JUN 10 MULTI-LEVEL MORTALITY REVIEW U.S. DEPARTMENT OF JUSTICE

BP-A0563 JUN 10 MULTI-LEVEL MORTALITY REVIEW U.S. DEPARTMENT OF JUSTICE FEDERAL BUREAU OF PRISONS Date: 09/09/2019 To: Office of Quality Management From: MW New York Health Services Subject: Mortality Review for Inmate Epstein #76318.054 Inst. MW-NY Name: Epstein. Jeffrey DOD : 08110/2019 DOB: 01/20/1953 Place of Death: Inst. Name of community hospital: Nature of Death: ___ Accidental: - Homicide 1. Suicide (Method) Hanging Cause(s) of Death: Asphyxiation Reg. #: Age: 66 Sex: Male76318-054 ✓ Community Hospital ___ OTHER New York Presbyterian Lower Manhattan Hospital Natural (chronic) - Natural (Acute) Race: White NARRATIVE SUMMARY: (Should include components below) Date of admission to the 07/06/2019 _i_New commit _Transfer from Holdover Status: _Inpatient at Inst _ Community Hospital _Outpatient Admitting 1. Sleep Apnea 2. Hyperuiglyceridemia 3. L4 L5 Lumbar Stenosis 4. (Pls. continue on supplementary page if necessary) Past diagnosis: 1. Sleep Apnea 2. Hypertriglyceridemia 3. L4 - LS Lumbar &cassis 4. (Pls. continue on supplementary page if necessary) Significant mental health _(Yes) (No) _(NA) Include specific Information as relevant to death: PDF Present/ea by P6013 EFTA00040930 Name: Epstein. Jeffrey Reg. #: 76318-054 DOB: 01/20/1953 Admitting diagnosis:(continue) Past diagnosis: (Continue) PDF Prescribeb by P6013 EFTA00040931 Description of course of illness (past and present) and cause of the death in sufficient detail to indicate circumstances of death, including treatment, medications, diagnostic testing. etc. Give findings of diagnostic exams. Insert pages in this section as required. Intake Screening History and Physical present? fit! Yes No _NA Date of most recent History and Physical 07/09/2019 Timeliness of Diagnostic and Treatment regimes? __No __NA Discharge summary from Attending M.D. on chart Institution Yes _NA Community Hospital Yes _LJ'10 _NA Autopsy / No NA Toxicology _Yes ._Yes _l_No _NA Death Certificate Available _Yes /No _NA INSTITUTION MEDICAL CARE REVIEW: Severity of ifiness at time of admission to hospital / Health Services Unit — Critical st/Stable Unknown Prognosis on admission to hospital / health Services Unit Poor 1Good NA Were diagnostic procedures appropriate and timely j_Yes No Was treatment appropriate to diagnosis and instituted timely Yes No Prognosis with treatment Poor Good Unknown My complications adversely affecting outcome: Yes Describe briefly Asphyxiation Secondary to Hanging. Was treatment appropriate to complication Surgical Procedures (list) Appropriate pre-operative evaluation completed, including lab, physical exam, updated history Complications related to surgical procedures (describe) Prognosis following surgical procedure Patient compliant with treatment / medications / Yes No Yes No „t NA Yes No ✓ NA Yes —No ULNA _ Poor — Good i Unknown _Yes _No _CNA 3 PDF Prescribed by P6013 EFTA00040932 Discussion with patient or patient's family regarding prognosis _Yes _No ULNA DNR order Yes I No Date Advance Directive / Living VY.II _Yes _No ✓ NA LOCAL COMMUNITY HOSPITALIZATIONS ONLY: Type of admission Routine _i_Emergent _ Other Method of transportation appropriate to patient condition _._1_Yes No — NA Severity of condition at time of admission to local hospital ✓1 Critical — Stable _ Unknown Prognosis on admission to local hospital __ Poor — Good — Unknown Were diagnostic procedures appropriate and timely _(_Yes _No Was treatment appropriate to diagnosis and instituted timely I _Yes _No i Prognosis with treatment Poor _ Good _ Unknown Any complications adversely affecting outcome: 1 Yes No (describe briefly) Asohyxiation Secondary to Hamitic Was treatment appropriate to complication Surgical Procedures (list) Appropriate pre-operative evaluation completed. Including lab, physical exam, updated history Complications related to surgical procedures Describe Yes _No __Yes _No Yes _YestiNo Prognosis following surgical procedure — Poor _ Good _i_ Unknown Patient compliant with treatment / medications Yes __No __I_NA Discussion with patient or patient's family regarding Yes _No lif\Lik patient prognosis 4 PDF Prescribed by P6013 EFTA00040933 DNR order Yes Date Advance Directive / Living Will Yes Date REVIEW OF EMERGENCY MEDICAL CARE: Was death related to a medical emergency ✓Yes _No Response to medical emergency notification timely yYes _No __CIA PhysicianYes _No _NA Physician Assistant Nurse Practitioner _No _—NA Nurse(s) I Yes _No _NA Emergency Medical Techs _Yes _No NA Others _Yes Yes CPR / Yes _No _NA ACLS List protocol (s) used Of appropriate) _I__Yes _No _NA By EMS. Problems encountered during medical emergency, e.g., _Yes d_No _NA equipment, communications, transportation. Describe bnefly: Providers responding maintain current certification / credentials in BUS, ACLS (if required) Yes _No _NA SUMMARY REVIEW: Inmate Jeffery Edward Epstein I473618-054 a 66 year old male with a history of Obstructive Sleep Apnea on CPAP at night, a history of Hypertriglyceridemia treated with Vaseepa, no past Mental Health History prior to incarceration and L4-L5 Stenosis. On July 23.2019, at 2:00 am. he was placed on Suicide Watch for 31 hours and 5 minutes due to abrasion located on the lower anterior surface of his neck area. On July 24,2019 he was taken off Suicide Watch and was placed on Psychological Observation. On July 30.2019, he was removed from Psychological Observation and was placed in the Special Housing Unit where he was housed with a cell mate. On August 8, 2019, he was seen by Psychology Services and denied suicidal ideation, intention or plan. On August 10, 2019, at 6:33 am. Special Housing Unit Staff found inmate Epstein unresponsive in his cell and attempted to wake him. The body alarm was activated in SHU and the Control Center announced a medical emergency. CM was initiated by Special Housing Unit Staff. At 6:35 am. medical staff responded and continued CM and the AED was applied. The Control Center called for an ambulance. The EMS arrived at 6:45 am. and the paramedics continued CPR. Inmate Epstein remained unresponsive. Inmate Epstein was incubated, and the ACLS Protocol was initiated by the EMS. No pulse found, no shock was advised and the inmate was prepared for transport to local hospital while continuing CPR. At 7:10 a.m. the EMS departed institution en route to New York Presbyterian Lower Manhattan Hospital. At 7:36 a.m. the inmate was pronounced dead by the ER Physician 5 PDF Prescribed by P6013 EFTA00040934 Documentation in medical record reviewed by Mortality Review No _NA Committee and found to be within acceptable limits. If no, describe Did patient receive appropriate and adequate health care, consistent __No _NA with community standards, during his incarceration in the Federal Bureau of Prisons? If no, explain State any strengths and weaknesses that existed: I. The Mortality Review Committee reviewed the Medical Record. The patient received timely and appropriate medical and psychological care. 27. Recommendation(s) if any. The Mortality Review Committee reviewed the Medical Record. No recommendations at this time 6 PDF Prescnbed by P6013 EFTA00040935 28. Attachments: 1. Medical Record 3 Death Certificate 2. Narrative Summary 4. Autopsy Report 5. Other Documents as appropriate (list) ALL INFORMATION CONTAINED IN THIS REPORT IS EXEMPT AND TO BE CONSIDERED FOR REVIEWNIEWING ON A NEED TO KNOW BASIS ONLY. REVIEW COMMITTEE: 7 PDF Prescribed by P6013 EFTA00040936 OFFICE OF THE REGIONAL DIRECTOR Comments: - Agree with Institution MRC — Disagree with Inst. MRC Recommendations or Action taken: Regional HSA Date Regional Director Date PDF Prescribed by P6013 EFTA00040937 OFFICE OF QUALITY MANAGEMENT Comments: Signature of Review Committee Member PDF Prescribed by P6013 EFTA00040938