Death Review of Detainee Irene Bamenga ICE Report 2011
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Office of Professional Responsibility U.S. Department of Homeland Security 950 L’ Enfant Plaza Washington, DC 20024 DETAINEE DEATH REVIEW Case Number Detainee Alien Number Citizenship Date of Death Detention Facility Facility Type 201111495 Irene BAMENGA (b)(6), (b)(7)c France July 27, 2011 Albany County Jail – Albany, New York IGSA OVERVIEW The U.S. Immigration and Customs Enforcement, Office of Professional Responsibility, Office of Detention Oversight, initiated this review after receiving information that ICE Detainee Irene BAMENGA, a citizen and national of France, died at the Albany Memorial Hospital located in Albany, New York. At the time of her death, Detainee BAMENGA was in ICE custody at the Albany County Jail (ACJ) pending removal proceedings. Detainee BAMENGA died on July 27, 2011, due to cardiomyopathy. This review found that Detainee BAMENGA was admitted into the United States on July 22, 2005, as a visitor for pleasure under the Visa Waiver Pilot Program. On July 15, 2011, US Customs and Border Protection (CBP) officers encountered BAMENGA at the Lewiston Bridge Port of Entry in Lewiston, NY, after Canadian Immigration officials denied BAMENGA entry into Canada. On the same date, CBP officers issued BAMENGA a Notice to Alien Ordered Removed/Departure Verification, Form I-296, charging removability pursuant to § 212(a) of the Immigration and Nationality Act (INA) or deportable under the provisions of § 237 of the INA as a Visa Waiver Pilot Program violator. On July 15, 2011, BAMENGA entered ICE custody at the Allegany County Jail in Belmont, NY. On July 21, 2011, ERO FOD Buffalo officers transferred BAMENGA to the Albany County Jail for staging, as she was scheduled for removal through the John F. Kennedy International Airport in New York, NY, on July 28, 2011. OFFICIAL USE ONLY SENSITIVE Page 1 of 20 DEPARTMENT OF HOMELAND SECURITY 1. CASE NUMBER 201111495 Immigration and Customs Enforcement Office of Professional Responsibility PREPARED BY (b)(6), (b)(7)c REPORT OF INVESTIGATION 2. REPORT NUMBER 002 HB 4200-01 (37), Special Agent Handbook 3. TITLE Bamenga, Irene/Unknown/0108 Death-Detainee/Alien (Unknown Cause)/ALBANY, ALBANY, NY 4. FINAL RESOLUTION 5. STATUS Closing Report 6. TYPE OF REPORT Detainee Death Review 7. RELATED CASES 8. TOPIC Closing Report for Detainee Death Review of Irene BAMENGA (b)(6), (b)(7)c 9. SYNOPSIS On July 27, 2011, the Joint Intake Center (JIC), Washington D.C., received notification regarding the death of U.S. Immigration and Customs Enforcement (ICE) Detainee Irene BAMENGA. Detainee BAMENGA, a citizen of France, died on July 27, 2011, at the Albany Memorial Hospital in Albany, New York. The New York State Medical Examiner reported Detainee BAMENGA died due cardiomyopathy. On August 15, 2011, the ICE Office of Professional Responsibility (OPR), Office of Detention Oversight (ODO) initiated a Detainee Death Review (DDR) of Irene BAMENGA's death. This report documents the findings of the review. 10. CASE OFFICER (Print Name & Title) (b)(6), (b)(7)c Agent Supervisor 12. APPROVED BY(Print Name & Title) (b)(6), (b)(7)c 11. COMPLETION DATE 14. ORIGIN OFFICE - ICE-OPR Special 12-JAN-2012 ICE OPR Office of Detention Oversight (ODO) 13. APPROVED DATE 15. TELEPHONE NUMBER 12-JAN-2012 No Phone Number - ICE-OPR Special Agent Supervisor THIS DOCUMENT IS LOANED TO YOU FOR OFFICIAL USE ONLY AND REMA NS THE PROPERTY OF THE DEPARTMENT OF HOMELAND SECURITY. ANY FURTHER REQUEST FOR DISCLOSURE OF THIS DOCUMENT OR INFORMATION CONTA NED HEREIN SHOULD BE REFERRED TO HEADQUARTERS, DEPARTMENT OF HOMELAND SECURITY, TOGETHER WITH A COPY OF THE DOCUMENT. THIS DOCUMENT CONTA NS INFORMATION REGARD NG CURRENT AND ON-GO NG ACTIVITIES OF A SENSITIVE NATURE. IT IS FOR THE EXCLUSIVE USE OF OFFICIAL U.S. GOVERNMENT AGENCIES AND REMAINS THE PROPERTY OF THE DEPARTMENT OF HOMELAND SECURITY IT CONTAINS NEITHER RECOMMENDATIONS NOR CONCLUSIONS OF THE DEPARTMENT OF HOMELAND SECURITY. DISTRIBUTION OF THIS DOCUMENT HAS BEEN LIMITED AND FURTHER DISSEM NATION OR EXTRACTS FROM THE DOCUMENT MAY NOT BE MADE WITHOUT PRIOR WRITTEN AUTHORIZATION OF THE ORIGINATOR. OFFICIAL USE ONLY SENSITIVE OFFICIAL USE ONLY SENSITIVE Page 2 of 20 DEPARTMENT OF HOMELAND SECURITY 1. CASE NUMBER 201111495 PREPARED BY (b)(6), (b)(7)c REPORT OF INVESTIGATION CONTINUATION HB 4200-01 (37), Special Agent Handbook 2. REPORT NUMBER 002 10. NARRATIVE On July 27, 2011, the JIC was notified of the death of Detainee Irene BAMENGA (Alien Number (b)(6), (b)(7)c ). Detainee BAMENGA, a citizen of France was born on November 10, 1981 and died on July 27, 2011 at the Albany Memorial Hospital located at 600 Northern Boulevard, Albany, New York. Detainee BAMENGA was 29 years old at the time of her death. Detainee BAMENGA was in ICE custody at the Albany County Correctional Facility (ACCF) on the date of her death. The Albany County Sheriff's Office (ACSO) owns and operates the ACCF. The ACCF is a mixed-use facility that houses inmates received from area law enforcement jurisdictions, as well as adult male and female federal detainees over 72 hours. The ACCF is an intergovernmental service agreement (IGSA) facility contracted by the United States Marshals Service (USMS) to house federal detainees. ICE is an Authorized User in accordance with the contract. (b)(6), (b)(7)c During the week of August 22, 2011, OPR ODO Special Agent (SA) and (b)(6), (b)(7)c Supervisory Special Agent (SSA) conducted the on-site segment of the ODO (b)(6), (b)(7)c DDR. The agents were assisted by Program Manager (PM) PM (b)(6), (b)(7)c is employed by MGT of America Inc. (MGT), a national management and consultant firm, contracted by ICE to provide subject matter expertise in detention management and correctional health care. As part of the review, agents interviewed staff at the ACCF, the Allegany County Jail (ACJ), U.S. Customs and Border Protection (CBP), and the ICE Office of Enforcement and Removal Operations (ERO). Additionally, agents reviewed immigration, medical, and detention records pertaining to Detainee BAMENGA. The following is a time-line of the events regarding Detainee BAMENGA while she was in ICE custody. (b)(6), (b)(7)c On July 15, 2011, at approximately 5:35 p.m., CBP Officer (CBPO) encountered Irene BAMENGA at the Lewiston Bridge Port of Entry (POE) in Lewiston, New York. Irene (b)(6), (b)(7)c (b)(6), (b)(7)c BAMENGA, her husband and attempted to enter Canada from the United States. BAMENGA was denied entry into Canada due to lack of a valid I-94 (Arrival-Departure Record) from the United States. All three individuals attempted to re-enter the United States and were detained by CBP officers at the Lewiston Bridge POE. CBP officers researched BAMENGA's immigration status and learned that she entered the United States as a Visa Waiver Pilot Program participant in 2005. BAMENGA was authorized to remain in the United States until October 21, 2005. SSA (b)(6), (b)(7)c and CBP Internal Affairs (IA) SA OFFICIAL USE ONLY (b)(6), (b)(7)c SENSITIVE interviewed CBPO (b)(6), (b)(7)c on August OFFICIAL USE ONLY SENSITIVE DEPARTMENT OF HOMELAND SECURITY Page 15 of 20 1. CASE NUMBER 201111495 PREPARED BY (b)(6), (b)(7)c REPORT OF INVESTIGATION CONTINUATION HB 4200-01 (37), Special Agent Handbook 2. REPORT NUMBER 002 10. NARRATIVE Death regarding BAMENGA (Exhibit 36). According to the Certificate of Death report, BAMENGA' s immediate cause of death was cardiomyopathy and the time of death is listed as 1:17 a.m. The death certificate indicates an autopsy was performed on BAMENGA. Coroner (b)(6), (b)(7)c (b)(6), (b)(7)c (b)(6), (b)(7)c and M.D., signed the Certificate of Death pertaining to BAMENGA. ICE has been denied access to the BAMENGA autopsy report by the Albany County Department of Law based on New York State County Law 677. The ICE Office of Principal Legal Advisor (OPLA) has made efforts to obtain the autopsy report without success. According to (b)(6), (b)(7)c information supplied by Albany County Attorney the autopsy report cannot be disclosed at the request of the Department of Homeland Security (Exhibit 37). MEDICAL COMPLIANCE REVIEW: MGT of America, a national management and consultant firm, contracted by ICE to provide subject matter expertise in detention management including health care, reviewed the medical care of Detainee BAMENGA while housed at the ACCF and the ACJ. MGT of America found that the ACCF and the ACJ were not compliant with the ICE NDS for medical care. Specifically, MGT determined that the ACCF and ACJ failed to dispense ordered medications, delayed in starting medications, failed to verify medications, and provided incorrect dosing of medications. The MGT of America report is attached to this ROI (Exhibit 38). MORTALITY REVIEW: (b)(6), (b)(7)c A mortality review was conducted by Dr. , a clinical consultant medical doctor contracted by ICE to evaluate the medical care provided to Detainee BAMENGA while in ICE custody. Dr. (b)(6), (b)(7)c assessed the care provided by the ACCF as inadequate. Specifically, Dr. (b)(6), (b)(7)c documented in her report that both the ACCF and the ACJ were remiss in not conducting a thorough clinical evaluation and assessment of BAMENGA whose congestive heart failure would deteriorate when poorly managed. According to Dr. (b)(6), (b)(7)c report, BAMENGA should have been placed on a restricted sodium diet. Additionally, an electrocardiogram should have been done and a chest x-ray should have been completed. According to Dr. (b)(6), (b)(7)c laboratory testing should have been done to include digoxin levels, electrolytes, a complete blood count, and thyroid function studies. Dr. (b)(6), (b)(7)c Mortality Review Report is attached to this report (Exhibit 39). IMMIGRATION AND DETENTION HISTORY: Irene BAMENGA, a native of Angola and citizen of France, entered the United States as a visitor OFFICIAL USE ONLY SENSITIVE OFFICIAL USE ONLY SENSITIVE DEPARTMENT OF HOMELAND SECURITY Page 16 of 20 1. CASE NUMBER 201111495 PREPARED BY (b)(6), (b)(7)c REPORT OF INVESTIGATION CONTINUATION HB 4200-01 (37), Special Agent Handbook 2. REPORT NUMBER 002 10. NARRATIVE under the Visa Waiver Program (VWP) at Boston, Massachusetts on July 22, 2005. Detainee BAMENGA was authorized to remain in the United States until October 21, 2005. On July 15, 2011, BAMENGA was encountered by CBP at the Lewiston Bridge, Lewiston, New York, after having been refused entry into Canada for failure to provide a valid I-94, Nonimmigrant (b)(6), (b)(7)c Visa Waiver Arrival/Departure Form. CBP Assistant Port Director issued an Order of Removal for Detainee BAMENGA in accordance with Section 217 of the Immigration and Naturalization Act (INA). From July 15, 2011 to July 21, 2011, Detainee BAMENGA was housed at the Allegany County Jail, located in Belmont, New York pending removal from the United States. On July 21, 2011, Detainee BAMENGA was transferred to Albany County Correctional Facility, located in Albany, New York. Detainee BAMENGA was scheduled for removal from the United States on July 28, 2011. CRIMINAL HISTORY: According to the National Crime Information Center (NCIC), Detainee BAMENGA was assigned (b)(7)e the FBI # NCIC records indicate Detainee BAMENGA has no additional arrests prior to her encounter with CBP on July 15, 2011. INVESTIGATIVE FINDINGS: Detainee BAMENGA came into ICE custody on July 15, 2011, and her congestive heart failure was documented consistently while in ICE custody. The New York State Department of Health Certificate of Death documents that Detainee BAMENGA's immediate cause of death was cardiomyopathy. A review of the Medical Administration Records (MAR) pertaining to BAMENGA revealed the ACCF and ACJ failed to dispense ordered medications, delayed in starting medications, failed to verify medications, and provided incorrect dosing of medications. According to information provided by Dr. (b)(6), (b)(7)c "missed medication dosing as well as incorrect medication dosing were significant factors that contributed to the decompensation of her congestive heart failure." [Agent's note: decompensation is failure of the heart to maintain adequate blood circulation, marked by labored breathing, engorged blood vessels, and edema (www. medical-dictionary.thefreedictionary.com.)] This review revealed the ACJ and the ACCF were not in compliance with the ICE NDS Medical Care Standard. The ICE NDS, Medical Care, Section (I), Policy, indicates all detainees shall have access to medical services that promote detainee health and general well-being. MGT of America reviewed Medical Administration Records (MAR) and determined that the ACCF and ACJ failed to OFFICIAL USE ONLY SENSITIVE OFFICIAL USE ONLY SENSITIVE DEPARTMENT OF HOMELAND SECURITY Page 18 of 20 1. CASE NUMBER 201111495 PREPARED BY (b)(6), (b)(7)c REPORT OF INVESTIGATION CONTINUATION HB 4200-01 (37), Special Agent Handbook 2. REPORT NUMBER 002 10. NARRATIVE the BAMENGA's medical records from her community provider, or ordering laboratory tests. ACJ policy does not address handling of medications received with new detainees, including documenting receipt, inventory, disposal or release by either booking or medical staff. Interviews with ACJ medical staff revealed that in ACJ practice, medications are turned over to the medical unit when received, and returned to ICE detainees upon release or transfer. A review of the contract between the United States Marshals Service (USMS) and the ACCF for housing detainees at the ACCF revealed ICE is listed as an "Other Authorized Agency User" (Exhibit 40). According to the contract, "Detainees shall also be housed in a manner that is consistent with federal law and the Federal Performance-based Detention Standards." ICE does not have a separate and independent contract with the ACCF that specifies requirements of the ICE NDS for housing ICE detainees. OFFICIAL USE ONLY SENSITIVE OFFICIAL USE ONLY SENSITIVE DEPARTMENT OF HOMELAND SECURITY Page 19 of 20 1. CASE NUMBER 201111495 PREPARED BY (b)(6), (b)(7)c REPORT OF INVESTIGATION Exhibit List HB 4200-01 (37), Special Agent Handbook 2. REPORT NUMBER 002 01 - Form I-213, Record of Deportable/Inadmissible Alien (7/15/2011) 02 - I-94 Arrival/Departure information related to BAMENGA 03 - CBP Vehicle Utilization Log (7/15/2011) 04 - ACJ Vehicle Log used to document activity at the facility (7/15/2011) 05 - Homeland Security Form I-203 Order to Detain or Release Alien (7/15/2011) 06 - ACJ Booking Observation Report (7/15/2011) 07 - ACJ History and Physical Examination (7/18/2011) 08 - ACJ Medication Record 09 - ICE Detainee Interview Log (7/19/2011) 10 - Certificate of Issuance of Immigration Detainee Handbook (7/19/2011) 11 - ICE Personal Property Notice (7/19/2011) 12 - Detainee Interview /Visitation Worksheet (7/19/2011) 13 - ACJ Grievance Records 14 - ACJ Vehicle Log used to document activity at the facility (7/21/2011) (b)(6), (b)(7)c 15 - Email from SDDO (7/20/2011) 16 - Homeland Security Form I-203 Order to Detain or Release Alien (7/21/2011) 17 - Copy of Allegany County Sheriff's Office check number (b)(6), (b)(7)c (7/20/2011) 18 - Memorandums pertaining to Detainee Transfer Sheets 19 - Form I-216 Record of Persons and Property Transferred (7/21/2011) 20 - ACCF Offender Management System (OMS) data (7/21/2011) 21 - Correctional Medical Services Medical and Mental Health History and Screening form (7/21/2011) 22 - ACCF Interdisciplinary Progress Notes 23 - Correctional Medical Services Physician Orders 24 - ACCF Medication Administration Record 25 - ACCF Housing Assignments for BAMENGA 26 - Correctional Medical Services Health Services Request Forms (7/25/2011) 27 - ACCF Inmate Service Unit Intake Interview packet (7/26/2011) 28 - ACCF Register Log (7/26/2011) 29 - Detainee Interview/Visitation Worksheet (7/26/2011) 30 - ACCF Inmate Classification Test results (7/26/2011) 31 - ACCF Classification Policy 32 - ACCF Post Log for 6 West (7/27/2011) 33 - Colonie EMS Prehospital Care Report 34 - ACCF Incident Report # 11-106 35 - Albany Memorial Hospital Emergency Department Report (7/27/2011) 36 - New York State Department of Health Certificate of Death (7/27/2011) OFFICIAL USE ONLY SENSITIVE OFFICIAL USE ONLY SENSITIVE DEPARTMENT OF HOMELAND SECURITY Page 20 of 20 1. CASE NUMBER 201111495 PREPARED BY (b)(6), (b)(7)c REPORT OF INVESTIGATION Exhibit List HB 4200-01 (37), Special Agent Handbook (b)(6), (b)(7)c 37 - Albany County Attorney Email (8/11/2011) 38 - MGT of America Medical Compliance Review (6/29/2011) (b)(6), (b)(7)c 39 - Mortality Review by Dr. 40 - U.S. Marshals Service IGSA Detention Contract with ACCF OFFICIAL USE ONLY SENSITIVE 2. REPORT NUMBER 002 BEST COPY AVAILABLE BEST COPY AVAILABLE BEST COPY AVAILABLE BEST COPY AVAILABLE BEST COPY AVAILABLE BEST COPY AVAILABLE BEST COPY AVAILABLE BEST COPY AVAILABLE BEST COPY AVAILABLE BEST COPY AVAILABLE BEST COPY AVAILALBE BEST COPY AVAILABLE BEST COPY AVAILABLE BEST COPY AVAILABLE BEST COPY AVAILABLE BEST COPY AVAILABLE BEST COPY AVAILABLE BEST COPY AVAILABLE BEST COPY AVAILABLE BEST COPY AVAILABLE BEST COPY AVAILABLE BEST COPY AVAILABLE BEST COPY AVAILABLE BEST COPY AVAILABLE BEST COPY AVAILABLE BEST COPY AVAILABLE BEST COPY AVAILABLE BEST COPY AVAILABLE BEST COPY AVAILABLE Review of Detainee Death (b)(6), (b)(7)c Irene Bamenga, A-Number Medical Record Review Findings Allegany County Jail, Belmont, New York Albany County Correctional Facility, Albany, New York Section 1: Timeline As requested by the ICE Office of Professional Responsibility, Office of Detention Oversight, MGT of America, Inc. participated in a review of detainee Irene BAMENGA’s death while in (b)(6), (b)(7)c (b)(6), (b)(7)c ICE custody. MGT accompanied Special Agents and for site visits to the Allegany County Jail and Albany County Correctional Center August 23 – 25 2011, and participated in interviews of correctional and medical staff at both facilities. Additionally, MGT reviewed the medical record of detainee BAMENGA and inspected documentation of staff training in emergency response and distribution of medication. MGT’s participation was requested to determine compliance with ICE National Detention Standards (NDS) governing medical services. The following chronicles detainee BAMENGA’s period of detention at the Allegany and Albany County facilities based on documented and reported information. Italicized text in parenthesis defines or explains medical terminology and abbreviations. MGT’s findings with respect to compliance with ICE NDS and general observations for which there are no applicable NDS components are documented in commentary. Background ICE Significant Event Notification – Significant Incident Report documents that on July 15, 2011 detainee Irene BAMENGA was issued a Notice to Alien Ordered Removed/Departure Verification by Customs and Border Protection (CBP) officers after being denied entry into Canada by Canadian immigration officials. An Order to Detain or Release Alien signed by CBP Enforcement Officer (b)(6), (b)(7)c directed her detention at the Allegany County Jail (ACJ) pending removal proceedings. In the Remarks section of the form was documented, “Congestive Heart Failure she takes medications to control her medical problem. Subject has medication with her.” Friday, July 15, 2011 ALLEGANY COUNTY JAIL Allegany County Sheriff’s Office Inmate Personal Property Receipt documents detainee BAMENGA’s personal property as $20 in currency, white sneakers, yellow brazil shirt, and shorts. Suicide Prevention Screening Questionnaire completed by Deputy (b)(6), (b)(7)c Saturday, July 16, 2011 Allegany County Jail Booking Observation Report completed by Deputy( )(6), (b)(7)cdocuments detainee BAMENGA responded affirmatively when asked if she was on medication, stating “lots of them.” In addition, she reported an allergy to Tramadol (treats moderate to severe pain) and DDR Medical Compliance Review: Detainee Irene BAMENGA Section 1: Timeline Page 1 positive tuberculosis (TB) test 12 years ago. No medical conditions or special needs documented. COMMENT: The Booking Observation Report includes health-related observation and interview questions intended to identify immediate medical or special housing needs. Facility policy J-3.10 assigns responsibility for completion of the report to booking officers and includes provisions for referral for immediate medical attention if required. ICE NDS, Medical Care, section (III)(D) requires that all new arrivals receive initial medical and mental health screening by a health care provider or an officer trained to perform this function. MGT verified officers are trained in the intake screening function. Compliance is met. According to Deputy(b)(6), (b)(7 cdetainee BAMENGA was received with a large bag of medications which he took directly to the Medical Unit. Because of the hour, medical staff was not present to directly receive the medications. COMMENT: ACJ policy does not address handling of medications received with new detainees, including documenting receipt, inventory, disposal or release by either booking or medical staff. MGT was informed that in practice, medications are turned over to the Medical unit when received, and returned to ICE detainees upon release or transfer. (b)(6), (b)(7)c Registered Nurse (RN), per interview. Detainee BAMENGA was screened by RN (b)(6), (b)(7)c stated she reported to the facility on a Saturday because she was on-call for the purpose of performing TB testing and follow-up medical screening on new prisoners. RN (b)(6), (b)(7)c documented the encounter by noting the following on the Booking Observation Report completed by Deputy(b)(6), (b)(7) Congestive Heart Failure (CHF) and high blood pressure; ASA (aspirin to reduce risk of heart attack), Digoxin (heart medication), Lisinopril (hypertension), and Furosemide (diuretic) on a daily basis; Spironalactone (diuretic) twice a day; and Carvedilol (HTN, heart failure, and angina/chest pain), dosage frequency documented as “?”. In addition, RN (b)(6), (b)(7)c documented a previous positive TB test in 2002, “was treated;” and blood pressure of 138/92 (slightly elevated). During interview, RN (b)(6), (b)(7)c stated detainee BAMENGA was not certain of Carvedilol dosing. She reported the detainee’s lungs were clear, her heart rate was regular, and she observed no swelling. A TB test by PPD was not planted because the detainee previously tested positive; instead, authorization for chest x-ray was to be requested. RN (b)(6), (b)(7)c stated detainee BAMENGA voiced no medical complaints, and was not asked for information on her private provider or when she was last seen. RN (b)(6), (b)(7)c reported there were two large medication organizers belonging to the detainee “stuffed” with various medications. The detainee informed her she had taken her medications the day before and asked why she could not have them. RN (b)(6), (b)(7)c stated she informed detainee BAMENGA the facility does not allow prisoners to take their own medications because they are not verified. She instructed the detainee to obtain information on dosages from her husband. Upon inquiry, RN (b)(6), (b)(7)c stated procedures are in place for off-hours consultation with a provider concerning medications or other matters; however, because BAMENGA’s screening was normal, she did not believe action before Monday was necessary. DDR Medical Compliance Review: Detainee Irene BAMENGA Section 1: Timeline Page 2 (b)(6), (b)(7)c COMMENT: According to RN (b)(6), (b)(7)c and Nurse Practitioner (NP) The ACJ Medical Unit does not document encounters or actions in Progress Notes or other chronological record. RN (b)(6), (b)(7)c she typically makes a note in the SOAP format (Subjective, Objective, Assessment, Plan) if there are findings of significance. MGT was informed detainee BAMENGA’s medications were placed in her personal property. Monday, July 18, 2011 “Informed Consent – Consent for Detainees” form signed. COMMENT: ICE NDS, Medical Care, section (III)(L) requires health care providers to obtain signed and dated consent forms from all detainees before any medical examination or treatment, except in emergency circumstances. Compliance is met. NP (b)(6), (b)(7)c conducted a physical examination, making hand-written notes on the same Booking Observation Report used by RN Harrington to document the medical screening, and generating a type-written “History and Physical Examination” report. Findings were documented as follows: History and Physical Examination • Past medical history: CHF (congestive heart failure- excessive amount of fluid in lungs), HTN (hypertension/high blood pressure), and anemia (reduction of circulating red blood cells) • Past surgical history: right lung • Medications: ASA daily, Spironalactone twice a day, Lasix (diuretic) daily, Digoxin daily, Carvedilol daily, and Lisinopril daily. • Allergies: Tramadol (pain medication) • Denies tobacco, alcohol and illicit drug use • Suicide and mental health referral: negative • General appearance: 29 year-old black female, “appears as stated age;” alert and oriented. • Vital signs: temperature 99.8, pulse 88, respirations 20, blood pressure (BP) 128/84 (slightly elevated), weight 206 lbs. • Cardiac: Regular rate and rhythm. COMMENT: ICE NDS, Medical Care, section (III)(D) requires that health care providers conduct a health appraisal and physical examination on each detainee within 14 days of arrival. Compliance is met. COMMENT: Detainee BAMENGA was not placed on a restricted diet despite her weight and history of hypertension. NP (b)(6), (b)(7)c generated the following: Problem List • Height, 67 inches; weight, 206 lbs. • Previous positive PPD DDR Medical Compliance Review: Detainee Irene BAMENGA Section 1: Timeline Page 3 • • • Problems: HTN, CHF, and Anemia Treatment: ASA 81 mg daily, Spironalactone 25 mg twice daily, Lasix 20 mg daily, Digoxin 0.25 mg daily, Carvedilol 20 mg daily, and Lisinopril 20 mg daily. Date documented for listed problems and treatment: 7/7/2011. During interview, NP Ralyea, the incorrect date was a typographical error. Medication List • Allergies: Tramadol • Medications (start date July18, 2011) o ASA 81 mg daily o Spironalactone 25 mg twice daily o Lasix 20 mg o Digoxin 0.25 mg daily o Carvedilol 20 mg daily o Lisinopril 20 mg daily Orders • Diagnosis: CHF, HTN, anemia • Allergies: Tramadol • Date order of 7/18/2011 and Date Stop of 10/18/2011 for the following: o Tylenol 2 tablets by mouth as needed for fever or pain o ASA 81mg daily o Spironalactone 25mg twice daily o Lasix 20 mg daily o Digoxin 0.25mg daily o Lisinopril 20mg daily o Carvedilol 20mg daily COMMENT: The order for medications was made three days following the detainee’s arrival. During interview, NP b)(6), (b)(7)c stated the medications ordered, including dosage, were as reported by detainee BAMENGA. She did not attempt to verify the medications before ordering them. According to the Nursing 2010 Drug Handbook, Carvedilol is to be administered twice daily, and according to WebMD, pulse should be taken when Digoxin is administered to ensure it is not too slow. The order for Digoxin did not include this provision. NP (b)(6), (b)(7)c stated she did not consider pursuing the detainee’s medical records from her community provider, or ordering laboratory tests. Treatment Authorization Request approved for chest x-ray due to positive PPD history. Approved July 19, 2011. COMMENT: ICE NDS, Medical Care, section (III)(D) requires that all new arrivals receive TB screening by PPD (mantoux method) or chest x-ray. PPD is to be the primary screening method unless contraindicated, as was the case with detainee BAMENGA. ACJ took appropriate action to request authorization for a chest x-ray, though it was not completed prior to her transfer on July 21, 2011. NP b)(6), (b)(7)c stated that though not DDR Medical Compliance Review: Detainee Irene BAMENGA Section 1: Timeline Page 4 documented, detainee BAMENGA was screened for, but did not exhibit signs or symptoms of TB. Medication Administration Record (MAR) documents Officer BAMENGA her evening dose of Spironalactone. (b)(6), (b)(7)c gave detainee COMMENT: MGT was informed medications are distributed by officers trained in the function when medical staff is not on site. MGT verified Officer(b)(6), (b)(7)ccompleted training. ICE NDS, Section (III)(I) requires that written records be maintained of all medications given to detainees. Compliance is met for the term of detainee BAMENGA’s detention in the ACJ. Tuesday, July 19, 2011 MAR documents detainee BAMENGA was given ASA, Lasix, Digoxin, Lisinopril, Carvedilol, and Spironalactone by RN (b)(6), (b)(7)c in the morning, and her evening dose of Spironalactone in by Officer (b)(6), (b)(7)c COMMENT: There was no documentation supporting Officer training in distribution of medication. (b)(6), (b)(7)c completed Wednesday, July 20, 2011 MAR documents detainee BAMENGA was given ASA, Lasix, Digoxin, Lisinopril, Carvedilol, and Spironalactone by RN (b)(6), (b)(7)c in the morning, and her evening dose of Spironalactone in by Officer (b)(6), (b)(7)c NP (b)(6), (b)(7)c stated she was notified by Intake that detainee BAMENGA was being transferred. She prepared a Medical Summary of Federal Prisoner/Alien in Transit form documenting the detainee had a previous positive PPD and treatment in 2000; chest x-ray “not done yet.” Departure date was recorded as July 20, 2011; “Destination” and “Reason for Transfer” left blank. Current Medical Problems were documented as HTN, CHF, and anemia; recorded medications, dosage, and “Medication Requirements for Care En Route” were consistent with Medication List, Orders and MAR. No special needs affecting transportation noted. NP (b)(6), (b)(7)c stated the transfer summary was placed in a sealed envelope bearing the detainee’s name and marked, “CONFIDENTIAL.” She stated the envelope and blister packs containing detainee BAMENGA’s remaining medications were forwarded for transfer. COMMENT: ICE NDS, Detainee Transfers, section (III)(D)(6) requires that health care providers be given advance notice prior to the release, transfer or removal of a detainee so that medical staff may determine and provide for any medical needs. Section (III)(D)(6) further requires IGSA facilities to prepare transfer summaries documenting TB clearance, current mental and physical health status, medications, and contact information for the transferring medical official. In addition, ICE NDS, Medical Care, section (III)(N) requires placement of medical information in sealed envelopes marked “MEDICAL CONFIDENTIAL.” Compliance with all requirements is met. DDR Medical Compliance Review: Detainee Irene BAMENGA Section 1: Timeline Page 5 COMMENT: Facility physician Dr. (b)(6), (b)(7)c did not increase Coreg to twice daily, and did not order that detainee BAMENGA’s pulse be taken before giving Digoxin. Problem List documented chronic problems as CHF, HTN, and anemia. Detainee signed Informed Consent for urine pregnancy test and consent for HIV testing. COMMENT: No documentation of pregnancy or HIV testing. It is noted, however, RN documented negative in the “Pregnancy Test Results” of the intake screening form. (b)(6), (b)(7)c During interview, RN b)(6), (b)(7)cstated the medications were received with the detainee in blister packs; further, that medications received from another facility in this manner may be administered upon physician approval. RN b)(6), (b)(7)cstated detainee BAMENGA made no comments concerning her medications and expressed no concerns or complaints. MAR documents detainee BAMENGA was given all medications this date as ordered. MGT was informed only medical personnel distribute medications. Friday, July 22, 2011 MAR documents detainee BAMENGA was given morning doses of all medications; “NS” (No Show) recorded for evening dose of Spironolactone. COMMENT: HSA (b)(6), (b)(7)c provided policy J-D-02.06, “Medication Administration Record,” which states “Absent” is to be documented if the prisoner is “not present, and no reason for the absence was given.” She stated the expectation is that the nurse goes to the cell to determine the reason for the absence or refusal; further, that the prisoner be referred to the ordering practitioner following three missed doses. She provided the Medication Administration Documentation lesson plan supporting nurses are trained accordingly. HSA (b)(6), (b)(7)c stated she reviewed nursing staff’s medication distribution practices in light of the fact “NS” was recorded on detainee BAMENGA’s MAR on July 22, 24, 25 and 26, 2011. On none of the days “NS” was recorded did the nurse seek out the detainee, and no action taken to notify the provider after the third dose was missed. HSA (b)(6), (b)(7)c stated failure to follow policy was addressed with three specific staff members who recorded “NS,” and correct procedures have been reviewed with all staff. Saturday, July 23, 2011 MAR documents detainee BAMENGA was given all medications as ordered. Sunday, July 24, 2011 MAR documents detainee BAMENGA was given morning doses of all medications; “NS” recorded for evening dose of Spironolactone. Monday, July 25, 2011 MAR documents detainee BAMENGA was given morning doses of all medications; “NS” recorded for evening dose of Spironolactone. DDR Medical Compliance Review: Detainee Irene BAMENGA Section 1: Timeline Page 7 MAR documents a new entry for Digoxin: “Digoxin to be given daily and to hold dose if apical pulse is [less than] 60 and notify MD.” MAR documents apical pulse was 88 and Digoxin given. COMMENT: As noted previously, checking pulse prior to giving Digoxin is expected practice, however, there is no corresponding Physician’s Order or other documentation reflecting what precipitated the instruction. Tuesday, July 26, 2011 Health Services Request Form: “I am not being given the full dosage of my medications. Two of the six different meds are meant to be take twice a day and so far I have only be given 1 dosage in the morning. The two medecines are spironolactone and carvedilol [sic].” Date and time received illegible, as are the initials of the individual who conducted triage and referred the detainee for nurse’s sick call. Documented in the “Health Care Documentation” section of the form are, “Seen on 7-26” and “Coreg ordered [twice per day].” Health Services Request Form submitted by detainee: “Shortness of breath at night especially when laying down, palpitations when laying down. Dizziness upon standing up when palpitation and shortness of breath occur.” “FOR MEDICAL USE ONLY” section of form for documenting date and time received are blank, as are sections for recording triage and “Health Care Documentation.” According to HSA (b)(6), (b)(7)c the “FOR MEDICAL USE ONLY” section is to be completed when a medical staff person is handed a request form directly by a detainee. It is not completed if received through another source. HSA (b)(6), (b)(7)c further stated both the triage and Health Care Documentation sections should have been completed. COMMENT: ICE NDS, Medical Care, section (III)(F), Sick Call, requires facilities to have a mechanism that allows detainees the opportunity to request health care services. Facility policy J-E-07.00 supports compliance with the standard. In addition, section (III)(F) requires health care providers to review request slips to determine when the detainee will be seen. Compliance is supported with respect to one of detainee BAMENGA’s sick call requests. 9:40 AM Physical Assessment completed by NP (b)(6), (b)(7)c Weight documented as 200 lbs; BP 110/80 (normal range); other vital signs within normal limits. History of positive PPD; treated in 2000 in Paris, France. Past medical history of HTN, CHF for five years; past surgical history of right lobectomy (surgical removal of lobe of any organ or gland). Current medications recorded. Described as cooperative and alert and oriented to person, place & time; denied chest pain and shortness of breath. COMMENT: Compliance with ICE NDS, Section (III)(D) requiring physical examination within 14 days of arrival is met. COMMENT: Detainee BAMENGA was not placed on a restricted diet despite weight and history of hypertension. DDR Medical Compliance Review: Detainee Irene BAMENGA Section 1: Timeline Page 8 ACCF Incident Report by Officer (b)(6), (b)(7)c documents the following: “On July 27, 2011 I was working on the 6 West Housing Unit 11 to 7 shift. At approximately 12:15 AM I was notified by inmates in Bay L3 that inmate Bamenga was sick. I then called for a relief officer so the inmate could be taken to medical. At approximately 1219 I notified the Unit Supervisor because inmate would not answer me. At 1223 I entered L3 Bay to rouse Bamenga. Inmate Bamenga did not respond. I then notified Medical via my portable radio to respond immediately while inside L3 Bay. I then left the bay to activate the units alarm system At 1224 Medical staff entered the bay and CPR was commenced. I administered chest compressions for inmate Bamenga while nurse (b)(6), (b)(7)c worked the ambu bag. EMS arrived at 1235 and took over care for inmate Bamenga. At 1253 EMS transported inmate Bamenga from the unit.” During interview Officer b)(6), (b)(7)creported that when he conducted count at 11:00 PM, detainee BAMENGA was lying in bed. He stated she appeared to be awake because her eyes were open. He stated that when first notified by her dorm-mates that she was ill, he followed standard operating procedure by calling for an escort officer. While waiting, inmates stated “she is really sick,” so he decided to walk from his station to her housing area. From outside, he called her name a few times and asked if she was OK. Receiving no reply, he returned to his station to verify escort was on its way. He then walked back to the housing area and decided to enter. He stated detainee BAMENGA looked “really sick,” so he grabbed her arm and finding her nonresponsive, notified Medical via his radio and returned to his station to hit the alarm. Nurse (b)(6), (b)(7)c (b)(6), (b)(7)c and Nurse arrived “quickly” and together, they removed detainee BAMENGA from her upper bunk. Once she was on the floor, Nurse (b)(6), (b)(7)c applied the ambu-bag and Nurse (b)(6), (b)(7)c initiated CPR, subsequently being relieved by Officer (b)(6), (b)(7)c and Nurse (b)(6), (b)(7)c COMMENT: Asked why he did not enter the housing unit when he called for detainee BAMENGA and did not receive a reply, he stated that as a male, he did not want to enter a female unit; further, he did not feel it was necessary because he could see everyone. He further stated, “They tell us not to go in because it could be a trap and you don’t want to go in alone.” During interview, Captain (b)(6), (b)(7)c stated officers are trained not to enter cells by themselves except in medical emergency. It is noted Officer (b)(6), (b)(7)c report documents four minutes elapsed between being alerted detainee BAMENGA was sick and finding her unresponsive upon calling to her from outside the housing unit. Instead of returning to his station to notify his supervisor as documented in his report, or to check on escort as reported during interview, Officer b)(6), (b)(7)ccould legitimately have called medical emergency by radio and entered the unit. Another four minutes elapsed before he entered and attempted to wake detainee BAMENGA, whereupon he called Medical by radio and again returned to his station to activate the alarm system. A total of nine minutes elapsed between notification the detainee was ill and commencement of CPR. COMMENT: MGT was provided with a memorandum on Albany County Sheriff’s Office letterhead stating Officer b)(6), (b)(7)ccompleted cardio-pulmonary resuscitation (CPR) re-certification training March 1, 2011. In addition, CPR certification cards expiring in (b)(6), (b)(7)c (b)(6), (b)(7)c 2012 were produced for Nurse and Nurse ICE DDR Medical Compliance Review: Detainee Irene BAMENGA Section 1: Timeline Page 10 NDS, Medical Care, section (III)(H) states detention staff must be trained to respond to health-related emergencies within a four-minute timeframe. Compliance with training requirements is met. 12:58 AM Interdisciplinary Progress Notes documents, “EMS [with patient] to Memorial Hospital, life support machines on [patient].” 1:00 AM Interdisciplinary Progress Notes documents, “Health Services Administrator of situation.” 1:05 AM Interdisciplinary Progress Notes documents, “MD (b)(6), (b)(7)c (b)(6), (b)(7)c informed notified of incident. 1:20 AM Interdisciplinary Progress Notes documents, “Dr. (b)(6), (b)(7)c from Memorial Hospital stated the [patient] was pronounced dead at 0115.” Albany Memorial Hospital Emergency Department Reports dictated by Doctor documented the following: (b)(6), (b)(7)c “Chief Complaint: cardiac arrest. History of Present Illness: This is a 29-year-old female who arrives from the Albany County Jail in full cardiopulmonary arrest. History obtained from EMS providers, and some history from her family when I had called them. She is a 29-year-old with a history of anemia and congestive heart failure who has been taking multiple medications, apparently laying in bed, not terrible [sic] responsive for several hours, but her cellmates were not initially concerned because her eyes were open and they thought she was simply not communicative. However, when the [sic] tried to rouse her, they were unable to. At that point, the guards were summoned. Jail medical staff responded and started CPR. EMS was called simultaneously. On EMS arrival, the guards had performed approximately ten minutes of CPR. EMS found her to be asystole…” Certificate of Death documents manner of death as natural cause; cased referred to coroner; autopsy performed. Immediate cause of death: cardiomyopathy (disease that affects heart muscle, diminishing cardiac performance). DDR Medical Compliance Review: Detainee Irene BAMENGA Section 1: Timeline Page 11 MEDICAL COMPLIANCE REVIEW Section 2: Missed Medication Summary Detainee Irene BAMENGA Following are medications detainee BAMENGA reported she was taking at the time of her arrest, subsequently ordered by Allegany and Albany County providers. Column A summarizes doses not given as ordered by the providers. Column B summarizes doses missed pending provider order at Allegany County, failure to distribute ordered medications at Albany, and incorrect dosing of Carvedilol. * A B EC ASA None 3 Lasix None 3 Lisinopril None 3 Digoxin* None 3 Pulse taken for Digoxin 2 9 Carvedilol/Coreg 1 15 Spironalactone 2 9 MORTALITY REVIEW REPORT NAME: Bamenga, Irene ID#: (b)(6), (b)(7)c DATE OF BIRTH: November 10th, 1981 FACILITY: Albany County Correctional Facility DATE OF DEATH: July 27th, 2011 The preliminary autopsy report and certificate of death indicated that 29 year old Irene Bamenga, a citizen of France, died of cardiomyopathy. This mortality review was conducted based on a review of booking, classification, investigative reports and statements, as well as medical records from Allegany County Jail, Albany County Correctional Facility and Albany Memorial Hospital Emergency Room. Narrative Summary: 7/15/2011: Bamenga was brought to the Allegany County Jail with documentation indicating she had congestive heart failure and was on several medications which she had on her person. The booking officer conducted a booking observation and a suicide screening questionnaire which indicated no special circumstances that required immediate intervention. 7/18/2011: The nurse practitioner conducted a medical history and physical examination on Bamenga. No information regarding a chief complaint was elicited from the patient. A past medical history of treatment for latent tuberculosis infection, hypertension, congestive heart failure and anemia was noted and her current medications were as follows: aspirin 81 mg daily, spironolactone 25 mg twice daily, lasix 20mg daily, digoxin 0.25mg daily, carvedilol 20mg daily and lisinopril 20mg daily. On examination, Bamenga’s vital signs indicated a low grade fever with a temp of 99.8, pulse=88, respirations=20 and blood pressure=128/84. Her cardiac and respiratory examination was documented as normal with no signs of congestive heart failure. Her medications were ordered by the nurse practitioner. A review of the medication administration records only documented administration of her medications on 7/19 and 7/20/2011. It is not clear whether she received her medications from the evening of 7/15/2011 to 7/18/2011 as well as on the morning of 7/21/2011. She was transferred to the Albany County Correctional Facility on 7/21/2011 early that morning. 7/21/2011: Bamenga arrived at the Albany County Correctional Facility at approximately 6:00pm. She received a medical and mental health history. The history of anemia, congestive heart failure, hypertension and positive PPD was given including medications listed on transfer sheet. However, no further medical history was elicited at that time to determine the severity of her medical conditions that might have triggered an earlier than scheduled evaluation by the nurse practitioner or physician. A call was placed to the physician who gave verbal orders for her current medications. A chest xray was ordered to rule out active tuberculosis and Bamenga was placed in general population. 7/25/2011: Bamenga completed two health services request forms. In her own words, she wrote, “Shortness of breath at night especially when laying down; palpitations when laying down; dizziness 1 upon standing when palpitations and shortness of breath occur.” “I am not being given the full dosages of my medication. Two of the six different medications are meant to be taken twice a day and so far I have only been given one dosage in the morning. The two medications are spironolactone and carvedilol.” Sometime on or after 7/26/2011, the triage nurse wrote on the slip that Bamenga was seen on 7/26 and that coreg 25mg twice daily had been ordered. Legibility of the medication administration record was poor in some instances; however, it appears that the nursing staff documented with “NS” that Bamenga did not show for her 9pm spironolactone dosages on 7/22, 24 and 26. 7/26/2011: The nurse practitioner conducted a physical assessment of Bamenga. Her vital signs were temp=97.9, pulse=82, resp=16, B/P=110/80. She documented that Bamenga denied pain/discomfort and also denied chest pain or shortness of breath. She found no abnormalities in the cardiovascular and respiratory evaluation and no edema in the lower extremities. She did increase the carvedilol (coreg) to 25mg twice daily. I could find no documentation indicating that the nurse practitioner had appropriately explored the patient’s symptoms of shortness of breath at night, of palpitations when lying down and of dizziness upon standing. On completion of the examination, there was no indication as to status of Bamenga’s chronic medical conditions nor were any tests ordered to make that determination. 7/27/2011: At approximately 12:15am inmates in the housing unit notified the correctional officer that Bamenga was sick. The officer responded but was unable to arouse Bamenga and at 12:23am, he activated the medical response system and the unit’s alarm system.CPR as instituted with chest compressions and the ambu bag. There was no documentation that an automatic external defibrillator was applied by the facility’s staff. At 12:35am, the community emergency medical system/ambulance arrived, took over care and transported the patient to Albany Memorial Hospital. Efforts to resuscitate this patient were unsuccessful and the patient was pronounced dead at 1:15am. Conclusions and Recommendations: If we are to believe the physical assessments conducted by the two nurse practitioners at the Allegany County Jail and the Albany County Correctional Facility on July 18th and July 26th respectively, then, it is highly unlikely that this patient’s immediate cause of death would be cardiomyopathy due to her congestive heart failure. The clinical course of congestive heart failure is usually slowly progressive with symptoms of worsening shortness of breath that becomes visible, swelling of the lower extremities known as peripheral edema, and lung findings such as a productive cough and rales in the lungs on auscultation. None of these findings were documented. Based on the patient’s complaints on 7/25/2011, we can conclude that this patient’s congestive heart failure was worsening; this may have been due to the combination of incorrect dosing of carvedilol, missed doses of spironolactone, a diuretic, and increase in dietary sodium. Carvedilol should be prescribed at a twice daily dosage and in her case, the initial dose should have been documented as 25mg and not 20mg. The formulation does not exist in a 20mg form. I am not clear as to why she was a “no show” for some of her 9pm spironolactone doses. Was she sleeping and not aroused for those doses? Did the nursing staff 2 recognize the severity of her disease and make any attempts to ensure medication compliance? I saw no documentation of such efforts. Because this patient’s congestive heart failure did not appear to have worsened severely, I believe that we must look at other causes of her death. Based on her symptoms of palpitations on July 26th, she may have died from a cardiac arrhythmia which would not be found on autopsy. What would cause a cardiac arrhythmia in this patient? Digoxin toxicity and alterations in potassium level can both cause fatal cardiac arrhythmias. Digoxin concentrations are increased by about 15% when digoxin and carvedilol are administered concomitantly. Therefore, increased monitoring of digoxin is recommended when initiating, adjusting, or discontinuing carvedilol. Was this patient hyperthyroid? We do not know because we did not investigate the complaint of palpitations. Did this patient have a myocardial infarction due to her cardiomyopathy? Did this patient throw a pulmonary embolus? Toxicology studies will be crucial in helping to determine the final cause of death. However, regardless of this patient’s final cause of death, both facilities were remiss in not conducting a thorough clinical evaluation and assessment of this patient whose congestive heart failure would deteriorate when poorly managed. The assessments by both nurse practitioners did not include whether Bamenga’s congestive heart failure and hypertension were controlled. There was no plan to determine what type of anemia this patient suffered from. This patient should have been placed on a restricted sodium diet, an electrocardiogram should have been done, the chest x-ray should have been completed and laboratory testing should have been done to include digoxin levels, electrolytes, a complete blood count and thyroid function studies. Previous medical records were being sent by Bamenga’s attorney but there was no documentation that the records had been received. The physician should have been consulted for guidance in initial management of this young cardiac patient and this did not occur in either facility. Subsequent early follow up by the physician would have been appropriate. Finally the early use of an automatic external defibrillator (AED) is standard practice in responding to a life threatening emergency and it is recommended that an AED be obtained and the facility’s medical as well as correctional staff be trained in its use. Submitted by: (b)(6), (b)(7)c MD, Clinical Consultant Diplomate of the American Board of Family Medicine Date of Review: September 4, 2011 3 From: To: Subject: Date: (b)(6), (b)(7)c Re: BAMENGA mortality review follow up questions Thursday, September 29, 2011 2:52:50 PM QUESTION 1: What bearing, if any, may have missed medications had on detainee BAMENGA’s death? For example, Coreg is usually prescribed twice a day but BAMENGA only received it once a day. Did receiving it once a day instead of twice a day make a difference in her health? ANSWER 1: This patient suffered from a chronic cardiac condition namely, congestive heart failure. Appropriate medication management including appropriate dosing and patient compliance is critical in controlling this condition. Based on Banenga's medical complaints on her sick call request forms on July 25th, it is clear that her congestive heart failure which was stable on entry, had now decompensated. Yes, missed medication dosing as well as incorrect medication dosing were significant factors that contributed to the decompensation of her congestive heart failure. Other factors were increased sodium intake through dietary intake. QUESTION 2: To what degree did failure to take the actions referenced in the final paragraph of the Mortality Review Report have relevance to detainee BAMENGA’s death; i.e., had they been taken, could the death have been prevented? ANSWER 2: If this patient's death was indeed cardiomyopathy due to congestive heart failure, then this death could have been prevented if the appropriate steps were taken to determine the severity of her congestive heart failure followed by an appropriate treatment plan to control her cardiac condition. QUESTION 3: Should nurse practitioners/medical personnel at both facilities have known that Coreg is usually prescribed twice a day? ANSWER 3: If nurse practitioners in New York State have prescriptive authority (can order medications), then the expectation is that they would have the training, knowledge and skills to prescribe medications appropriately. Yes, we providers do make errors in prescribing if we are not using electronic prescribing systems. However, our health care system's check and balance is the pharmacist who has electronic drug pharmacy systems. Normally, when a dose of medication that does not follow the drug manufacturer's prescribing recommendations, is prescribed, the pharmacist will contact the prescribing practitioner to determine if this was an error. I could not determine if this communication occurred nor whether the practitioners had access to electronic prescribing systems. Dr.(b)(6), (b)(7)c we are unable to obtain the autopsy report for this case due to New York state privacy laws. However, regarding the mortality review you provided in this case, can you please answer the following 3 questions. QUESTION 1: What bearing, if any, may have missed medications had on detainee BAMENGA’s death? For example, Coreg is usually prescribed twice a day but BAMENGA only received it once a day. Did receiving it once a day instead of twice a day make a difference in her health? Detainee BAMENGA reported she took her medications the day she was taken into custody, July 15, 2011. Based on documentation and interviews, the following summarizes medications received and missed July 16 – 26, 2011. Detainee BAMENGA was found unresponsive shortly after midnight on July 27, 2011. ASA <![if !supportLists]>· <![endif]>Physical exam July 18, 2011: detainee reported taking daily <![if !supportLists]>· <![endif]>Ordered July 18, 2011: 81 mg daily <![if !supportLists]>· <![endif]>Received July 19 – 26, 2011 <![if !supportLists]>· <![endif]>Missed doses: 3 (July 16, 17, 18) Lasix <![if !supportLists]>· <![endif]>Physical exam July 18, 2011: detainee reported taking daily <![if !supportLists]>· <![endif]>Ordered July 18, 2011: 20 mg daily <![if !supportLists]>· <![endif]>Received July 19 – 26, 2011 <![if !supportLists]>· <![endif]>Missed doses: 3 (July 16, 17, 18) Lisinopril <![if !supportLists]>· <![endif]>Physical exam July 18, 2011: detainee reported taking daily <![if !supportLists]>· <![endif]>Ordered July 18, 2011: 20 mg daily <![if !supportLists]>· <![endif]>Received July 19 – 26, 2011 <![if !supportLists]>· <![endif]>Missed doses: 3 (July 16, 17, 18) Digoxin <![if !supportLists]>· <![endif]>Physical exam July 18, 2011: detainee reported taking daily <![if !supportLists]>· <![endif]>Ordered July 18, 2011: 0.25 mg daily <![if !supportLists]>· <![endif]>Received July 19 – 26, 2011 <![if !supportLists]>· <![endif]>Missed doses: 3 (July 16, 17, 18) <![if !supportLists]>· <![endif]>Order amended July 25, 2011: dose to be held if apical pulse is less than 60. Recorded pulse July 26: 88; July 26: 82 Carvedilol/Coreg <![if !supportLists]>· <![endif]>Physical exam July 18, 2011: detainee reported taking daily <![if !supportLists]>· <![endif]>Ordered July 18, 2011: 20 mg daily <![if !supportLists]>· <![endif]>Received one dose per day July 19 – 25, 2011 <![if !supportLists]>· <![endif]>Ordered July 26, 2011: 25 mg twice daily in response to detainee report she should receive the medication twice per day. Detainee did not receive second dose July 26, 2011. <![if !supportLists]>· <![endif]>Missed doses: 14, based on Dr (b)(6), (b)(7)(C) statement concerning twice per day administration (none received July 16, 17, 18; received one per day July 19 – 26, 2011) Spironalactone <![if !supportLists]>· <![endif]>Physical exam July 18, 2011: detainee reported ordered twice per day <![if !supportLists]>· <![endif]>Ordered July 18, 2011: 25 mg twice per day <![if !supportLists]>· July 25. <![endif]>Received twice per day starting evening, July 18 – July 21, 2011; July 23; <![if !supportLists]>· <![endif]>Missed doses: 9 (two per day July 16, 17, 18; evening July 22, 24, 26) QUESTION 2: To what degree did failure to take the actions referenced in the final paragraph of the Mortality Review Report have relevance to detainee BAMENGA’s death; i.e., had they been taken, could the death have been prevented? QUESTION 3: Should nurse practitioners/medical personnel at both facilities have known that Coreg is usually prescribed twice a day? (O) 202-732-(b)(6), (b)(7)c