EFTA00138273

# Bureau of Prisons Health Services Clinical Encounter

| Inmate Name: | EPSTEIN, JEFFREY EDWARD |
| :--- | :--- |
| Date of Birth: | 01/20/1953 |
| Encounter Date: | 07/23/2019 06:20 |

| Sex: | M | Race: |
| :--- | :--- | :--- |
| Provider: | MLP | Unit: H01 |

Injury Assessment - Non-work related encounter performed at Health Services.

## SUBJECTIVE:

INJURY 1 Provider: MLP

Date of Injury: 07/23/2019 01:27 Date Reported for Treatment: 07/23/2019 08:25

Work Related: No Work Assignment: UNASSG

Pain Location:

Pain Scale: 0

Pain Qualities:

Where Did Injury Happen (Be specific as to location):

Special Housing Unit Z05-Cell 124 L

Cause of Injury (Inmate's Statement of how injury occurred):

"I do not know. Just went to drink a little water and wake up snorting".

Symptoms (as reported by inmate):

None



## OBJECTIVE:

## Temperature:

<table><thead><tr><th>Date</th><th>Time</th><th>Fahrenheit</th><th>Celsius</th><th>Location</th><th>Provider</th></tr></thead><tbody><tr><td>07/23/2019</td><td>06:30 NYM</td><td>97.5</td><td>36.4</td><td>Oral</td><td>MLP</td></tr></tbody></table>

<table border="1"><tr><td colspan="6">Pulse:</td></tr><tr><td>Date</td><td>Time</td><td>Rate Per Minute</td><td>Location</td><td>Rhythm</td><td>Provider</td></tr><tr><td>07/23/2019</td><td>06:30</td><td>92</td><td>Via Machine</td><td>Regular</td><td>MLP</td></tr></table>

## Respirations:

<table><thead><tr><th>Date</th><th>Time</th><th>Value</th><th>Location</th><th>Position</th><th>Cuff Size</th><th>Provider</th></tr></thead><tbody><tr><td>07/23/2019</td><td>06:30 NYM</td><td>140/85</td><td>Right Arm</td><td>Sitting</td><td>Adult-regular</td><td>.MLP</td></tr></tbody></table>



SaO2:


<table><thead><tr><th>Date</th><th>Time</th><th>Value(%)</th><th>Air</th><th>Provider</th></tr></thead><tbody><tr><td>07/23/2019</td><td>06:30 NYM</td><td>96</td><td>Room Air</td><td>. MLP</td></tr></tbody></table>

## Exam:

## General

Affect

Yes: Cooperative

<table><tr><td>Appearance</td></tr><tr><td>Yes: Appears Well, Alert and Oriented x 3</td></tr><tr><td>No: Appears Distressed, Lethargic, Dyspneic, Appears in Pain, Pallor, Cyanotic, Diaphoretic, Disheveled,</td></tr></table>

Generated 07/23/2019 09:05 by

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SDNY_00015018

Bureau of Prisons - NYM

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EFTA00138274

Inmate Name: EPSTEIN, JEFFREY EDWARD
Date of Birth: 01/20/1953
Encounter Date: 07/23/2019 06:20

Sex: M Race: MLP
Provider: MLP
Unit: H01

Exam:
Acutely Ill

Pulmonary
Auscultation
Yes: Clear to Auscultation, Vesicular Breath Sounds Bilaterally
No: Crackles, Rhonchi, Wheezing

Exam Comments
Inmate for injury report as requested by Operational Lt.
He is ambulatory, oriented x 3. In not apparent distress, smiling during this clinical encounter. Alleges, that he does not know what happened. Can not explain the marks on his neck. Responded: "I don't know".
He does not want to talk of the events leading to the marks on his neck.
He does not look in any distress or pain.
Has an circular line of erythema at the base of the neck. Reaching 2/3 of the neck circumference, 2 inches wide, sparing the back of the neck. Has one section of this erythema in the front with marks of friction.
No inflammation, no deformities, no hematomas, no lacerations, no tenderness. Patient moving his neck without any restriction. Denies having any pain or discomfort. Denies any respiratory problem.
Has another small erythema on left knee about 2cm in diameter(mild).
As per information from custody staff inmate Epstein was found in his cell with a rope around his neck and sitting on the floor.
Inmate is currently placed on suicide watch.

ASSESSMENT:
Injury, unspecified, T1490 - Current - R/O self inflicted injuries.

PLAN:

Disposition:
Follow-up at Sick Call as Needed
Placed on Suicide Watch
Follow-up in 2-4 Hours

Other:
For follow up with psychology service.

Patient Education Topics:

| Date Initiated | Format | Handout/Topic | Provider | Outcome |
| :--- | :--- | :--- | :--- | :--- |
| 07/23/2019 | Counseling | Access to Care | | Verbalizes Understanding |
| 07/23/2019 | Counseling | Plan of Care | | Verbalizes Understanding |

Copay Required: No
Cosign Required: Yes

Telephone/Verbal Order: No
Completed by MLP on 07/23/2019 09:05
Requested to be cosigned by MD.
Cosign documentation will be displayed on the following page.







Generated 07/23/2019 09:05 by

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SDNY_00015019

MLP

Bureau of Prisons - NYM

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EFTA00138275



BP-A0308
JAN 17


ADMINISTRATIVE DETENTION ORDER

U.S. DEPARTMENT OF JUSTICE
FEDERAL BUREAU OF PRISONS



TO: Special Hqssing Unit Officer



Date/Time: 07-10-2019

FROM:___; LIEUTENANT___, (Name/Title)

SUBJECT : Placement of___ EPSTEIN, JEFFERY ___ , Reg. No.___ 7-10-2019 ___ , in Administrative Detention

___(a) Is pending an investigation for a violation of Bureau regulations;

___(b) Is pending an SIS investigation.

___(c) Is pending investigation or trial for a criminal act:

___(d) Is to be admitted to Administrative Detention

___(1) Since the inmate has requested admission for protection;

I hereby request placement in Administrative Detention for my own protection.

Inmate Signature/Register No.: ___

Staff Witness Printed Name Signature: ___

___(2) Since a serious threat exists to individual's safety as perceived by staff, although person has not requested admission; referral of the necessary information will be forwarded for an appropriate hearing by the SRO.

___(e) Is pending transfer or is in holdover status during transfer.

| | |

| :--- | :--- |

| ✓(f) | Is pending classification; or |

___(g) Is terminating confinement in Disciplinary Segregation and has been ordered into Administrative Detention by the Warden's designee.

It is this Correctional Supervisor's decision based on all the circumstances that the above named inmate’s continued presence in the general population poses a serious threat to life, property, self, staff, other inmates, or to the security or orderly running of the institution because*

Therefore, the above named inmate is to be placed in Administrative Detention until further notice. The inmate received a copy of this Order on

[date / time] 2-10-9

Staff Witness Signature/Printed Name___ Date 2-10-19

Supervisor 24 hour review of placement: Signature/Printed name___

- In the case of DHO action, reference to that order is sufficient. In other cases, the Correctional supervisor will make an independent review and decision, which is documented here.

Record Copy - Inmate Concerned (not necessary if placement is a result of holdover status); Copy - Captain; Copy - Unit Manager; Copy - Operation Supervisor - Administrative Detention Unit; Copy – Psychology; Copy - Central File

PDF

Prescribed by P5270

[Replaces BP-A0308 of JAN 88.]





SDNY_00015020


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EFTA00138276

Cop-00T 78514-054 TARTAGLIONE

1 Legal Call in light of Event w Epstein on 7-23-19



SDNY_00015021


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