory hallucinations.” PMHNI HD Joocumented the following «DE LA ROSA's vital signs were all within normal limits, except for an elevated blood pressure of 135/85, DE LA ROSA was calm, cooperative, and fully oriented, and his affect was broad but with Some inappropriate laughter at times. «DE LA ROSA had no loose associations” or flight of ideas.” «DE LA ROSA made multiple statements about being the Antichrist but aso being filled with the Holy Spirit. + DE LA ROSA stated he would be dead within three days, that he might dic three times, and that he wanted to be alone and relax. a DE LA ROSA denied low mood, anxiety. and suicidal or homicidal ideations, plans, or im DE LA ROSA declined medication treatment. pint Jrquocd Jew Be Jon the interview due to her previous encounters with DEL KOS. FHNNPE JEDI LA ROSA was vate pisses bt ested he same sateen shout SRE being the Antichrist to LCSWlLey | Pin nd LCSW Follctivly determined DE LA ROSA was 4 positaf aber 0 himeaifand others PAPE) Fompleted am nl side rik sessment” and detrmined DE LA 2 oe : 214s also CorsCivi memorandum: Pending Investigation, dtcd April 2, 201% SF Cartamvita signs ar time stamped a 10:51 a.m. while others are time stamped a 1:33 pm. PMHNP_~ Jia no document penuh he noe and did ot clectrnialy sign-off on the note nt FDP. ne ogi Re Pend mh 0 ERA ho wo Sonn ol —- vera by halicar or security staff Tr Eahuation for audiory hallucinations. Bier | Zmrocrae auger is aughics hi is amespected dus to dntociion from he opi a ircumtancs. Los soiations over when pens responses ao eatin oh questions beng pose oi “Fi fers to disconnected rambling o rapid shifing of eas with oly superiil ssoised somection between th See cCW Progress Note by PAINT Jae Apel 24, 2018. The sid isk assessment includes risk and protective factors and mental satus Son elements 1 

DETAINEE DEATH REVIEW - Efrain DE LA ROSA JICMS 1 ROSA was at “Moderate Acute Risk”! for suicide; he ordered one-on-one suicide watch” and scheduled mental health follow-up for the next day. or ALS pm. rif hopes a Special Needs Form completed by LCSW which directed DE LA ROSA's placement on suicide watch in a safety cell. > LCSW] included handwritten instructions for security to maintain one-on-one visuals and allow only a smock, blanket, and finger foods. AC2:37 pan. Shift Supervisor FOU Jocumented DE LA ROSA's placement on suicide watch per medical.” According © a memorandum submitted by Unit ManagerP® O00] 10 Chief of Unit Managemen Ise: placed DE LA ROSA in segregation pending investigation for protective custody. ™ This memorandum was also signed by DE LA ROSA. At2:48 pm., Ofteers FTI hd TOT _Jondueted a strip search of DE LA ROSA." The documented reason Tor the Search was suicide watch and Shift Supervis signed the form. AU4:4S pa, security placed DE LA ROSA into RHU 7A, cell 112, where he remained until transfer to Columbia Regional Care Center (CRCC) on May 4, 2018.1% Security staff initiated a 1 Accontng oth IHSC Significant Slf-Harm snd Suicide Prevention and Inrvention Operations Memorandum (OM 16.002), moderate acute ik would require one-on-one suicide watch. Consideration for moderate seve risk ince, bt ar not mite fo. the presence of wiidal iestion ith vagus pla andlor nent the presence of multiple isk factors and high seu dies, “5 According to OM 16-0002, suicide watch aways involes continuous visual observation of one detainee by one security stall member (one-to-one). All detsinces on suicide vaich must be housed individually in aclldecmed Safe by custody siaff and medical Saf, Custody Saf collaborate ith on-site medical af fo eview the cel housing a suckle watch detainee and crsure th cll i a suicide Fesiant a Possible (6.5. ho rorsions of any Kind that would enable hanging o inflicting self harm). Suicide wach detainees ave hes belongings and isd clothing removed, wear a suicide smock, us suicide blanket, have mates 1 sleep on he floor or on ined ed, and ae given ood hat an be consumed thou the use of wensils finger foods). Custody stl document elle checks every 1 ute, and heal case provider (RN o higher documenta wee check at least every 8 hours, 15 See Special Necds Form, dated Apel 24, 2018, 1% See Confinement Record, dated April 24, 2018. 154 See Memorandum Re: Pending Investigation, dated April 24, 201. ERAU was unable to confi if DE LA ROSA's placement in segregation pending invesigation for protective custody is elated to his Apel 21, 2015, incident statment ora separate even loge. 5 See Record of Search dated Apel 24, 201, 1% See SDC Cellnate Housing Hiory dated Mach 13, 2013 - May 4, 2013. During ERAU'S interview with IHSC Commander[PX®) ®X7C)_ Jicalth Services Administrator (HSA), on August 14, 2018, he explained SDC wilzed the RTOS TRE Fath overflow. to nclde sce watch. AL the time of DE LA ROSA’ detention, venovations inthe Medical Health Unit (VHU) were erway, therfore observation cls wre ited. and DE LA ROSA was placed in RHU. He acknowledged although those cells a ot ant. gaur, detainees pace on suicide watch in these cell re on one-on-one observation 14 14 

DETAINEE DEATH REVIEW — Efrain DE LA ROSA JICMS | Cdim— Suicide Observation Checklist'” for this date and documented welfare checks every 15 minutes. AUSAS pm. Rf Jeonduced a suicide watch nursing assessment'®” and documented DE ROSA’s comments remained consistent, and he denied suicidal and homeidaT deations or auditory and visual hallucinations. RE dio documented security staff placed DE LA ROSA in suicide smock nd blanket ad SATed sicde watch wr ed medial rounds, o include the completion of vital signs each shift, and mental REaTth Founds would occur cach day. On April 25, 2018, at 1:00 am., seal watch pursing assessment DE LA ROSA denied auditory and visual hallucinations and suicidal ideation Bur SGTed he had conversations with God. Additionally. it was noted that DE LA ROSA’s vita signs were all within normal limits, except for an elevated blood pressure of 13287. A945 ne) RN, completed a suicide watch nursing assessment and documented DE TA ROSA'S vitglsiens were all within normal limits, except for an elevated previous night bu felt etter since he Was able to sleep through the night. At1:16 pm., sa off on DE LA ROSA’s mental health assessment and documented that DETAROSA dered suicidal or homicidal ideations but stated God was trying to kill him." Ee bio documented DE LA ROSA’s vital signs were all within normal limits, except for an elevated blood pressure of 147/83. se ‘medical staff would continue to monitor DE LA ROSA in MHU for concern of Suicidal ideations. Aton unknown ime, Leow Jocumened 1 follow-up subeide risk assessment and noted that DE LA ROSA continued To discuss his relationship with God. that he had already died, and 7 The Suicide Observation Checklist i uilzd 1 record the detainees activity every 15 minutes, such as skcping. walking, or sanding at the door. Security also maintains a CAR during suicide watch. = See Suicide Observation Checklist, dated April 24, 2018. Unless ERAU discovered a significant issue related t0 future Suicide Observation Checklists, hey are not furher discussed within the report ol 7 er the ICE PBNDS 2011. Significant Self-harm and Suicide Presenion and Intervention, Section F: Housing cast very § hours conducted by clinical sft” and IHSC OM 16-002. Section 5: Policies and Procedures, Housing and Monitoring. * While on-site, healthcare provider (RN or higher) must perform rounds and document ‘observations irthe health record at least every eight hours.” The CW form used by RNs to document suicide ‘wath rounds i not san one usd fo segregation rounds. The suicide watch form includes vital signs and SOAP cements. oY 10 See CW Progress Note-by RNC uated April 24. 2018. 11 See GW Progen Nove by RN sid Ap 25,2018, 57 by RN ited Apil 25, 2013. According to the AHA. this blood pressure reading indicates sage two hy pert GION Sage two hypertension i characterized by systolic reading of atleast 140 or a dasolc readin of at legs 00 1 See €CW Progress Note by Dr Jes April 25, 2018, 15 15 

DETAINEE DEATH REVIEW — Efrain DE LA ROSA JICMS[T0 1] if he died again he would be raised from the dead.!™* LCSW[biic) Hocumented that DE LA ROSA stated he wanted to return to Mexico and see females and did not want to be in general population as he did not want o fight with people. LCSW [Doh assessed DE LA ROSA's level of insight and judgement as poor and noted that he would remain on suicide watch due to 0300. nd mr commen wh LCV Rome Sh emer on On April 26, 2018, at approximately 9:00 a.m., a Supervisory Immigration and Enforcement Agent (SIEA), or equivalent, conducted an Administrative Segregation Review (ICE Form I- 885) of DE LA ROSA.""* The ICE Form 1-885 documented “Yes” responses for the questions, “Does the reason for initial placement remain valid” and, “Is the detainee unwilling or unable to live in general population.” Although the ICE Form 1-885 directions state, “If any of the above factors are marked *Yes." the detainee must continue hisher existing status, unless the Officer in Charge (OIC) determines otherwise,” the reviewer recommended DE LA ROSA’s removal from protective custody. Furthermore, if the reviewer interviewed DE LA ROSA, the reviewer did not document so on the ICE Form 1-885 or elsewhere in the detention file.''® The Field Office Director, or representative, signature line and date is blank but the box “Continue Status” is checked. A9:50am. rea conducted a suicide watch nursing assessment and documented DE TA ROSAS vital signs were all within normal limits except for an elevated blood pressure of 137/88.11% RN my DE LA ROSA had no complaints and denied experiencing suicidal homicidal GEOR or hallucinations. AL10:43 am." Dr] Be Joni a mental health assessment and documented DE LA ROSA’s vital siens were all within normal limits except for an elevated blood pressure of 137/88.120 Dre ocd that DE LA ROSA denied suicidal or homicidal ideations and stated no one was trying to kill him. Drie nade no changes to DE LA ROSA's treatment or follow-up plans. When asked about BE LA ROSA's repeatedly elevated blood pressure readings, DEE Jud DE LA ROSA’s blood pressure was abnormal on an irregular basis, 50 she believed Was potentially anxiety related versus a medical issue. 21 ora Teer na . CCW Progress Not by LCSW[D0c ated Aprit 25, 2013, LCSWDRoclid not sign he noe wit Apt 26,2013, 4:14 pm. but documented ATT he progress ote tha t was STA cir for April 25, 2013 5 See Administra Segregation Review. dated Api 26, 2013. The form includes name snd Signature on the SIEA or equivalent in but oth ar legible. SDC was unible o confirm the signatory therefore, ERAU was unable to merview the individual about the form dels 1 ERAU notes ICE Fon 1-885 do no nce designated section to document completion of an nerve with he deaince, hough he ICE PBNDS 2011. Special Management Unis standard egies documenaton of one. 1 ERAU notes here ae mulile instances where compliance ith the ight hour heslthars rounds cannot be confined du t unknown round Sec SOW Progras Na AEE Apel 26,2018, FERAL sores DIDI Jd not dociient the precise ime of the assessment; therfore, this time reflects when DEL Jock BE L.A ROSA vil sins SEECEAY Progress Note by DE Jad Api 26,2018. 1 ERAU interview with Dr Ted August 14, 201. Ditie, 16 16 

DETAINEE DEATH REVIEW — Efrain DE LA ROSA JICMS | 600 pan. RN conducted a side watch nursing assessment and documented DE LA ROSA denied homicidal suicidal ideations or hallucinations. RN) Jia not record vital signs. A835 pan NTT one a suicide watch nursing assessment and documented DE LA ROSA's vital SERS Were all within norma limits except an elevated blood pressure of 12477.18 RNP ted DE LA ROSA was cooperative with the examination. Aan unknown ome RN, conducted a musing assessment, RNP] uilized the segregation evaluation rather than the suicide watch assessment, did not document vital signs, and did not sign her note until July 19, 2018.1 Avan ynknown time, LCSW[Bitke Fondueted a follow-up suicide ris assessment, LCSW (Eicon ELA KSA int vt ham lft nc vol ds ss JORTBle deaths. It was also noted that DE LA ROSA denied auditory or visual hallucinations but stated he heard things and did not want to be around others because of that. LCSW [P® ®7C)| ‘documented assessment findings of delusional disorder and schizophrenia. DE LA ROSA remained on suicide watch. On this date only, security staff documented 15-minute rounds on the Mental Health Observation Checklist form rather than the Suicide Observation Checklist form. "> On April 27, 2018, at 8:51 am. PMHNP[OCFomplted a follow-up suicide risk assessment and documented DE LA ROSA's vita} sions Were all within normal limits except an elevated blood pressure of 122/71. As that although DE LA ROSA continued to deny suicidal ideation, plan, or intent to harm himself, he again stated he would soon die three horrible deaths and be resurrected three times. PMHNP also noted that DE LA ROSA continued to express grandiose beliefs that he was the Antichrist but believed that God was using him as an instrument of change to save the world. According to the assessment, DE LA ROSA reported speaking directly to God and being answered by God and DE LA ROSA continued to refuse oy — ono) Frame ah rae Pt i as - et Progress Note by Ned ALIGNS. Acsotguo the MA Bibione a ’ emg CCW Program Nore by RN | Luc April 26, 2018. — en aig sisted so ETE ctr SDC me oe se it. DUET oR] EA cn Apt bm 15, 2018 respectively they plained mses who Conduct RTT: RTC TAVE STOUR hat dentles deviees on neta hai esvaion and sce Emr EVEL a2 01. csi ster mt 27.3018, at 1100: bat documnteh ai the pogiss nse tat was TT Sn for Apr 36. 2015. Thre eon iony Sel ty seth tr 5 =e Mental Health Observation Check. dated Ape 26. 2015, ERAU nots upon comparison, the forms Bn ae ESTERA mote EMEP id not document he rcs ime of the sessment thelr, ise refs Fe | spe ome 4 DE LA ROSA vil signs. oo ” 

or } ove DETAINEE DEATH REVIEW - Efrain DE LA ROSA JIcMS[™® | treatment and stated he did not need medication. PMN] —Jietermined DE LA ROSA was danger to himself and potently 1 others. PMHNRES yc FIs the ase with LCSW B17] and determined medical staff would refer DE LA ROSATO CRCC for inpatient hospitalization. LCSW documented confimatry Sg off and once with the " plan on May 2, 2018. At9:30 am. [IO BI0 | RN, conducted a suicide watch nursing assessment and documented DE LA ROSA denied hallucinations or homicidal suicidal ideation." RN [did not record vital signs or sign the note until July 19, 2018, nine days after DE LA ROSA™ death. At12:40 pm. RNC, Jronducted a suicide watch nursing assessment and documented DE LA ROSA's vitals were al within norma limits except for an elevated blood pressure of 4590.1 NET rote DE LA ROSA was asymptomatic relative to his clevated blood pressure and that she made Dr O00 ware, AL2:39 pm." DPD Jeonducted a mental health observation assessment. Dr. POO ocureaied BELA ROSA vial were all within normal limits neept fo an TEVGTHIon prosure of 14890. DAT PNAC noted DE LA ROSA was sontaly unchanged in overall presentation, and medical Stat would continue to follow up with mental health until medical staff determined proper placement. A10:30 pa RN, conducted a suicide watch nursing assessment and documented DE TA ROSA'S vital signs were all within normal limits except for an elevated blood pressure of 146/86." REE DE LA ROSA was sitting on his bed, alert, and fully oriented and not experiencing audiory or visual hallucinations On April 28, 2018, at 8:40 am. ox Jonduced a mental health observation assessment and documented DE LA ROSAS Vial Signs were all within normal limits except for an elevated blood pressure of 124/80. —_— EO [Terry co) PR, with CROC for cae of detainees Who equie psychic serves SWSH the Facility scope. SDC transfers 8 152 ERAU notes RN|_— 0d or document the precise time of the assessment; therefor, his im reflects when RN liocumented DE. LAROSAs wal signs, 4 ERAU notes Df BAERS Tament the precise in of the ssscsment therefore, his te reflects See eC Progress Rowe by Dr[DPO DIC) Jane April 27. 2015 17 ERAY notes DPX RNC) JRE mcument the precise time of the assessment; therefore, this time reflects. ‘hen DIPIO. O10) Jiocmenied DE LA ROSA's vil signs. See Eve DIE BIC Josed Ap 25, 2018, BRAU sts si odd eas eslthare round ore than 10 hots CTE 18 18 

DETAINEE DEATH REVIEW — Efrain DE LA ROSA JICMS[T™ Aud am. [TOPO IRN, conducted a suicide watch nursing assessment and documented DE LA ROSA fms were all within normal limits except for an elevated blood pressure of 124/80. Ei fod that DE LA ROSA denied suicidal/homicidal ideations or hallucinations. A439 pan. RN[Bke,_Jronducted a suicide watch nursing assessment and documented DE LA ROSA’s vital signs were all within normal limits except for an elevated blood pressure of 124776. On April 29,2018, at 12:50 am. ky. conducted a suicide watch nursing assessment and documented DE LA ROSAS vial signs were all within normal limits," AU7:11 am. SPETPIC NP, conducted a mental health observation assessment and documented DE TA ROSA’s vital signs were all within normal limits except for an elevated blood pressure of 139/88. ef pes that DE LA ROSA denied suicidal/homicidal ideations or hallucinations. Ats15 am. RNC Fonducted a suicide watch nursing assessment and documented DE LA ROSA’s vital signs were al within normal limits except for an elevated blood pressure of 130/88.144 ow A229 pam. RN[TG, Joonducted a suicide watch nursing assessment and documented DE LA ROSA*s-vital signs were al within normal limits except for an elevated blood pressure of 125/86." RN[—Jnoted that DE LA ROSA continued to deny suicidal and homicidal ideations or halluEmaions. On April 30, 2018, a 12:30 a.m. RN[[7ic, ronducted a suicide watch nursing assessment and documented DE LA ROSA’s vital signs were all within normal limits except for an elevated blood pressure of 145/88. Au8:25 am. RN[BTic, Jeonducted a suicide watch nursing assessment and documented DE LA ROSA’s vita signs were all within normal limits except for an elevated blood pressure of 152/92.147 Raf Joc that DE LA ROSA denied suicidal/homicidal ideations or hallucinations. rec pene iid 1% See «CW Progress Note by BF] dated April 28, 2018 ai 8:45 a.m. 7 cc COW Progress Note by R ted April 28, 2018 1 439 pn [=__Jiocumented DETA ROSA's vital signs. TFS CW Progress Note by NHDID) Fed April 29,2015. 15 See €CW Progress Note by R dated April 20,2015. 4 Se CCW Progress Not by od April 30, 2015. 1 See CW Progres Note by R ted Api 30. 2015 19 19 

DETAINEE DEATH REVIEW — Efrain DE LA ROSA JICMs [70] AUI2:29 pam, 1 Drie Jonducted ‘a mental health observation assessment and documented DE LA ROSA’s vital signs were all within normal limits except for an elevated blood pressure of 142/80. Dif footed that DE LA ROSA denied suicidal/homicidal ideations or hallucinations! Aan unknown time, LCSW[RIEic, Jeonducted a follow-up suicide risk assessment and documented DE LA ROSA continued to present with fixed delusions and consistently declined medication.” om described DE LA ROSA’s appearance and affect as odd. LESWRlC Join DE TA ROSA was at risk of being a danger to himself and others and he remainéd Todmed on the concept of death. DE LA ROSA again declined to be treated with medication. As of this date, referral to CRCC remained pending. On May 1, 2018, at 8:43 am. RN[ D0. konducted a suicide risk nursing assessment and documented DE LA ROSA’s vital Signs were all within normal limits except for an elevated blood prewar of 139/81. RNS, ted that DE LA ROSA vce mo sucidl homicidal ideations. : AUIZ09 pan, Dre Jonducied a mental health observation assessment and documented DE LA ROSA’s vital signs were all within normal limits except for an elevated blood pressure of 139/81." Dr Jnoted tha DE LA ROSA denied suicidal homicidal deatons or physical complaints AUR pm, LeswRRe June off on a wellness check and noted DE LA ROSA continued 0 present with fxed GETUSIOns and focused on concepts of death.'** LCSWIS3), Jnoted DE LA ROSA felt hopeless, helpless, and like he was a burden to others. In response t further questioning on these risk factors, DE LA ROSA stated he sometimes felt bad because he was in Jail and he was a burden to others because he was the Antichrist and rejected Jesus Christ LCSWIEL, Jnoted CRCC accepted DE LA ROSA and travel arrangements were pending. There was no confirmatory sign-off by another provider. At4:00 p.m. [POPC IRN, conducted a suicide risk nursing assessment but did not record vital signs." RN[ZGL ]documented DE LA ROSA denied suicidal homicidal ideations or hallucinations. inc) ow — Fac Dri nor documcn the prise me of he sessment erfors,this s refcts wher Df JiocameHA BELA ROSA' vil sims Se CW Progren NOC By LCSW ted April 30,2018 seo bs ot ign er note uni May 1.2018 0 3:1 pm. but documented \TATRS progress not that if was a or April 30.2018, There was Be] = Confimatory sign-off by anobez sider “BEAL ses DED), Ji no SHien he precise time of the assessment; therefore, thi ime reflects when DE JocimEHA BELA ROSAS vil sim 7 TEST Progress Note by Df Hated May 1, 2018, Sry em tac bl dag on, 5 See €CW Progress Note by RY] ted May 1. 2015. 0) 20 

DETAINEE DEATH REVIEW — Efrain DE LA ROSA JICMS[™™ On May 2, 2018, at 8:45 a.m.,'** Dri Jonducied a mental health observation assessment and documented DE LA ROSA’s vital signs were all within normal limits except for an elevated blood pressure of 137/89." At9:03 am, RNBiGie, _Joonducted a suicide risk nursing assessment and documented DE LA ROSA’s vital signs were all within normal limits except for an elevated blood pressure of 128/88.1% 719:30 pm. [FTP JRN, conducted a suicide risk nursing assessment and documented DE LA ROSAS vial 720s were all within normal limits except for an elevated blood pressure of 137/89. When RN ocd DE LA ROSA how he was doing, he responded everything was fine. Atan unknown time, LeswBio fonduced a follow-up suicide isk assessment! LCSW noted DE LA ROSA continu To present with inappropriate laughter and believed he would dic three terrible deaths soon. When asked about suicidal ideations, DE LA ROSA smiled while replying, “No, not right now.” At this time, DE LA ROSA’ transfer to CRCC remained pending. There was no confirmatory sign-off by another provider. On May 3, 2018, 9:57 am." Dr [177c, Jeonducted a mental health observation assessment and document DE LA ROSA’s vital signs were all within normal limits except for an elevated blood pressure of 141/101. At 12:40 p.m., an SIEA, or equivalent, conducted an Administrative Segregation Review (ICE Form 1-885) of DE LA ROSA." Findings were identical to the April 26, 2018, segregation review, but this time the reviewer recommended DE LA ROSA remain in protective custody. Once again, the reviewer did not document an interview of DE LA ROSA on the ICE Form I 885 or elsewhere in the detention file. On the same date, the Field Office Director, or ET representative, checked the “Continue Status” box and signed the form. er PEA poe orca ere nf hea hen, iss fc whe Dr Jiocumc APOE EA ROSA al signs. oe et hs ed May 2.2018 —- RAL soies RN. Jd oT oament the pris in ofthe assessment therefore his me reflects when J a PL 15 iE {—Jomed Vay 2. 2008 1 See «CW Progress Not {Ried May 2. 2015. TT 4 Sc cCW Progress Note by LCSW aid May 2, 2013. LCSWIERGY Jd no sig he noe it May 3. Rae} 2018, at 7:33 a.m. but documented within the progress note that it was a late entry for May 2, 2018. There was no. sonfimatory signi bY another provider DL JiocumBAFHEA ROSA vil sins Sgn progress Now by Dated May 3.2015, 14 Sec Administrative Segregato TREES, dated May 32015. The form includes ame and signature on the SIEA or equivalent in but both are lie. SDC was unl fo confi the signatory therefore, ERAU was unable 0 terview the individual about fe form deals. or » 2 

DETAINEE DEATH REVIEW - Efrain DE LA ROSA Jems [70] Au3:19 pan, “PPO JRN, conducted a suicide risk nursing assessment and documented DE TA ROSA™S Vial Signs were al within normal limits except for an elevated blood prewure of 21/89 und an clevted pals of 103 RNP EFT cid tht DE LA ROSA denied any pain A3:54 pan. LCSWIDITo_igned off on a follow-up suicide risk assessment and documented oT similar findings to the previous day's encounter.'*” When asked about suicidal ideations, DE LA ROSA replied. “I already told you.” There was no confirmatory sign-off by another provider 7 ad the transfer to CRCC remained pending. AL9:40 pm. RN[—_onducted a suicide risk nursing assessment and documented DE LA ROSA vital sjanixere all within normal limits except for an elevated blood pressure of 137/89." RN[_Jnoted that DE LA ROSA denied any suicidal/homicidal ideations or hallucinations. On May 4, 2018, at 12:57 am. | RN, signed off on DE LA ROSA’s transfer summary to CRCC and documented a diagnosis of schizophrenia, delusional disorder, and suicidal ideations.” RN[JFjc) Fleared DE LA ROSA for travel. Avan unknown ime, Dr FTIR Jeonducted a mental heath observation assessment and documented DE LA ROSA'S vital signs were all within normal limits except for an clevated blood pressure of 135/30. Dr 50 Jnoted that DE LA ROSA appeared cam and ‘cooperative with the exam and denied any physical complaints. DPOB Jie noted CRCC would admit DE LA ROSA on this date Prior to DE LA ROSA’s departure from SDC, Officer ®7%0_] attempted to obtain DE LAROSA’s signature on the Release section of the Detainee Forwarding Address Form!” and Discharge Checklist section of the Receiving & Discharge Checklis,” but DE LA ROSA refused to sign the forms. approximately 7:32 a.m., SDC released DE LA ROSA into the care of CRCC for mental health treatment, where he remained until June 12, 2018.7 eons Tao ERAU notes RITZ not document th precise tne of the assessment; therfore, tis time reflects oe Shem RN[D0)___Jlocimemed DE LA ROSA's vita signs. 14 See eC Pre Note by RN [DIOL DXDLC dated May 3, 2015. . brogress Noe by LSTIE=— Fed May , 3018 14 See CW Progress Note by RNa May 3, 205. 19 See CW Progress Note by RMD. _Liated May 4. 2018. See «CW brogres Noe by Dr 30208. ngs FTE soi ic Signs a1 9:44 a.m. the SDC CellnsTe Tow Fiktory and CoreCivie Offender Marsgement Sytem information Support DE LA ROSA departed SDC for CRC around 7:32 a.m: therfore, the exact time of the assesment is unkown 1 See Detainee Forwarding Address Form, dted May 4. 2018. 72 Se SDC Receiving & Discharge Checklist, dated May 4, 2018 7 Sc SDC Celt Housing History, dated March 1, 201 - May 3, 2018. SDC did not provide documentation related to DE LA ROSA’ transport 0 CRC. 2 2 

DETAINEE DEATH REVIEW — Efrain DE LA ROSA JICMS[T™ 1 AU2:00 pm. DE LA ROSA signed a Treatment Agreement and Consent form in Spanish. At2:29 pn. [FO PIICT_JCRCC RN, signed off on DE LA ROSA's Nursing Assessment. RN iocumented DF LA ROSA was abe to ea and ses English hu hat hi primary language Was Spanish and that his vital signs were all within normal limits except for an elevated Bld presse of 16097 RL, od nt DE LA ROSA ste hed of a vy was being admitted to the hospital other than people thinking he was crazy. RNID Jalso noted his behavior was cooperative, friendly, and that he demonstrated appropriaie interaction. Rf, Juror documented DE LA ROSA’s thought process anneared within normal limits. “Depression with Suicidal Ideations” and “Psychosis” in the {SSEssTient form. wre approximately 3:48 p.m., CRCC placed DE LA ROSA under suicide precautions for 24 ous. which included suicide apparel and restricted movement a the facility.” ers eR ta unknown, CRCC RN, documented DE LA ROSA had an elevated blood pressure. of not document any other concerns but further noted an MD directed nursing staff [0 0Psefve DE LA ROSA’s blood pressure and notify the MD if his blood pressure remained high Atapproximately 9:45 a.m., FE Jonduced a Suicide Shift Assessment form in which she documented DE LA ROSA denier Sureitlal or homicidal ideations or hearing voices ‘commanding he hurt himself. AUILE33 am., DE LA ROSA signed a Neuroleptic (Antipsychotic) Medication Consent Form in English.” According to the CRCC Order Record History, medical staff prescribed DE LA ROSA the antipsychotic medications Haldol and Zyprexa while hospitalized at CRC. * Atapproximately 4:46 p.m., CRCC staff discontinued DE LA ROSAS suicide precautions. On May 7, 2018, at 12:29 p.m., DfT OC] psychiarist, signed off on DE LA ROSA’s initial psychiatric evaluation.™ According to the motes, DE LA ROSA stated while in prison, he was previously diagnosed with schizophrenia because he told staff he heard the voice of God. He further stated he refused to take medication at SDC because he believed there was nothing wrong with him sa [noted DE LA ROSA believed God spoke to him regularly. as do many other religious individuals. As such, Drfi% _|noted CRCC staff would need to continue observation of DE LA ROSA to determine iT signs and symptoms of schizophrenia 7 See CRC Treament Agreement and Consent form, ded May 4, 2015 7 See CRCC Nursing Assessment, dated May 4, 2015. 7% See CRCC Provider Treatment Order, dated May 3. 2015 17 See CROC Provider Treatment Onder - Verbal Telephone, dated May 4, 2015. 7 See CRCC Suicide Shit Assessment, dated May 5. 2015. 7 See CRCC Neurolepic (Antipsychotic) Medication Consent Form, dated May 5, 2018. 19 See CRC Order Record History. dated May - July. 2015. 5 See CRC Provider Treatment Order - Verbal Telephone, dated May 5. 2018. 15 Se CROC Initial Peychiaric Evaluation dated May 7, 2018, 2 2 

DETAINEE DEATH REVIEW - Efrain DE LA ROSA JICMS[™™ | were present. Drf0 Jocumented DE LA ROSA's thought form and content were coherent and appropriate, respectively. On May 9, 2018, at 9:16 a.m [7 PC ]Social Worker, signed off on DE LA ROSA’ initial psychosocial assessment and documented DE LA ROSA had a history of hypertension." On May 12,2018, at 1208 pan. Dr" psychiatrist, documented DE LA ROSA had told staff he was the Antichrist and would die in three days.'™ Drie, pod that DE LA ROSA stated God spoke with him on a daily basis, using the voice OF is own father, and ‘communicated with him through the television. DE LA ROSA stated he would be killed by someone soon in a horrible way but could not tell Dr raluten. DE LA ROSA added he would be resurrected and then used by God 10 rid the world oT everything else evil. Dr. Er ohio noted that DE LA ROSA said he had previously been killed and resurrected but WOuITTo! go into additional detail. DE LA ROSA claimed to look forward to death but did not intend to harm himself because God would take care of that by having someone else kill him. May 20,2018, at 2:53 p.m., Df Jue DE LA ROSA continued to believe he was the Act and ht be wou be RT nares, According 0D ET Jot DE LA ROSA stated he knew the dat this would occur but could not share That information with DA 0 DLA ROSA shospore hs he vic God. who old i zod bad TES. But denied having suicidal or homicidal thoughts. On June, 2018, at 11:49 am., Dr J, Jnoted DE LA ROSA had shown significant improvement and was compliant with his psychotropic medication, even though DE LA ROSA did not think it was necessary. '* a DE LA ROSA continued to express he was the Antichrist and that at some port Tie would be killed and then resurrected. Dr[P® P70] also noted DE LA ROSA steadfastly maintained he was not suicidal and had no thoughts of harming himself or others. oe] further documented DE LA ROSA had reached the ‘maximum benefit of being at CRCC Bur recommended continued psychiatric treatment upon discharge. On June 10, 2018, at 4:15 p.m, offs] documented that although DE LA ROSA continued to have the delusion that he was The Antichrist and that he would be killed and rune, eva ot dl © DO ain od DE LA ROSA decd he ‘maximum benefit of being at CRCC an recommended continued psychiatric treatment upon discharge; she further commented that CRCC completed DE LA ROSA’s discharge summary. CRCC’s psychiatric discharge summary of DE LA ROSA’s care documented the following: ™ 19 See CROC Psychosocial Initial Assessment, dated May 9, 2015 14 See CROC Psychiatrist Progress Note, dted May 12, 2018 1% See CROC Pryehiatis Progress Note dated May 20, 2013. 15 See CRCC Paychitist Progress Noe, dated June 5, 2015. 19 See CRC Paychiatist Progress Note, dated June 10, 2018 15 See CROC Pryehiatric Discharge Summary. dated June 5, 2015. Altough th dat of servi nots June 5, 2015, the provider signed off on the document on July 13, 2018 at 512 pan. thee days afer DE LA ROSA's deh. Ii unclear if SDC received the discharge summary prior to DE LA ROSA's death. 2 2 

DETAINEE DEATH REVIEW — Efrain DE LA ROSA JICMS[T0 1] + On admission to CRC, DE LA ROSA reported he was able to hear the voice of God. Medical staff initially thought the patient's beliefs about communicating with God could have been part of his religious belief system, rather than evidence of psychosis. However, as DE LA ROSA became more comfortable discussing his experiences, it became clear the patient had delusions. DE LA ROSA also believed he was the Antichrist and that he had been killed twice before and arisen from the dead. He also said he believed he would be killed again shortly but commented he was not permitted by God to disclose when that would happen. «DE LA ROSA denied suicidal thoughts while at CRCC, and there was no evidence he was suicidal while hospitalized. «DE LA ROSA was initially resistant to taking medication but by the time of discharge he was compliant. «Although Dre resco DE LA ROSA Haldol"” and Zyprexa, he continued 10 be delusional but was less guarded and interacted better with other patients; he also participated in group activiics «DE LA ROSA stated he would consider taking medication after discharge although he did not feel he needed it. + DELAROSA's insight and judgment were chronically impaired. «Laboratory tests performed were non-contributory and his condition was stable for discharge, having reached the maximum hospital benefit. « CRCC listed DE LA ROSA’ discharge medications as Zyprexa (20 mg) and Haldol (5 mg). Although not reflected in the CRCC discharge summary, the CRCC medical record documents ‘medical staff ordered DE LA ROSA amlodipine in response to his elevated blood pressure. Additionally, the Medication Reconciliation for Discharge Transfer lists Norvasc, along with Zyprexa and Haldol, as discharge medications.” On June 11, 2018, prior to DE LA ROSA’s return to SDC, Officerfol0 Lom DE LA ROSA’ ICE Custody Classification Worksheet." Officer] —Jassigned a custody level of high, and a supervisor approved the rating on June 13, 2018. On June 12,2018, 2:20 am (CROC RN, added a nursing progress note stating DE LA ROSA was with the security officer for discharge. At 8:30 a.m., upon DE LA ROSA's return from CRCC to SDC, RN English conducted DE LA ROSA’s medical pre- screening.'”’ RN English documented receipt of a medical transfer summary from CRCC. At 1 Haldo is an aipsychoti medication sed to eat mental disorders, inching schizophrenia 7 Zyprexa san antipsychotic medication usd to eat mental diorders, including schizophren, 1 5d CROC Onder Record History - Medication Onder, dated May - June 2013 7 Norvase i a brand name fo amlodipine, which san anihypertensive medication 19 See CRC Medication Reconcilision fo Discharge Trans List, dted July 8, 2013 1% See ICE Custody Classification Worksheet, dated Jun 11, 2018. ERAU nots the special vulnerabilities scton omitied mention of any serious mental ess. 1% ERAU notes both the officers and supervisor's signatures were illegible. 1% See CROC Nursing Progress not, dad Jun 12, 2015 17 See CW Progress Noe by RN) Jed Joe 12,2018, 2 25 

DETAINEE DEATH REVIEW - Efrain DE LA ROSA JICMS [1 following: + DELAROSA's vital signs were all within normal limits «DE LA ROSA reported a history of schizophrenia, hypertension, and alcohol abuse. + DELA ROSA was taking the medications Haldol (5 mg), Norvasc (10 mg), and Zyprexa Omg). RN[EiDie, Jeeared DE LA ROSA for custody but designated he intake screening as abnormal and referred him to a provider. DE LA ROSA also signed an IHSC Medical Consent Form for general treatment.” AU: am Ome ebook DE LA ROSA into SDC. AUI0:17 am., SDC assigned him to general population unit 7, pod B, cell 104. Atan unknown time, wesw ko cd a mental health assessment duc 0 DE LA ROSA’s return from CRC.” WIoiic, Jdocumented that DE LA ROSA stated he was given medication at CRCC, taking his last dose the prior evening, but did not feel i helped. DE LA ROSA also mentioned he did not want to continue to take his medication as he did not need them. Although he again discussed his future deaths and resurrections, DE LA ROSA stated he would not harm himself. LES Joed she discussed medication compliance and reoccurrence of symptoms with BETA ROSA. AUR09 pam. ri a telephone order for amlodipine (10 me) in the morning and ola ZAPTRE™ (2 mg) and haloperidol*>* (5 mg), both in the evening, for DE LA ROSA (0 keep-on-person (KOP).:** ERAU notes there were no signed consent forms for the two psychotropic medications, olanzapine and haloperidol. On ane 13.3019 am [TTT] conta sts si examination as medical suff last exammed DEA ROSA at SDC on March 15, 2018.2 The examination revealed that DE LA ROSA's vital signs were all within normal limits excep for an levated blood pressure of 12377. Additionally, DF LA ROSA dened any pain Ne ‘completed an Abnormal Involuntary Movement Scale (AIMS) test to determine if DE LA ROSA een papery ET Jc 12.20 17 See IHSC Medical Consent Fork GIG une 12, 2015. 20 See Commitment Summary, dated Jun 12, 2015. 1 Se Cella Housing History Report dated June 12,2018 - July 10, 201% Se ey COE Tne 1 ie ot ihe oe uni ly 1, pn dente HAR mem SAP or S08 note vas locked on July 1. 2015. There was no confirmatory sign-off by snothe provide. = Olanzapine is generic Zyprexa Haloperidol is generic Haldo, 2 ergo Ets EFTETET Joe n 15,200. ioe DFT ro ee thre medications on his dat. pe FESR Ta did ot tart hes unl June 14-205 of the delay is unknown. 250 GW Progress Noe by NFL une 13,2018 2 2% 

DETAINEE DEATH REVIEW - Efrain DE LA ROSA JICMS 0] was experiencing side effects from psychotropic medications; the score was zero. NPP P00] noted a follow-up would oceur in two weeks.” On June 14, 2018, at an unknown time, Ottceffiie, Jeomplted the remainder of DE LA ROSA’s intake process back into SDC. At 1:36 pti SDC moved DE LA ROSA to general population unit 5. pod A, cell 213.2 On this date, SDC medical staff began attempts to administer the medication Dr[70 P70] had ordered for DE LA ROSA on June 12, 2018.2" DE LA ROSA refused all medications up to and including the day of his suicide; documentation and follow-up by medical staff related to his refusals were limited. Although there were many occasions medical staff documented on his Medication Administration Record (MAR) that DE LA ROSA did not present for pill call, medical staff did not document any efforts to account for DE LA ROSA to confirm if his failure to report for pill call constituted a refusal of his medications. As such, medical staff could have educated him on the associated risks and had him sign a refusal form. Furthermore, as discussed later in the report, security staff placed DE LA ROSA in segregation again, during which time medical staff repeatedly documented DE LA ROSA did not present for pill call, although medical staff administered medications directly to the detainee through their cell door while in segregation. Additionally, medical staff did not consistently notify providers DE LA ROSA was not taking his prescribed medications and, when notified. a provider did not follow up consistently. Exhibit 2 details specifics related to refusals, referrals to providers. and provider follow-ups, unless a significant event tied to medication administration occurred 21! On June 15,2018, at 238 pn [TOT JLicensed Practical Nurse (LPN), notified NP POO Yi DE LA ROSA elise Bs morning amlodipine dose Three days hater, in the Action Taken section, NHI, Jocumented “noted.” This is the first of 17 telephone encounters nurses sent NF.2), notifying her of DE LA ROSA’ refusals.2* At no time after DE LA ROSA'’s ret from CRCC on June 12, 2018, did NHI, see him. Nelo puted she conferred with mental health personnel and reviewed DE LA ROSA's chart, and medical staff scheduled him for follow-up appointments. 2'* NEED, hdded that medical staff rescheduled these follow-up appointments due to staffing Tosues. Except for an encounter on June 19, 2018, there was no documentation provided to confirm medical staff scheduled or 7 ERA notes ther i no documentation a medical provide followed up within two weeks 2% See SDC Intake Documents, dated June 14, 2018. ERAU notes DE LA ROSA signed all nike processing documents on his dat. It is unknown why security did not complet the remainder of DE LA ROSA’ intake process uni two days tr. See Cellmate Housing History Report, dad June 12, 2018 - July 10,2018, 0 See MAR 1 See Enhibit 2 Creative Corrections Detsinge Death Reviews Healthcare and Security Analysis 2 or gone Enc y LBL os 152018 19 AS mentioned above, specifics ea SREY 17 refusals of mediation and subsequent referrals providers by way of telephone encounters are detailed in EXhibi 2 and are ot frthr discussed within the report unless a significant vent occured refted tt. 2 2 

DETAINEE DEATH REVIEW - Efrain DE LA ROSA JCMS] identified this issue and recommended providers document why appointments are not carried out in the future. >'$ On June 18, 2018, at approximately 4:51am [7 ©© Licensed Vocational Nurse (LVN). otfcd NE LCSWETC ia DE LA ROSA refused hi previo ight's Haldol and Zyprexa fosei= PBS Jespanded that the mental health provider was formed LCSW EL red mic if Shes 3n pone vi DE LA ROSA for June 19,2018. On June 19,2018, at 10:55 am., Losey Jimed off on her assessment of DE LA ROSA in response to his medication refusals. > STiedocumented DE LA ROSA stated he did not need ‘medication but still believed he was the Antichrist. LCSWDie iso documented that DE LA ROS dre sn hs of lamang ny vost FOWL roid ‘medication education, explained the importance of compliance, and insti DE LA ROSA to report to staff immediately should he begin to have thoughts of self-harm or command auditory Hatucinations. Dr DO" Tosyehologis, reviewed nd concurred with LCSW PID B10] encounter note seven days Tater He further noted the BHU would continue to monitor DE LA ROSA’s continuity of care needs and mental status examination in consult with the mental health team and Dr POET JIHSC Chie Pychiait. DIZ, is directed staff 0 noy BHU if a higher Tevel of care became necessary. A452 pm. Officer uocumened an incident with DE LA ROSA and cited him for the prohibited act oT making a sexual proposal*'* AU5:10 pm [FOO JRN, completed DE LA ROSA’s segregation clearance assessment and documented DE LA ROSA’s vital signs were all within normal limits except for an clovared blood presarc of 13286. REE DEA ROSA was in no acute distress and within normal limits of behavior, Sect md cognitive functioning and cleared him for segregation 20 A605 pam, — ordered DE LA ROSA’s placement in disciplinary Segregation’ and secary FOV DETA ROSA to RHU unit 7 pod A, cel 1072 - 5 RAD ere wit HAP PT cd August 14,2015. Hi 21 See Telephone Encounters by TVR[—_ dated June 17. 2018: see also MAR. Medical staff notifisd ECSW 5 —| [EIS DE LA ROSA's mdicaton Ti and follow-up telephone counter sent 0 NFL Jon one ther ELE. Tare, 3013. Alla ication by mis Sl efning DE LA ROSA's ETT iu dy Comet at bic ot hh dbl sa mo LOW [5 —bDE LA ROSA™ medication refusal on these two occasions, she was not a prescribing provider: therefore. SP Joould have been he provider o ake action. ar Tr This OXNIC) 21 See Incident of Prohibited Acts ind NOTeE of Charges, dared June 19, 2015. Se Bsc Noe by RN ated June 19. 201% confirm TTRR[ = Joviewed Ea medica record o was aware of his ongoing sss elated to mena lcs TTT on refusal. 1 See Confinement Record, dated Jne 19, 20 See Climate Housing History Report, dated Jie 12,2018 July 10,2015 2 ar 28 

DETAINEE DEATH REVIEW — Efrain DE LA ROSA JCMS] AU643 pm, Case Counselorfoiric) Jinitiated an investigation related to DE LA ROSA's offense” Case Counsclorf)c, _Jocumented DE LA ROSA was very calm and admitted approaching the officer. Case Comelorifl Tubscquenty referred the incident to the IDP and issued DE LA ROSA his Detainee Rights are IDP Hearing. On June 20,2018, at 12:31 p.m. security moved DE LA ROSA to RHU unit 7, pod B, cell 105, where he remained until his death. 2 avis pm LET ies tons me ssn. LWT] discussed DE LA ROSA'S placement in segregation with him and, when questioned Tour is behavior, DE LA ROSA stated the officer was beautiful, and he liked her. LCSW ®X0C)_] documented DE LA ROSA continued to deny the need for medication. DE LA ROSA mdicated he did not have any concerns related to housing in segregation or though of self-harm. LCSW Bilge DE LA ROSA met SMI criteria due to “one or more psychiatric symptoms, ese taking psychiatric medications and still presenting active moderate to severe symptoms. Serious limitations in mental functioning.” She also noted that he would benefit from “No” answer in response to the questions, “Does the detaine present any SE1VE sympioms” and “Is the detainee compliant with his/her treatment?” She provided no explanation for the conflicting information. unter WEFT as se ai HC at vi ps SoC as not an appropiate laceTeTT G7 DE LA ROSA, but nether she nor HSAPTD BCT] produced a copy of the e-mail. >?” Furthermore, LOSWRE Jocumenied completion of an IHSC Form 883, but one was not located in DE LA ROSA'S medical file or provided during the onsite view DET, Toward wih LCSWEEL, cower wt nd nerd he same narrative as the June 9, 2018 encounter. Atan unknown time, SDC informed DE LA ROSA his disciplinary hearing would occur on June 21,2018, at 10:10 am. The form documented DE LA ROSA did not request staff representation or witnesses present a the hearing. v7 2 See Investigation Report, dated June 19, 2015. st Housing History Report, dad June 12, 015 - July 10, 2015. Warden Peterson explained security moved all detaiees rom RU Pod A to 78, du tan si conditioner malfunction 2° See CW Progres Note by LCSW ad June 20,2015 identified a having significant pRyerRe: impairment utilizing the SMI criteria. the BH will immediately notify he HSA and document the following ino the Patient Report spreadsheet which he or she submits 10 BHU at HSC headquarters on a weekly basi: (1) Name. (b) Alen #, (© Facility. (4) Status (c.2. hospitalized, medical housing unit, general population, tc.) (0) Dingnosis, (1) Corset Symptoms, and (¢) Updates Treatment Plan” Furthermore, the BHP must complete a Mental Health Review Form (IHSC Form 883) for every patient on the Patient Report spreadsheet at the inclusion of the patent on the lst and once a month theater ss long asthe detainee remains on he lst which is determined by the evaluation completed by the mental health care provider.” Eun 2 See Notice of IDP Hering. dated JERET0-2015. 2 2 

DETAINEE DEATH REVIEW — Efrain DE LA ROSA JIcMs [70] On June 21, 2018, at 10:55 a.m. the IDP conducted a disciplinary hearing for DE LA ROSA’ violation. The hearing officer, Assistant Shift Spe TE comes DE LA ROSA admitted 10 the charges. A supervisor reviewed and CORCUred with the findings the following day. Assistant Shift SupervisorfS19 Jentenced DE LA ROSA to 30 days’ segregation. On June 22, 2018, at 10:00 a.m., an SIEA, or equivalent, completed an ICE Form 1887.27 The ICE Form 1-887 documented “Yes answers to multiple factors, which required DE LA ROSA to continue his segregation status, unless the OIC determined otherwise. Again, the reviewer did not document an interview of DE LA ROSA on the ICE Form 1-887 or elsewhere in the detention file. The SIEA recommended DE LA ROSA remain in disciplinary segregation and the (Acting) Assistant Field Office Director (AFOD) agreed to continue the status wre 5 TAROSA On June 27, 2018, at 4:11 pn. PMIAINPL— Signed off on a mental health assessment and mented DE LA ROSA had no active Symptoms and did not meet SMI criteria. PMHNP BBicrJepored DE LA ROSA"s mood was happy, his affect was ppropite is behavior ‘Pleasant and cooperative, and his judgment was insightful. PE od DE LA ROSA was receiving psychotropic medications and talk therapy for treatmett, a that he was - ‘compliant with his medication. When asked to elaborate on the latter, J 2 ed that DE LA ROSA reported he was taking his medication, and he assumed DE A ROSA wa being truthful since he seemed much beter.> Additionally, PMHNP[2'S) hoted that DE LA ROSA continued to deny thoughts of self-harm. Dr|_—Foncurred with PMHNHEE.:, encounter note two days later and entered the same WGTFFATVe as previous encounters. According othe MARTTI JR. administered igh doses of aldol and olnapine and DE LA ROSA complied ™ ERAU was unable to discuss either this medication adminisigation or two additional administrations of night medications on June 28 and 29, 2018 with RN?) Las her employer, InGenesis, separated her from service at SDC on-AugGst 10, 2018. FSA VO) _Jexplained that InGenesis separated RN _—Jrom service after the discovered she TATE Tuly 10, 2018, entry on DE LA ROSA's STATS HSAPD TE 20 See IDP Report, dated June 21, 2015, 1 See Disciplinary Segregation Onder, dated June 21, 2015. 2 See Disciplinary Segregation Review, dated June 32. 2018. All signatures on this form were illegible 2 Similar to the ICE Form 1-85. i docs no include a designated section t document completion ofa interview withthe detainee. 34 See IDP Report, dated June 22.2013 2 See cOW Progress Note by PALI ed Jue 27, 2015. 4 ERAU nerve with PMHNADIS) Ki Aug 15, 2015 2 See MAR oo SX ERAU meri with HS APT OO August 14,201; Sel mir Jt Presi Satin, dated August 10,2018, 9 ERAU imerview with SAL ited August 14. 2018, In his instance, Ripe Jocumented DE LA ROSA refused his mediator he did not approach Bs cell. 30 30 

DETAINEE DEATH REVIEW — Efrain DE LA ROSA JICMS 1 concluded, considering this information and DE LA ROSA’s consistent non-compliance with medication treatment, these successful entries were highly unlikely. A Confinement Review Committee reviewed DE LA ROSA’s placement in SMU and determined that he should remain removed from the general population for disciplinary reasons. Other than an EARM entry, there was no other documentation provided to support this review ocurred. On July 2, 2018, SDC staff notified ERO Atlanta of DE LA ROSA’s scheduled return o general population on July 18, 2018.34! On July 3, 2018, at 9:32 aum., Security Chief[FI5,._Fompleted an ICE Form 1-887. He concluded the reason for DE LA ROSA's placement remained valid but proceeded to check the box to recommend DE LA ROSA’s removal from disciplinary segregation. Security Chief fii, did not document an interview of DE LA ROSA on the ICE Form 1-887 or elsewhere in the detention file. “The Field Office Director, or representative, signed the same day but did not document their determination of DE LA ROSA’s segregation status. DE LA ROSA remained in segregation. SDC was unable to produce a CWL for this date. On July 4, 2015, at 12:24 pm. PMHNP[Dchigned off on a mental health assessment and documented the same findings as his previous assessment, 0 include DE LAROSA's compliance with medication. Again. DeE Foncurred with PMHNFfGc, [encounter note and entered the same narrative as previous chcounters. July 10,2018 - Day of Death A104 pam. LCSW, fiend off ana meptal health assessment and again documented DE LA ROSA met SMI Grier" TesWEbe, fied DE LA ROSA presented as pleasantly delusions] and the content of his deloS RAE april fn nature VEER posi ha DE LA ROSA denied hearing any voices or thoughts of self-harm and expressed To desire to take medications as he did not believe he needed them. LOWE Jeminded DE LA ROSA of the benefits of medication compliance, but DE LA ROSA stfifet md stated, “I don’t need them.” Lewin, Fonfimed she conducted the assessment in her office and reported the encounter was ROFMAT=** Leslie Jocumantd completion of an IHSC Form 883 again, but one was not located in DE LAROSA-s medical file or provided during the on-site review. 0 See EARM entry for DE-LA ROSA, dated July 2. 2015. 1 See EARM entry for DE LA ROSA. dated July 2, 2015 2 See Disciplinary Segregation Review date July 3. 2015, 2 See cCW Progress Note by PMNHIDIO Wed Jy 4, 2018. 4 Se CCW Progress Note by LESWOI®_ Vaed July 10, 2015. ERA interview wih LCSW Jed August 14,2018. a1 31 

DETAINEE DEATH REVIEW - Efrain DE LA ROSA JCMS] wr or DrfElo koncurred with LeswTo_ foe and entered the same narrative as previous encounters. AU8:40 p.m. Officer [or Jeonducea a security round and looked into DE LA ROSAS Cll AGS112 pan, SATA 10:04 pan, Offcefe Jed conducting addons! rounds ona clipboaid atside of DE LA ROSA's cell hokaian BIE = 12 —] confirmed Oreo efi not look in DE LA ROSA cell at these times. A 10:05 pm. Office Jeter Pod 75 o assume the 3 sift post At 1008 pan., Oftcclflc, pearly nurse 10 a cell on the opposite side of the room from DE LA ROSA. At 10:57. oe FE Joes to Pod 7A, entered 7B, looked through Re cS STR hp 1195 GH reo the center of the unit and at 10:17 p.m., moved to his desk. oral (ET Wen he assumed post, he started to fill out the detainee information on each CARI CWL for the followipe dav because at midnight, he would need to post the new ones on their clipboards. one Ti that while escorting a nurse © another detainee’s cell, he noticed the last recorded SecuFty round conducted by frm at 10:04 pm; therefore, he believed he had time before the next required security round to start paperwork needed for the following day during his shift. AUL0:33 pan, otteefiic Fontes his first security round. 2! He approached DE LA ROSA's cell, looked if 0Ved to record his round, and then looked in the cell again gfte he on the cell door several times, and afer he received no response, called for medical emergency by radio. Tg he saw multiple socks wrapped around the top bunk rail. = — staf Tied he did not open the door and enter the cell himself as he was trained not to do 50 alone. 4 AM0:34 pm. ote Fchssimned to Pod 7A, responded to the medical emergency. Office proach TE LA ROSA’s cll, looked in, and spoke into his radio. Officefinic, | or 6 See Progress Not by LenB) td uy 10,2018. BRAU nots Dic, Jonfiematory signed te vr July 11, 2013, the day after DE EA ROSA expired. Ria) 20 See pod THEBES ted July 10, 2018. On this date, Offic [rerun omer 20000 — 1000 pm) igned o Pod 75, Sed CWE dted uly 10,2018, se alo Pod 78 video supseillce forage, ded oy 10-307. ERAU was anal to nerview OMGE{— Jy SDC terminated Office —for aly 26. 201 for fling t propery observe DE LA-ROSA while cond CTT Tis rounds. or 3 ASDC, SH Naa 6:00am 0 ERAU imcrview with OMe Jed August 14, 2018, od 7B video surveil EEE dated Joly 10, 2015 RAD ro ah Ofer Aust 14,2015 29 See Incident Report by OTE Yatd Jly 10, 2018 SS ERAU row with Oe Jord Aust 4,201. 5 See Pod TB acd Joly 10,2018 = 2 

DETAINEE DEATH REVIEW - Efrain DE LA ROSA JICMS [0 _] stated he called for a possible hanging over the radio then immediately wen to the RHU Control Center to retrieve the cut-down tool. = Office 0 assigned to the RHU Control Center, stated she heard the medical mre law Ofc, sain DELL ROSY sll hen Office CTE] on pounded on the window and askEE EF he cut-down tool? Offa Jook the tool from its storage box on the wall, removed it from its pouch, and placed the 150 the pass-through ov Ofte EIA | a! 9 2 or AUI035 pm, Office ued to DE LA ROSA’s cell accompanied by Lt. one) Eom Office Te. opened the cll door 2 1 sted upon exe RT iced DE LA ROSA’s feet were flat on the floor and hat Re was drooling. Officer Ble, nd ie Jprocesded 10 ft DE LA ROSA upward, while Officer] Jett through SOTRs tied AOU TS neck. AUL0:36 p.m. the officers placed DE LA ROSA on the floor, and ote Inman began cardio pulmonary resuscitation (CPR): Captain [FT ®176) urrived on the scene shortly after. AUI0:37 pam, security turned the dayroom lights on, and ceo aioe witha ca m— Officer?) [stated she was in Central Control when She heard the medical emergency call Tocated the and then ran to Pod 7B. Unless otherwise noted, the following events are based ona review of the py Oficeffc |OrficerpiB, fave DE LA ROSA one rescue breath, or wr oe] DOC) | 5 BRA interview with Oca] — _Jited August 16,2015. Office] _—Jekmowedged he should not ave left iv lout proper relief and THT Te made 3 judgment call 10 retrieve THe cut-down tool versus breaching the cell a he was WI hos. close ic lhc fesponders wer 0 he pod. SSERAU interview with Ofeel——Jited August 14, 2018 2 See Pod THERE dated July 10, 2015. ERAU notes two minus and four seconds clapsed from the time when Oc —TTaaked nto DE LA ROSA's cell when the offices opened the cel door. ERA interview with LUPE dated August 14. 2015 _— | Sc mie lor bic acto 1020s. ome tn ch 0] _ compresions without a breathing mask or CPR mou sis. During rv; OVGEIOR) oined out a CPR sk pouch on his bel and stated he forgo abou t during the rene. See Pod TBE Hated uly 10, 2015. ERA iteven wik OTe fed Aust 14. 208. Offices Js member of he SDC Emrgency Response Team (ERT). The time samp shown inthe right-hand comm of the handheld camer ooage is approximately an hour and Uhre minutes behind the time samp shown in SDC ge adhd gc foo shows ENR fred DE LA ROSAS Troop The pod B00] hows RNC) etd DE LA ROSA's coll a 1030.35 pn. As such. any even Tue Te =n been adjusted 10 3d one hour and thce minutes in this report. 5 3 

3 . p DETAINEE DEATH REVIEW — Efrain DE LA ROSA JICMS[™ | AU10:38 pm, OFfGa{—_Jook over chest compressions for Officer, J RNFTTOTO ] and another nurse arrived Pod 7B with a gurney, backboard, and two emergency bags. RN Bloke moDE LA ROSY col tired gery bss. ad kd wher he “Automatic external defibrillator (AED) was. L%i%c, hen entered the cell with the backboard. In the approximate two minutes [P00 preceding RN Jamia and subsequent ambu bag?® placement, officers gave DE LA ROSA only one ré&scte breath. AU10:39 pm. Ble Jae she needed an oxygen tank, a crash cart, and for someone to call Emergency Medical Services (EMS).*_At this time, Stewart County Fire & EMS apache opontento SDC LIE Jook ove CTR nd REE ean ated she needed an oxygen tank, an AED, additional arses from Intake, and a crash art. AIO pan. Officer [fe Jered the cell with an AED. Two other nurses arrived moments later. RN[E Jor ied the AED pads, and another SDC nurse took over CPR. AU10:42 pam., Officer PT Jarrived at DE LA ROSA's cell with an oxygen tank. Between 10:42 p.m. and 10:47 p.m., three nurses coordinated CPR efforts; the AED never advised shock * AU 10:43 p.m. RNS ]lted”™ DE LA ROSA’s head back during CPR for the first time. AU10:48 p.m., an EMS responder entered DE LA ROSA’ cell. The EMS responder removed the AED pads from DE LA ROSA’s body, then he and an SDC nurse pulled DE LA ROSA into the 7B dayroom. At 10:50 p.m.. an EMS responder r-applicd AED pads to DE LA ROSA and another then intubated him. At 10:55 p.m., EMS responders lifted DE LA ROSA onto their sumey and a minute later, wheeled him out of the unit. AUI0:S7 pm, an EMS responder canbe OO) | Office Jilly performed chest compressions correctly; however, gL one point bis band pesiion moved envard SITE LA ROSA'S chest. In the minute nd 24 seconds Offic Jormed CPR before RN = kvl and subscquent oxygen mask placement he never gave DETITROSA a rescue breath. While re tomes cnc commen ete CO i nD LA ROSA ts i ce Te mack op te bi Fale vep bck and Ep DELAROSA'S Sel within seconds a oT ony snd id nt kon DE LA ROSA. ; "An amb bg sa ban RT Gavi commonly uSB AS ove positive pressrs ventilation o atic who are Blo | maison icq HC) 4 An oxygen tank was present on the gurney; however, it was nonfunctional due t0.a disconnected regulator nh ervien, AR Ad hat th regulator was in the bag, but during the emergency, RN [= ould no cat TS Sevan Couny Fire & EMS Prehospital Car Report, dated Jly 10, 2018 0) Se Pod TBITNE) dated July 10, 2018. ERAU was only able to confirm the identity of one xc ETHEL Tre amy STIRS medical Saf’ indent statements. meres and actions inthe SRE] B08 FopafieT me another TN pines Desh e-mail, dated Jy 11, 2018 7 Creativ Con advised that the had il method of openin the siray safctine, proved th cmrgency responder propery place His or he hands in performance of he i. During RABE Jet Review with medical af, he Knife that the a (rst method would hve bec FTE 3 cctively and more simpy, opens a airway without having rey on prope hand placement at te eck as one would ned 10 do ith he head tl method p 34 

DETAINEE DEATH REVIEW — Efrain DE LA ROSA Nicms[™ | heard stating DE LA ROSA was clinically dead as they placed him into the ambulance, bu that they were going to do everything they could to reverse that. The PIE fds. AUI06 pm., the ambulance left SDC for SGRMC.2"! Bie] fess Oten PFT na FT J eo ac.” Office ode in the fron Seat o Tie ambulance with DE LA ROSA, while Officer [F007 | allowed i the chase vehicle.” J Eo EMS rdSporlers performing CPR through the rear windows of the ambulance. ** While en route 0 the hospital, EMS requested to terminate CPR as DE LA ROSA was not responding, his skin was cool to the touch, and his pupils were fixed and unreactive: an SGRMC Emergency Room NP (unnamed) denied the request, therefore EMS continued CPR efforts. AULLES pn. EMS arived to SGRMC." Officer 5c, stated hospital staff took DE LA ROSA to a curtained area and continued to perform CPR.” At 11:27 p.m., SGRMC RN[P® O00] (Jo por DE LA ROW van lr nd pry rs i ENS performing bag/mask venilations; no signs of life were present. AULL29 pm, SGRMC DFC pronounced DE LA ROSA dead 7 Au11:35 pan. RNS) fontacted CaptaifSc, io inform him of DE LA ROSA’s death. A150 pan, Captain ST Jeatied RN [FTE pack and advised hr to cal the coroner. On July 11,2018, at 12:27 am, HATO O00 called R[F) Jand notified her an autopsy would be required 1 ”r A L24 am, Deputy Coroner PH Jurrived at the hospital. offend [PO BC remained with DE LA ROSA unl Deputy Cormeriey Jomived SoRMC. Art tan Dy Come BF i ih DE LAROSA 140m. 0 cers Jand[P0_ fieparted and at 2:16 am. they retumed to § wo | omen] Fi, JFPETSGRNC, andar 216m, fey retuned 0 SDC se SevarCouty Pe ES Bhopal Ca Reon id uy 10,2018 KAU ieriow wir ase Auge 14.2015, 2) ERAU iron wilh OF Jat Aust 1. 2018. 4 ERAU interview with Oca JIT August 15, 201% 9 See Sewan County Fire & ENTS Pshospital Car Report, dated Jly 10, 2018, - ERA imerview with OcefS et Aue 15 201, 4 Se SGRMC Emery DeptlmentED) Summary Nursing Notes, dated July 10, 2013 See SGRMC ED Vast Note Report, dated Jy 11. 2015 20'Scc SGRMC ED Summary Nursing Notes, dated Joy 10, 2018. Officer] —Jiviscd ERAU that she informed CopufE by clphon of DE LA ROSA sah bot vis bl pro Gocumctaion 0 uport Simei 2 See Hospital Logbook, dated uly 10, 2015 3s 3 

DETAINEE DEATH REVIEW - Efrain DE LA ROSA JICMS[T™ Post-Death Events «SDC collected incident reports from all involved staff immediately following the medical emergency. On July 10, 2013, OfficerlX®. nitallv wrote only a two-line incident report but, per instruction by Facility Investigator, she wrote a second, detailed report on July 23, 2018. Officer xplained that she did not realize a detailed report was necessary, as she had never Been involved in a response (0 a hanging before. . Copuinfic ued that after DE LA ROSA’s death, Warden Peterson instructed him to nolify the SReRfF's Department. Sheriff Larry Jones arrived to SDC at 12:30 a.m. on July 11.2018 Sheriff Jones stated he spoke with the Warden and then interviewed Officer Following the interview, he contacted the GBI and noted that GBI arrived on Aeame at 1:15 am. Conf Fomed the review team that he escorted one of the GBI agents to DE LA ROSA'S cell. When told he would be awhile, he lef the agent with an officer. + OnJuly 11, 2018, SDC inventoried DE LA ROSA’s property and tumed it over to ERO staff, along with the $0.31 remaining in DE LA ROSA's account. At the time of the site visit, ERO had not returned DE LA ROSA’s property to his next of kin, as there was. an ongoing investigation. + OnJuly 11, 2018, Warden Peterson assigned Facility Investigator PTT io review the events surrounding DE LA ROSA’ suicide. She submilied a written report to te Wade on Avi 6.2018 Fay Ineo POO afomed ERAU that her investigation involved a review of written reports, TEVIEWS With security and ‘medical staff, and extensive review of video footage. Her review did not include analysis of actions taken by medical personnel. . HSAPTTETC Jeonducted an After-Action Review with HSC and CoreCivic medical Staff.” MEDICAL CARE AND SECURITY REVIEW ERAU reviewed the medical care SDC provided DE LA ROSA, as well as the facility's efforts 10 ensure he was safe and secure while detained at the facility. ERAU found deficiencies in SDC’s compliance with certain requirements of the ICE PBNDS 2011 (as revised in 2016). 2 See Incident Statements by OCS — dated July 10, 2018, and July 23, 2018. 2 See Stewart County Sheriff's ONE TRCTent Report dated July 10, 2015. 25 See Disposition of Non Allowable Property and Innate Account Summary, both dated July 11, 2015 2 See ConeCivic General Counsel Office of Investigations, Investigative Report Form by Facil Investigator [FP BUX0 dated August 6, 2018. FISARE) BCI} did not advise ERAU of the After-Action Review date 3 3 

DETAINEE DEATH REVIEW — Efrain DE LA ROSA siems[™ 1. ICE PBNDS 2011, Medical Care, Section (V)(U)(4) states, “Distribution of medication (including over the counter) shall be performed in accordance with specific instructions and procedures established by the HSA in consultation with the CMA. Written records of all prescribed medication given to or refused by detainees shall be maintained... All prescribed medications and medically necessary treatments shall be provided to detainees on schedule and without interruption, absent exigent circumstances.” oe . . an RN falsely recorded refusal of psychiatric medications on he might of DE LA ROSA 's suicide, July 10, 2015. + ERAU was unable to confirm if the June 14, and 17, 2018, amlodipine administrations were given or refused due to illegible entries on the MAR. 2. ICE PBNDS 2011, Medical Care, Section (V)(AA)(1) states, “Upon admission at the facility, documented informed consent shall be obtained for the provision of health care services.” « DELA ROSA did not sign a general consent for treatment form when first admitted 10 SDC. 3. ICE PBNDS 2011, Medical Care, Section (V)(AA)(4) states, “Prior to the administration of psychotropic medications, a separate documented informed consent, that includes a description of the medication’ side effects, shall be obtained.” «There is no documentation that medical staff requested DE LA ROSA sign a separate consent form for the psychotropic medications haloperidol and olanzapine when ordered on June 12, 2018. 4. ICE PBNDS 2011, Medical Care, Section (V)(AA)(9) states, “Medical staff shall explain the medical risks if treatment i declined and shall document thir treatment fforts and refusal of treatment in the detainee’s medical record. Detainees will be asked to sign a translated form that indicates that they have refused treatments. * Medical staff documented DE LA ROSA refused his medications 29 times between June 15 and July 10, 2018, but medical staff completed refusal forms for only 21 of the 29 refusals. * Medical staff entered “No-Show™ on the MAR 20 times between June 14 and 26, 2018. Fificen of the 20 no-shows occurred after security placed DE LA ROSA in Segregation; therefore, he could not voluntarily report to receive medications. Entries of “No-Show”, especially in segregation, do not constitute affirmative documentation that the detainee refused medications as required by the standard. There is no documentation medical staff confirmed the detainee was refusing medications on these 15 occasions, that they explained the risks associated with these refusals, or that they completed refusal forms. w a7 

DETAINEE DEATH REVIEW - Efrain DE LA ROSA snemsP 5. ICE PBNDS 2011, Medical Care, Section (V)(AA)(10) states, “The clinical medical authority and facility administrator shall look into refusals of treatment to ensure that such refusals are not the result of miscommunication or misunderstanding.” «Medical saff did not notify the Clinical Director that DE LA ROSA was refusing ‘medications; therefore, the Clinical Director was unaware of this issue. However, nurses sent 17 telephone encounters to Nelo he ‘mid-level provider responsible for following-up on medication refusals/nSTSSFs. The NP did not see DE LA ROSA, claiming medical staff postponed scheduled appointments; medical staff were unable to produce documentation supporting scheduling occurred at al. 6. ICE PBNDS 2011, Significant Self-harm and Suicide Prevention and Intervention, Section (V)(F) states, “All suicidal detainees placed in an isolated confinement setting will receive continuous one-to-one monitoring, welfare checks at least every cight hours conducted by clinical staff, and daily mental health treatment by a qualified clinician.” «Medical staff did not meet the cight-hour timeframe on at least three occasions. On April 25, 2018, there was an § hour and 45-minute gap betwen a healthcare round at 1:00 am. and the next round at 9:45 a.m. On April 27, 2018, there was a 10 hour and 10-minute gap between a healthcare round at 10:30 p.m. and the next round at 8:40 am. on April 28, 2018. On April 29, 2018, there was a 10 hour and 1-minute gap between a round at 2:29 p.m. and the next round at 12:30 a.m. on April 30, 2018. ERAU was unable to positively idenify other occasions when medical staff may have exceeded the eight-hour timeframe, as numerous Staff members did not enter the exact time of the encounter. Timing of vital signs and medical staff sign-offs suggest there may have been multiple other instances of welfare checks exceeding the cight- Hour imeframe, particularly when a round was due on the night shift 7. ICE PBNDS 2011, Significant Self-harm and Suicide Prevention and Intervention, Section (V)(K) states, “A critical incident debriefing following a suicide or serious suicide attempt shall be offered to all affected staff and detainees within 24 to 72 hours after the critical incident.” + _ Although other officers involved in the incident reported getting one, Officer Ee rode in the ambulance with DE LA ROSA. was not offered a critical ETE debriefing or supportive counseling services by SDC. 8. ICE PBNDS 2011, Custody Classification System, Section (V)(H)(3) states, “Special Reclassification Assessments: Staff shall complete a special reclassification within 24. ours before a detaince leaves the SMU, following an incident of abuse o victimization, and at any other time when warranted based upon the receipt of additional, relevant information, such as after a criminal act, or if a detaince wins a criminal appeal, is pardoned or new criminal information comes to light.” © A reclassification review factoring DE LA ROSA’ disciplinary conviction was conducted on April 10, 2018, following his IDP disciplinary hearing and sentencing 3 38 

DETAINEE DEATH REVIEW — Efrain DE LA ROSA ems] on April 6, 2018. However, security staff did not complete a reclassification review within the 24 hours preceding DE LA ROSA’ release from disciplinary segregation on April 18, 2018. 9. ICE PBNDS 2011, Disciplinary System, Section (V)(A)(6-8) states, “When a detainee as a diagnosed mental illness or mental disability, or demonstrates symptoms of mental illness or mental disability, a mental health professional, preferably the treating clinician, shall be consulted to provide input as to the detainee’s competence to participate in the disciplinary hearing, any impact the detainee’s mental illness may have had on his of her responsibility for the charged behavior, and information about any known mitigating factors in regard to the behavior... If a detainee has a mental disability or mental illness but is competent, the disciplinary process shall consider whether the detainees mental disabilities or mental illness contributed to his or her behavior when determining what type of sanction, if any, should be imposed. A mental health professional should also be consulted as to whether certain types of sanctions (e.g., placement in disciplinary segregation, loss of visits, or loss of phone calls) may be inappropriate because they Would intefere with supports that are a pat of the detaince’s treatment o recovery plan.” «There is no documentation that security staff consulted a mental health professional prior to disciplinary hearings on April 6 and June 21, 2018, or that the hearing officer considered the degree to which DE LA ROSA’s mental illness may have contributed 10 his behavior. ERAU acknowledges that DE LA ROSA’s mental illness was likely not known to security personnel at the time of the hearings as patient diagnoses are confidential and. per the medical record, he was asymptomatic. Ultimately, ERAU ecommengPS pr. 000000000000] 10. ICE PENDS 2011, Disciplinary System, Section (V)(H) states, “The detainee in IDP proceedings shall have the right o du process, which includes the rights to... have an IDP hearing within 48 hours after the conclusion of the investigation or the conclusion of the Unit Disciplinary Committee (UDC) hearing... The IDP shall conduct the hearing ‘within 48 hours after the investigation or the conclusion of the UDC hearing, unless the detainee requests more time to gather evidence or otherwise prepare a defense. In cases where a hearing is delayed, the reason(s) must be documented (¢.g., a continuing investigation of facts, unavailability of one or more essential witnesses, cic.) and, unless the detainee has requested the delay. approved by the facility administrator. 1f the detainee is being held in segregation, the delay shall not exceed 72 hours, barring an emergency.” © Ope 20001052 am, ut [EE Jems mesg for ic Ap 3,2018, disciplinary incident. The IDP hearing commenced at 12:42 p.m. on April 6, 2018, more than 48 hours afer the conclusion of the investigation. The hearing officer did not document the reason for the delay. 11. ICE PBNDS 2011, Searches of Detainees, Section (V)(D)(2)(b) states, “Officers must obtain supervisory approval before conducting strip searches. Staff may conduct a strip » 39 

DETAINEE DEATH REVIEW - Efrain DE LA ROSA Jems [70] search where there is reasonable suspicion tha contraband may be concealed on the person. “Reasonable suspicion’ means suspicion based on specific and articulable facts that would lead a reasonable officer to believe that a specific detainee is in possession of contraband. It is a more permissive (lower) standard than probable cause, but it is more than a mere hunch. It must be based on specific and aticulable facts—along with reasonable inferences that may be drawn from those facts—that the officer shall document in Form G-1025 or equivalent.” «The form documenting the sip search of DE LA ROSA on April 24 2018 states, “Suicide Watch” and does not document the specific facts that led the officer to believe DE LA ROSA was in possession of contraband. This practice also violates SDC RHU Post Orders, Section (II(C)(1)(b), which states, “ICE detainces will not be stip searched unless there is a ‘reasonable suspicion’ tht the detainee is concealing a weapon or contraband. A frisk search shall be performed in licu of a strip search.” 12. ICE PBNDS 2011, Special Management Units, Section (V)(A)(3)(a-b) states, “All facilities shall implement written procedures for the regular review of all detainees held in administrative segregation, consistent with the procedures specified below. A supervisor shall conduct a review within 72 hours of the detainee’s placement in administrative segregation to determine whether segregation is still warranted... The review shall include an interview with the detanec... A supervisor shall conduct an entical review afer the detainee has spent seven days in administrative segregation and every week thereafter for the first 30 days and every 10 days thereafter, at a minimum.” «There is no documentation ICE or security staff interviewed DE LA ROSA during administrative segregation staws reviews on April 26, 2018, and May 3, 2013. «The May 3, 2018 status review was delinquent, as it was due on May 1, 2018, seven days after DE LA ROSA’s initial placement in segregation. 13. ICE PBNDS 2011, Special Management Units, Section (V)(B) states, “A detainee may be placed in disciplinary segregation only by order ofthe IDP, or ts equivalent, after hearing in which the detainee has been found to have committed a prohibited act and only when alternative dispositions may inadequately regulate the detainee’s behavior.” «Security aff ordered DE LA ROSA's placement in disciplinary segregation on April 3.2018, and June 19, 2018, although the charges were not adjudicated until April 6, 2018, and June 21, 2018, respectively. 14. ICE PBNDS 2011, Special Management Units, Section (V)(B)(3) states, “All facilities shall implement writen procedures for the regular review of all disciplinary segregation cases, consistent with the following procedures: A security supervisor shall interview the detainee and review his/her status in disciplinary segregation every seven days to determine whether the detainee: Abides by all rules and regulations; and, Is provided showers, meals, recreation and othr basic living standards, a required by this detention “© 40 

DETAINEE DEATH REVIEW — Efrain DE LA ROSA JICMS[™™ | standard... The supervisor shall document his/her findings after every review, by completing a disciplinary segregation review (Form 1-887). The supervisor may recommend the detainee’s early release from the SMU upon finding time in disciplinary segregation is no longer necessary to regulate the detainee’s behavior. An early-release recommendation must have the facility administrator's approval before the detaince may be retumed to the general population. In conducting this review, the facility administrator will consider any request by the detainee to present written evidence or available witnesses. The review shall ake into account the detainee’s views.” «There is no documentation security staff reviewed DE LA ROSA's placement status in disciplinary segregation from April 6 to April 18, 2018. «The July 3, 2018, status review was delinquent, as it was due on June 29, 2018, seven days after the June 22, 2018, status review. Although an EARM entry noted that on June 27, 2019, a Confinement Review Committee reviewed DE LA ROSA’s segregation status and advised he remain in segregation, there was no additional documentation to support this review occurred. Furthermore, there is no documentation security staff interviewed DE LA ROSA during the disciplinary segregation status reviews on June 22. 2018, and July 3, 2018. + Opa 1h, 015, Scuty Oued DE LA ROS eo te general population after he served on] lays of the first 30-day disciplinary Segregation sanction. Security anil Tia not complete a status review documenting an intervie of the detaince and a recommendation for early release based on a determination that disciplinary segregation was no longer necessary. Security Cilio Jdocumencd the carly release only on the Confinement Record, without rationale, and did not obtain approval from the facility administrator. 15. 1CE PBNDS 2011, Special Management Unis, Section (V)(D)(1) sates, “A permanent log shall be maintained in the SMU to record all activities concerning SMU detainees (e.g., meals served, recreational time, visitors, etc.).” «There was no record of whether the lunch meal was served or refused on April 5, April 6, April 29, and June 22, 2018. 16. ICE PBNDS 2011, Special Management Units, Section (V)(M) states, “Detainees in SMU shall be personally observed and logged at least every 30 minutes on an irregular ol schedule. «SDC was unable to produce CWLs for April 4, April 17, and July 3, 2018; therefore, RAtHcould not verify completion of 30-minute security rounds. + On July 10,2018, Officer] — logged security rounds at 9:13 p.m., 9:39-p and [ — TT The ICE detention standards do not adres suspension ofthe alance ofa disciplinary segregation snction outside the satus review process a 4 

DETAINEE DEATH REVIEW - Efrain DELAROSAJICMS™ | the clipboard nex tothe detainees cell but he did not look in the cell to personally observe DE LA ROSA. “These issues also violate SDC RHU Post Orders, Section (II(B)(1)(i), which states, “Detainees in SMU shall be personally observed and logged at least every thirty (30) minutes on an imegular schedule... Observation will include looking in each cel 0 ensure that no unusual or unauthorized activities are occurring.” ERAU noted th following additional violations of SDC-speciic policy below: 1. SDC RHU Post Orders, Section (II)(L)(S) states, “Inmates/residents will be offered the opportunity to shower and shave at least three (3) times per week. In the event an inmate/resident refuses to shower for an entire one (1) week period, notify the Shift Supervisor/Unit Manager.” «Confinement Activity Records document security staff offered DE LA ROSA showers only twice during the week of April 8, 2018 (April 9 and 11, 2018) and twice during the week of July 1, 2018 (July 4 and 6, 2018). «There is no documentation that security staff notified a supervisor when DE LA ROSA did not shower during the period from April 3 to 18, 2018. 2. SDC Policy 9-13, Count Principles and Procedures states, "At shift change, the oncoming Correctional Officer will conduct an informal count of all inmates in his/her area of responsibility,” and SDC RHU Post Orders, Section (I)(G), Start of Shift states, “Verify that all cell doors and food tray slots are secure.” + Onluly 10,2018, oneefilo Jia not conduct a count or make a round to verify all cell doors and food tray STO Were secure uniil he had been on the post for 28 minutes. Officer informed ERAU that he timed his first security round based on Officer Tast documented security round, which was not appropriately conducted p7er ————] Conducting security rounds in accordance with the standard and facility poTicy specifically, verifying detainee welfare through direct observation at least every 30 minutes on an regular schedule—serves a fundamental and critical safety and security purpose in restricted housing. 3. SDC RHU Post Orders, Section (IV) states, “Never leave your post for any reason unless. properly relieved by an assigned officer or the Shift Supervisor.” « Onluly 10,2019, offceffAen his post, 7A, on two occasions, at 10:13 p.m. and 10:34 p.m. k Areas of Concern ERAU also noted the following concerns regarding DE LA ROSA’ medical care: «2 42 

DETAINEE DEATH REVIEW - Efrain DE LA ROSA JICMS «Nurses used template language programmed in ¢CW to document segregation rounds while DE LA ROSA was in the RHU for disciplinary reasons. All notes are virtually identical and did not include subjective information reflecting DE LA ROSA’s answers in response to queries. In DE LA ROSA case, nurses” findings that there was no evidence of hallucinatory and delusional thoughts would have been far better supported had they documented subjective information. Including this information helps to ensure that Segregation rounds serve the intended purpose of verifying detainee health and welfare. «On April 30, 2018, medical staff did not follow-up on or report DE LA ROSA’s elevated blood pressure reading of 152/92 to a provider to determine possible monitoring and treatment needs. DE LA ROSA's blood pressure was within AHA parameters for elevated blood pressure six times, Stage One hypertension 21 times, and Stage Two hypertension eight times. Despite these readings, SDC medical staff only prescribed DE LA ROSA blood pressure medication afier receiving the Medication Reconciliation for Discharge/Transfer List from CRCC. Furthermore, DE LA ROSA’s medical record documents his last blood pressure reading was on June 19, 2018, 21 days before his death. Whether or not the detainee’s refusal of medications impacted either his physical or mental health, Neo | as a prescribing provider, was obliged to act upon nurses” referrals, including educating the detainee on the risks. «During interview, i Sl he informed nurses after DE LA ROSA’s death that they are expected 10 ToTlow The blood pressure guidelines within IHSC Directive 03-10, Intake Screening and Intake Reviews, which details what action should be taken when a detainees blood pressure is elevated. HSA ET Jas unable to provide ERAU with documentation to support that he informed medical SEIT to follow these guidelines outside of the intake screening and intake reviews process. «On July 10.2018, RN[TFlc, ihe first medical responder to arrive at DE LA ROSA’s cell. brought emergency equipment with her: however, the AED was not present and the oxygen tank was disconnected from the regulator. eA Jexplined that medical staff did not replenish emergency equipment, to include (Te AED, ToTlowing a medical emergency earlier in the day. Ensuring necessary emergency equipment is available and operable is critical to an effective medical emergency response. a 3 

DETAINEE DEATH REVIEW — Efiain DE LA ROSA JCMS ERAU also noted the following concerns with security: «On April 21, 2018, DE LA ROSA submitted an incident statement in which he asked security to move him to segregation because his cellmate threatened his life. Although the Cellmate History Housing record documented DE LA ROSA’s cellmate was moved on April 23. 201, there is no documentation of when scriy received the statement or what specific action sceurity took pursuant to the claim. Within the detention fle, a memorandum dated April 24, 2018, documented security placed DE LA ROSA on administration segregation status pending investigation for protective custody. Following mental health assessment, medical staf placed DE LA ROSA on suicide watch, which continued until he was transferred to CRC. Although placement on protective custody apparently overlapped with suicide watch, documentation related to protective custody was limited. o After oteeffie Jou DE LA ROSA hanging and called a medical emergency, he did not enter Ieee until other officers arrived. reef Jones SDC trained him not 0 open a cell door in the RHU unless another officer ws present; however, SDC policy does not prohibit an officer from opening a cell door without another officer HN —— SAY shift opencd cell doors without another officer present fo allow detainees ou for showers. «The Classification Supervisor id not review and approve the detainees initial classification, completed March 13, 2018, until March 29, 2018, 16 days afer it was applicd. The ICE PENDS 2011 Standards do not set a specific timeframe for supervisory review but do stat thatthe purpose of the review is to check “for accuracy and completeness and ensure that cach detainee is assigned to the appropriate housing unit” Although in this case, DE LA ROSA's classification and housing assignment were appropriate, the purpose of supervisory review cannot be achieved if eview of the clasification decision is not timely. «There were multiple illegible signatures with no accompanying printed names on documents in the detention ile. Absent legible names, there i no way to account for actions and decisions a w“ 

DETAINEE DEATH REVIEW — Efrain DE LA ROSA JICMS[™™ | APPENDIX 1 CONFINEMENT ACTIVITY RECORDS “The table below shows the activities refused by DE LA ROSA and undocumented meals by security staf while DE LA ROSA was in segregation. Disciplinary Segregation from April 3, 2018, 8:52 p.m. to April 18, 2015, 6:10 p.m [Date [Activity Refused | Undocumented Meals | April 4,2018 Shower = April 5.2018 Recreation Lunch April 6, 2018 1- Lunch April 8, 2018 Recreation - April 9.2018 Shower - April 11,2018 | Shower & Recreation = April 12,2018 Recreation = April 13.2018 Recreation - April 14,2018 Recreation = April 16.2018 Recreation ~ Suicide Watch from April 24. 2018, 4:45 p.m. to May 4. 2018, 7:32 a.m. [Date [Activity Refused [Undocumented Meals | April 29.2018 - Lunch May 1,2018 Recreation = May 2, 2018 Recreation = May 3, 2018 No activities logged = May 4.2018 No activities logged — Disciplinary Segregation from June 19. 2018. 6:05 pum. to July 10, 2018, 11:06 pm. [Date [Activity Refused | Undocumented Meals | June 22,2018 = Lunch as 45 

DETAINEE DEATH REVIEW - Efrain DE LA ROSA JICMS [0 _] EXHIBITS I. Georgia Bureau of Investigation, Division of Forensic Sciences Autopsy, Official Report, dated October 2, 2018. 2. Creative Corrections Detaince Death Review Healthcare and Security Analysis a 46