ICE Mortality Review For Lorenzo Antonio Batrez Vargas

Office of Enforcement and Removal Operations ICE Health Service Corps U.S. Department of Homeland Security $00 12th Street, SW Washington, D.C. 20536 U.S. bmmigration and Customs Enforcement October 29, 2025 MEMORANDUM FOR: i (b)(6),(b(7(C),(b(7F) | DHSce, FACHE Assistant Director (b)(6),(b)(7)(C),(b)(7)(F) ICE Health Service Corps THROUGH: CAPT | (PM@(bN7NC) THF) | MD, MPH, CCHP, FAAFP Chief Medical Officer ICE Health Service Corps (b)(6),(b)(7)(C),(b)(7)(F) | (b)(6),(b)(7)(C),(b)(7)(F) | MS Chief of Staff ICE Health Service Corps CDR} (b)(6),(b)(7)(C),(b\(7)(F) | RIN Chief, Investigations Unit (b)(6),(b)(7)(C),(b)(7)(F) ICE Health Service Corps FROM: CDR e.0xr16).00); DNP Senior Investigator, Investigations Unit (b)(6),(b)(7)(C),(b)(7)(F) ICE Health Service Corps SUBJECT: Mortality Review ~ Report of Findings Lorenzo Antonio Batrez VARGAS, : (b)(6),(b)(7)(C) | Txecutive Summary: On August 31, 2025, the U.S. Immigration and Customs Enforcement (ICE) Health Service Corps (HSC) received notification of the death of alien Lorenzo Antonio Batrez VARGAS, i _(b)(6),(b\(7)(C)_ | ICE detained Mr. VARGAS, a 32-year-old Mexican male, at Florence Detention Center (FDC) and Central Arizona Florence Correctional Complex (CAFCC), both located in Florence, Arizona (AZ), from August 3 to 31, 2025, the date of his death. Mr. VARGAS’ autopsy is pending. Prior to his detention, on an unknown date, Mr. VARGAS entered the United States at an unknown location, without being admitted or paroled by an Immigration Officer. Between May 2026-ICFO-15303-000001

Page 2 of 9 2013 and July 2022, Mr. VARGAS filed five applications for Consideration of Deferred Action for Childhood Arrivals, Form 1-821D, with U.S. Citizenship and Immigration Services (USCIS). USCIS approved all Mr. VARGAS’ forms, with the final submission approved until July 24, 2024, In 2018, the Flagstaff Police Department (FPD) arrested Mr. VARGAS for several drug￾related offenses. Staff from Coconino County Jail (CCJ), in Flagstaff, AZ, contacted ICE. ICE issued Mr. VARGAS a Notice to Appear (NTA), Form 1-862, charging him with violating Section 212(a)(6)(A)() of the Immigration and Nationality Act (INA), as an alien present in the Jnited States without being admitted or paroled or who arrived in the United States at any time or place other than as designated by the Attorney General. An Immigration Judge (J) terminated Mr. VARGAS’ removal proceedings, and the Office of the Principal Legal Advisor filed a Motion to Reconsider (MTR). The Flagstaff Municipal Court found Mr. VARGAS guilty of driving under the influence, and an U granted the MTR. In August 2021, an IJ again terminated Mr. VARGAS’ removal proceedings. On August 2, 2025, FPD arrested Mr. VARGAS for a drug-related offense. ICE lodged form I-247A with CCJ, and CCJ turned over custody of Mr. VARGAS to ICE. ICE issued Mr. VARGAS Form 1-862, again charging him with violating Section 212(a6)A)() of the INA. On August 4, 2025, ICE housed Mr. VARGAS at FDC. On August 4, 2025, FDC health staff completed Mr. VARGAS’ initial intake screening and comprehensive health assessment, noting his histories of uncontrolled diabetes, a small left foot wound, and recent hospitalization for elevated blood sugar readings. An advanced practice provider (APP) ordered labs and a chest x-ray, which yielded negative results, and continued his diabetes medications and an antibiotic ointment for his foot wound. On August 7, 2025, ICE transferred Mr. VARGAS to CAFCC, in Florence, AZ, where a CAFCC APP reconciled and continued his medications, including tbuprofen, and ordered a chest x-ray. Between August 11 and 28, 2025, an APP completed Mr. VARGAS’ initial comprehensive assessment, diagnosed him with COVID-19, ordered labs, admitted him to the medical housing unit (MHU) for 12 days, and treated his COVID-19 symptoms and pneumonia, seen on his chest x-ray, with an antibiotic. During that timeframe, health staff responded to one emergency at Mr. VARGAS’ housing unit, where he complained of ongoing cold-like symptoms, chest and lower back pain, body aches, nausea and vomiting, and eye pain, and an APP treated his symptoms. On August 30, 2025, Mr. VARGAS complained of dizziness. The registered nurse (RN) who evaluated him documented normal lung sounds, with a productive cough, and unremarkable vital signs, except an elevated heart rate of 103 beats per minute, and oxygen saturation of 95 percent. The RN contacted an APP, who ordered labs and a chest x-ray for comparison. On the same date, Mr. VARGAS complained of difficulty breathing. The RN who evaluated him documented diminished lung sounds, normal vital signs, except rapid respirations of 20 breaths per minute, and contacted an APP to request an albuterol inhaler, which the APP approved. On August 31, 2025, at 6:04 am., Mr. VARGAS complained of shoulder pain, difficulty breathing, and a nonproductive cough. The RN who evaluated him documented diminished lung 2026-ICFO-15303-000002

Mortality Review —Lorenzo Antonio Batrez VARGAS, | i (b)(6), (b)(7)(C) | Page 3 of 9 sounds in all lobes, with labored breathing, and instructed Mr. VARGAS to continue using his prescribed inhaler. On the same date, at 6:32 a.m., during routine nursing rounds, an RN discovered Mr. VARGAS was unresponsive and pulseless, and activated a medical emergency code. Responding health staff performed life-saving measures; however, Mr. VARGAS remained unresponsive. At 6:42 a.m., custody staff called 911 and requested emergency medical services (EMS). At 6:48 a.m., EMS personnel arrived at the scene, assumed Mr. VARGAS?’ care, and initiated resuscitative efforts. At 7:02 a.m., due to unsuccessful resuscitative efforts, a Mountain Vista Medical Center physician instructed EMS personnel to cease all life-saving measures and pronounced Mr. VARGAS deceased. Mortality Finding: As aresult of VARGAS’ death, the THSC Assistant Director requested a mortality review to learn from his death by reviewing the care provided and the circumstances leading up to his death. The goal of the mortality review is to determine the appropriateness of clinical care; ascertain whether changes to policies, procedures or practices are warranted; and identify issues requiring further study. A mortality review committee (MRC) determined CAFCC did not provide Mr. VARGAS medical care within the safe limits of practice. Specifically, the MRC determined 1) Two RNs did not convey a complete picture of Mr. VARGAS’ current health status when they requested telephone orders from APPs; 2) An APP did not sign Mr. VARGAS’ electrocardiogram (EKG) strip to confirm review of his result; 3) CAPCC health staff did not manage Mr. VARGAS’ diabetes, COVID-19, and pneumonia appropriately; and 4) An RN deviated from the nursing scope of practice. The MRC convened on October 24, 2025, and consisted of the following IHSC members: Commander (CDR)}i.---- PUSMPUNCHPIE) clinical director, physician reviewer; Captain {CAPT (PH6), (b\(7)(C),(\(7 MF) | western n regional nurse manager, nurse reviewer; CAPT _o@oemoeme! The following summary of events was based on: 1) Mr. VARGAS’ FDC and CAFCC medical records; 2) Mr. VARGAS’ EMS report; 3) incident and notification reports; 4) ICE ENFORCE Alien Removal Module (ZARM) and ICE ENFORCE Alien Detention Module (EADM) database records; 5) Mr. VARGAS’ CAFCC detention file; 6) an on-site review and staff interviews conducted by CDRime.nmomme: at CAFCC, on October 8, 2025; 7) applicable CAFCC policies and procedures; and 8) applicable accreditation standards. Summary of Events On August 4, 2025, a licensed vocational nurse completed Mr. VARGAS intake screening, noted his history of diabetes and complaints of dizziness and blurred vision, documented normal vital 2026-ICFO-15303-000003

Page 4 of 9 signs and a blood sugar reading of 484 milligrams per deciliter [(mg/dL); normal fasting range: 70 — 99 mg/dL], collected a urine specimen, completed a urinalysis with abnormal results, including the presence of blood and glucose in his urine, and referred him to an APP for an urgent evaluation. FDC staff completed Mr. VARGAS’ chest x-ray for tuberculosis screening, and it showed negative results. e On the same date, an APP completed Mr. VARGAS’ comprehensive health assessment, noted his history of diabetes and recent hospitalization for elevated blood sugar, and ordered routine labs, including screening for sexually transmitted infections (STIs), antibiotic ointment for a small wound on his left foot, and long- and short-acting insulins. An RN administered regular insulin and intravenous fluids, reassessed his blood sugar, and documented a result of 161 mg/dL. On August 6, 2025, a licensed practical nurse (LPN) collected specimens for Mr. VARGAS’ STI screening. Mr. VARGAS’ lab results were negative results for all sexually transmitted infections, mcluiding human immunodeticiency virus (HTV). On August 7, 2025, ICE transferred Mr. VARGAS to CAFCC. On August 8, 2025, an LPN completed Mr. VARGAS’ intake screening. Mr. VARGAS reported a history of diabetes and the presence of a left foot wound that resulted from the amputation of three toes one year prior. Mr. VARGAS denied symptoms of tuberculosis and any current or prior drug or alcohol use. The LPN documented normal vital signs, recorded his blood sugar reading of 331 mg/dL, noted the presence of a “small,” non-draining wound on the bottom of his left foot, covered with an adhesive bandage, and without signs of infection, and scheduled an APP follow-up appointment. An RN contacted an APP and received verbal orders to continue the medications listed on his transfer summary, which included regular insulin (short-acting), insulin glargine (ong-acting), ibuprofen 600 milligrams (mg), and triple antibiotic ointment. On August 9, 2025, an APP completed Mr. VARGAS’ follow-up evaluation. Mr. VARGAS reported usual blood sugar readings above 500 mg/dL and his noncompliance with insulin use at home. The APP documented the presence of a “dime|-sized]” callous wound on the bottom of Mr. VARGAS’ left foot, an otherwise normal physical examination, and normal vital signs, noted the cancellation of Mr. VARGAS’ insulin glargine order, and ordered the pneumococcal pneumonia vaccine, which he later refused, NPH insulin (intermediate-acting) twice daily, and an x-ray of his left foot. The APP continued the order for wound care with triple antibiotic ointment and scheduled a follow-up appointment in one to two weeks. On August 11, 2025, an RN completed Mr. VARGAS’ sick call evaluation for his complaint of congestion, cough, and sore throat. The RN documented a blood sugar reading of 108 mg/dL, a slightly clevated blood pressure reading of 132/75 millimeters of mercury [(mmHg); normal range: less than 120/80 mmHg], otherwise normal vital signs, and normal lung sounds, and 2026-ICFO-15303-000004

Page 5 of 9 consulted with an APP. The APP gave a verbal order for a combination fever reducer and decongestant medication twice daily, as needed, for five days. On August 14, 2025, medical staff responded to Mr. VARGAS’ cell for his complaints of shortness of breath, sweating, headache, lower back pain, nausea, and vomiting, and transported him to the medical clinic. An RN documented elevated blood pressure and blood sugar readings, a normal oxygen saturation, and normal lung sounds with labored breathing, noted an elevated heart rate on his EKG but otherwise normal results, contacted the on-call APP, completed strep and COVID tests per the APP’s orders, and notified the APP of the positive COVID test result. The APP ordered Mr. VARGAS’ placement in medical observation under isolation for 12 days, vital signs twice daily, and a one-time dose of acetaminophen, and instructed the RN to schedule a next-day appointment. On August 15, 2025, an APP completed Mr. VARGAS’ follow-up evaluation, noted his nasal congestion, documented a normal physical examination, including clear lung sounds, and ordered a chest x-ray and urinalysis. Between August 15 and 19, 2025, nursing staff completed Mr. VARGAS’ vital signs and assessments, documented the presence of an unproductive cough, noted his denial of shortness of breath, and consistently documented normal oxygen saturation levels and clear lung sounds. On August 19, 2025, an APP completed Mr. VARGAS’ comprehensive health assessment, noted his previously reported medical history and active COVID diagnosis, reviewed his chest x-ray results, which showed infiltrates in the upper lobes of both lungs, documented clear ling sounds and the presence of drainage in his left car, continued his medications, and ordered an antibiotic. The APP also ordered routine labs, tests for Coccidioides (fungus that can cause lung infections) and HIV, and an EKG for September 1, 2025. On August 20, 2025, an RN evaluated Mr. VARGAS prior to his transfer from the medical housing unit to the restricted housing unit (RHU) for continued isolation, documented clear lung sounds and the continued presence of a cough and congestion, and cleared him for RHU. On August 26, 2025, an APP released Mr. VARGAS from isolation. On August 28, 2025, a medical assistant documented Mr. VARGAS refused his labs. An APP completed Mr. VARGAS’ follow-up evaluation for his left foot wound, documented a normal blood pressure, heart rate, and oxygen saturation, and continued the order for antibiotic ointment. On August 30, 2025, at approximately 2:40 p.m., an RN evaluated Mr. VARGAS for unspecified upper respiratory complaints and dizziness, documented normal lung sounds and vital signs, except a mildly elevated heart rate of 103 beats per minutes [(bpm); normal range: 60 — 99 bpm], and consulted with an APP. The APP ordered the previously refused labs, a combination fever 2026-ICFO-15303-000005

Mortality Review —Lorenzo Antonio Batrez VARGAS: (b)(6),(b)(7)(C) | Page 6 of 9 reducer and decongestant medication twice daily for four days, a chest x-ray for comparison, and respiratory isolation. 6 At approximately 7:00 p.m., an RN evaluated Mr. VARGAS for difficulty breathing and documented normal vital signs and diminished lung sounds. The RN contacted an APP and received an order for an albuterol inhaler (relaxes muscles surrounding airway). On August 31, 2025, at approximately 6:00 a.m., an RN completed Mr. VARGAS’ assessment, noted his complaint of shoulder pain (anspecified side) and difficulty breathing, documented diminished hing sounds and labored breathing, and instructed him to notify medical staff of any changes to his condition. e At approximately 6:32 a.m., medical staff responded to a medical emergency in Mr. VARGAS’ cell. Medical staff noted Mr. VARGAS’ unresponsive state, called for EMS, administered naloxone (reverses opioid overdose), initiated cardiopulmonary resuscitation, applied an automated external detibrillator, and administered one shock while awaiting EMS personnel’s arrival. e At approximately 6:45 a.m., EMS personnel arrived and assumed Mr. VARGAS’ care. e At 7:02 a.m., EMS personnel contacted a physician at Mountain Vista Medical Center, in Mesa, AZ, and the physician pronounced Mr. VARGAS deceased. The MRC used the following accreditation standards for this review: National Detention Standards, 2019, and National Commission on Correctional Health Care (NCCHC), Standards for Health Services in Jails, 2018. Strengths The MRC identified the following strength: The CAFCC health staff assignment sheet is well developed. Weaknesses 1. Communication @ On August 30, 2025, Mr. VARGAS complained of difficulty breathing and a cough. The registered nurse (RN) who evaluated him did not share his health situation and background with the on-call APP, but instead, only shared specific assessment findings and recommended the APP order Mr. VARGAS an albuterol inhaler for his diminished 2026-ICFO-15303-000006

Page 7 of 9 lung sounds, which deviated from the structured communication framework used to facilitate prompt and appropriate communication among health professionals. On August 30 and 31, 2025, the RN who evaluated Mr. VARGAS did not accurately convey his health status to the oncoming shift. Applicable standards of care for this finding: @ @ NCCHC: Standards for Health Services in Jails, 2018: J-E-08, Patient Safety. NCCHC: Standards for Health Services in Jails, 2018: J-E-07, Communication on Patients’ Health Needs. 2. Documentation On August 15, 2025, an RN completed Mr. VARGAS’ EKG during a medical emergency response for his complaint of chest pain. The EKG result showed sinus tachycardia. An APP acknowledged the finding in a progress note but did not sign the EKG strip to confirm review of the result. Applicable standards of care for this finding: 8 NCCHC: Standards for Health Services in Jails, 2018: J-A-08, Health Records. 3. Inappropriate Medical Care @ On August 8, 2025, a physician ordered a long-acting insulin, nightly, for Mr. VARGAS; however, the physician did not include a duration, which an APP identified the following day. Instead of clarifying the insulin order with the physician, the APP replaced Mr. VARGAS’ long-acting insulin with an intermediate-acting insulin, limiting his chances of achieving acceptable glycemic control. On August 19, 2025, an APP prescribed Mr. VARGAS antibiotics to treat his pneumonia; however, the APP’s prescribed antibiotic regimen did not align with the U.S. Centers for Diseases Control and Prevention (CDC) guidelines for treating community-acquired pneumonia. On August 19, 2025, the APP who developed Mr. VARGAS’ COVID-19 and pneumonia treatment plans excluded a higher-level provider follow-up evaluation and repeat diagnostic testing (chest x-ray) to assess the efficacy of the established treatment plan. 2026-ICFO-15303-000007

Page 8 of 9 @ On August 20, 2025, an RN relocated Mr. VARGAS from a medical isolation room (where close health staff monitoring is required) to a restricted housing unit, where close health staff monitoring is limited. The RN justified Mr. VARGAS’ transfer solely based on his COVID positivity and not his ongoing symptoms, which deviated from CDC guidelines. @ The APP who developed Mr. VARGAS’ COVID-19 treatment plan did not consider the use of antivirals to significantly decrease his risk of hospitalization and death, which deviated from the CDC guidelines for patients at increased risk for progression to severe COVID-19. e Despite Mr. VARGAS’ COVID-19 symptomology and preexisting condition (diabetes), which placed him at an elevated risk for developing complications from COVID-19, an APP released him from isolation to the general population without completing a physical examination or chart review to ascertain his current health status, only noting his completion of 12 days of isolation. @ The APP who diagnosed Mr. VARGAS with complicated pneumonia (unresolved symptoms within 48 to 72 hours) did not escalate his care to a physician or an infectious disease specialist for input. @ On August 31, 2025, the RN who evaluated Mr. VARGAS for his second complaint of difficulty breathing did not check his oxygen saturation to ascertain early signs of worsening respiratory distress. @ Although the radiologist who resulted Mr. VARGAS’ chest x-ray recommended a follow-up chest x-ray to “document resolution,” the APP who reviewed his chest x-ray result did not order a follow-up chest x-ray for comparison. e The APPs who gave telephone orders to the nursing staff on August 20 and 30, 2025, did not pursue additional inquiries from the nursing staff to ensure interventions were appropriate. @ On August 28, 2025, an APP documented a body temperature of 93.5 Fahrenheit during Mr. VARGAS’ foot ulcer assessment; however, the APP did not recheck his temperature. Applicable standards of care for this finding: @ NCCHC: Standards for Health Services in Jails, 2018: J-E-09, Continuity, Coordination, And Quality of Care During Incarceration. 2026-ICFO-15303-000008

Page 9 of 9 e¢ WNCCHC: Standards for Health Services in Jails, 2018: J-F-01, Patients with Chronic Disease and Other Special Needs. @ NCCHC: Standards for Health Services in Jails, 2018: J-F-02, /nfirmary-Level Care. * Centers for Disease Control and Prevention. 2024. “Clinical Course: Progression, Management, and Treatment.” COVID-19. 2024. https://www.ecde.gov/covid/hep/clinical-care/management-and-treatment. html. @ Centers for Disease Control and Prevention. 2024. “People with Certain Medical Conditions and COVID-19 Risk Factors.” CDC. gov. 2024. https://Awww.cde.gov/covid/risk factors/index html https://www.cdce.gov/covid/hep/clinical -care/management-and-treatment. html. e U.S. Centers for Disease Control and Prevention. 2023. “Management and Prevention Guidelines.” Pneumonia. October 13, 2023. https://www.cde.gov/pneumonia/hep/management-prevention-guidelines/index.html. e Metlay, Joshua P., Grant W. Waterer, Ann C. Long, et al. 2019. “Diagnosis and Treatment of Adults with Community-acquired Pneumonia. An Official Clinical Practice Guideline of the American Thoracic Society and Infectious Diseases Society of America.” American Journal of Respiratory and Critical Care Medicine 200 (7): 795- P15. https://doi.org/10.1164/recm.201908-1581ST. Recommendations « Forward these findings to the IHSC Deputy Assistant Director (DAD) of Health Care Compliance Division (HCCD). @ The IHSC DAD of HCCD wiil share these findings through appropriate communication channels to ICE, and CAFCC’s facility administrator and health authority, for review and any action(s) deemed appropriate. @ The respective THSC HCCD unit and ICE will ensure a corrective action plan, if applicable, is implemented and sustained. End of report. 2026-ICFO-15303-000009