EFTA00073831

2019-05665 Item 9, 13, 17 (partial), 18 (partial) EFTA00073831 Bureau of Prisons Health Services Clinical Encounter Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: NYM Encounter Date: 08/10/2019 07:25 Provider RN Unit: Z04 Emergency Code Resuscitation Event encounter performed at Special Housing Unit. SUBJECTIVE: Emergency Note Provider: RN Team Members: Provider Bole RN Team/Code Leader Code Events: Type Value Date CPR Compressions 08/10/2019 06:35 EKG/Monitor Lifepak 08/10/2019 06:39 No shock advised CPR Compressions 08/10/2019 06:40 Oxygen 15 L 08/10/2019 06:47 IV Access Peripheral IV 08/10/2019 06:48 18 g Left AC Page 001 of 148 Airway Endotracheal Tube 08/10/2019 07:08 Withheld pursuant to exemption ET Tube 7.5 24CM to L Lip line Placed by Paramedics Medications Epinephrine 1mg IV (b)(6) (b)(7)(A); (b)(7)(C) 08/10/2019 07:10 Epinephrine 3 doses and Sodium bicarb 2 doses administered by paramedics CPR Compressions of the Freedom of Information and Privacy Act, cro/10/2019 07:11 Medications Sodium Bicarbonate 1 mEaikg IV 08/10/2019 07:11 IV Fluids Normal Saline 0.9% 1000 ml 08/10/2019 07:12 Medications Epinephrine 1mg IV 08/10/2019 07:13 CPR Compressions 08/10/2019 07:14 Medications Sodium Bicarbonate 1 mEaikg IV 08/10/2019 07:14 Medications Epinephrine 1mg IV 08/10/2019 07:16 CPR Compressions 08/10/2019 07:17 Comments: Responded to a body alarm at 0635 for medical emergency on 9S. Upon arrival Inmate was received on the floor of his cell unresponsive with CPR in progress by correctional officers, Inmate was Cold, with circumferential Bruising around the neck and posterior mottling, Pupils Fixed and dilated, No Palpable pulses, Call place for EMS, CPR Continued, AED Placed No shock advised, CPR Continued. inmate transported to HSU treatment room with CPR in progress, 18g hep lock to L AC, O2 15 Lt ViA BVM. Pulse Check NO SHOCK advised. EMS and Paramedics arrived 0656. Placed on cardiac monitor asystole Resumed CPR. Inmate was intubated by Medics. 3 Rounds of Epinephrine administered. Pulse Check asystole, Inmate was transported to Local ER with CPR in progress. OBJECTIVE: Exam: General Appearance Yes: Unconscious Generated 08 10 2019 08.10 by RN Bureau of Prisons - NYM Page 1 of 2 EFTA00073832 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: NYM Encounter Date: 08/10/2019 07:25 Provider: RN Unit: Z04 Exam: ASSESSMENT: Cardiac Arrest PLAN: New Consultation Requests: Consultation/Procedure Target Date Scheduled Target Date Priority Translator Language Emergency Room 08/10/2019 08/10/2019 Emergent No Subtype: AMBULANCE Reason for Request: Cardiac arrest with CPR in progress Copay Required: No Cosign Required: Yes TelephoneNerbal Order: No Completed by RN on 08/10/2019 08:10 Requested to be cosigned by Cosign documentation will be displayed on the following page. Page 002 of 148 Withheld pursuant to exemption (b)(6) : (b)(7)(A) ; (b)(7)(C) of the Freedom of Information and Privacy Act Generated 08/1012019 08:10 by RN Bureau of Prisons NYM Page 2 of 2 EFTA00073833 Bureau of Prisons Health Services Cosign/Review Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Encounter Date: 08/10/2019 07:25 Provider: RN Facility: NYM Cosigned by on 08/12/2019 08:09. Page 003 of 148 Withheld pursuant to exemption (b)(6) ; (b)(7)(A); (b)(7)(C) of the Freedom of Information and Privacy Act Bureau of Prisons NYM EFTA00073834 Bureau of Prisons Health Services Clinical Encounter Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: NYM Encounter Date: 07/30/2019 15:58 Provider Unit: Z01 Chronic Care Chronic Care Clinic encounter performed at Health Services. SUBJECTIVE: COMPLAINT 1 Provider: Chief Complaint: Other Problem Subjective: PATIENT WAS REFERRED BY THE WARDEN FOR EVALUATION. PATIENT REPORTS HE HAS BEEN WITHOUT HIS MEDS FOR ABOUT 1 WEEK. HE ALSO REPORTS NUMBNESS IN HIS RIGHT ARM FOR A FEW MINUTES 3 DAYS AGO. STATES THE NUMBNESS WENT AWAY ON ITS OWN. BUT WAS VERY CONCERNING. HE DENIES RIGHT SIDED WEAKNESS. DIPLOPIA. FACIAL DROOP. DIFFICULTY SPEAKING OR SWALLOWING. HE REPORTS NOCTURIA OF ABOUT 5 TIMES.. HE DENIES DYSURIA. HE REPORTS H OF KIDNEY STONES. HX OF HTN FOR WHICH HE WAS TAKING TOPROL. HE AHS A HX OF SLEEP APNEA AND STATED HE HAS NOT SLEPT FOR 3 WEEKS ISNCE HE HASB EEN HERE SINCE HE DIE NOT HAVE ACCESS T HI CPAP MACHINE. I INFORME DHIM THAT WE RECEIVED HIS CPAP MACHINE AND IT WILL BE GIVEN TO HIM TONIGHT.. HE REPORT OTHER NON-MEDICAL ISSUE rage uu4 of 148 STATES HE FEELS OTHERWISE FINE. Pain: Not Applicable Withheld pursuant to exemption Seen for clinic(s): Pulmonary/Respiratory. Orthopedic,Rheumatology, Endocrine/Lipid (b)(6), (b)(7)(C) OBJECTIVE: of the Freedom of Information and Privacy Act Exam: General Affect Yes: Cooperative Appearance Yes: Appears Well. Alert and Oriented x 3 No: Appears Distressed, Dyspneic, Appears in Pain, Writhing in Pain, Pale, Pallor, Cyanotic, Diaphoretic, Disheveled. Unkempt. Acutely III Nutrition No: Appears Obese Pulmonary Auscultation Yes: Clear to Auscultation Cardiovascular Auscultation Yes: Regular Rate and Rhythm (RRR), Normal SI and S2 No: MITG Musculoskeletal Tibia / Fibula No: Edema Neurologic Generated 07 302019 16.12 by Bureau of Prisons - NYM Page 1 of 2 EFTA00073835 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: NYM Encounter Date: 07/30/2019 15:58 Provider Unit: 701 Exam: Cranial Nerves (CN) Yes: Within Normal Limits Motor System-General Yes: Normal Exam Motor System-Strength Yes: Normal Muscular Strength ASSESSMENT: Body mass index (BMI) 27.0-27.9, adult, Z6827 - Current Constipation, unspecified. K5900 - Current Essential (primary) hypertension, 110 - Current - BY HX. Hyperlipidemia, unspecified, E785 - Current Low back pain, M545 - Current Neuralgia and neuritis, unspecified, M792 - Current Prediabetes, R7303 - Current Sleep apnea, G4730 - Current PLAN: Page 005 of 148 New Medication Orders: Withheld pursuant to exemption Rxtl Medication Order Date Prescriber Order INsulin REG - Human (b)(8); (b)(dXM10;/0)(g)11%)58 SLIDING SCALE Subcutaneously each morning x of the Freedom of Information and Privacy Act 7 day(s) Pill Line Only Indication: Prediabetes Discontinued Medication Orders: Rx# Medication Order Date Prescriber Order 122148-NYM Insulin Reg (10 ML) 100 UNITSML lnj 07/30/2019 15:58 Inject regular insulin subcutaneously per sliding scale: twice daily — *pill line"' for 7 days Discontinue Type: When Pharmacy Processes Discontinue Reason: new order written Indication: Copay Required:No Cosign Required: No Telephone/Verbal Order: No Completed by on 07/30/2019 16:12 Generated 0730:2019 16:12 by Bureau of Prisons - NYM Page 2 of 2 EFTA00073836 Bureau of Prisons Health Services Clinical Encounter Inmate Name: EPSTEIN. JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: NYM Encounter Date: 07/30/2019 11:12 Provider: Unit: Z01 Chronic Care - Chronic Care Clinic encounter performed at Health Services. SUBJECTIVE: COMPLAINT 1 Provider: Chief Complaint: Other Problem Subjective: PATIENT REFERRED BY THE WARDEN FOR EVALUATION. PATIE RTS HE HAS BEEN WITHOUT HIS MEDS FOR ABOUT 1 WEEK. HE ALS S NUMBNESS IN HIS RIGHT ARM FOR A FEW MINUTES 3 DAYS AGO. STAT BNESS WENT AWAY ON ITS OWN, BUT WAS VERY CONCERNING. HE DEN SIDED WEAKNESS, DIPLOPIA, FACIAL DROOP, DIFFICULTY SPEAKING OWING. HE REPORT IA OF ABOUT 5 TIMES,. HE DENIES DYSURIA. HE REPORTS NEY STONES, HX OF HTN FOR WHICH HE WAS TAKING TOPROL. HE AHS A HX OF SLEEP AND STATED HE HAS NOT SLEPT FOR 3 WEEKS ISNCE HE HASB EEN E HE DIE NOT HAVE ACCESS T HI CPAP MACHINE. I INFORME DHIM THAT WE HIS CPAP MACHINE AND IT WILL BE GIVEN TO HIM TONIGHT.. HE REPORT OTHER NON-ME €W8 of 148 STATES HE FEELS OTHERWISEPIN Pain: Not Applicable Withheld o exemption Seen for clinic(s): Endocrine/Lipid, Orthopedic/Rheumatology' Respiratory (b)(6) (b)( XC) OBJECTIVE: of the Freedom of Information Pulse: &Quin. Dale lime Rate Per Minute Location Provider 07/30/2019 13:02 94 eaudouin, Robert MD 07/30/2019 09:40 88 Via Machine Robert MD 07/30/2019 09:30 87 Via Machine Robert MD Respirations: pate Time Rate Per Minute Provider 07/30/2019 09:30 NYM 12 Blood Pressure: Date limes Value Location Position Cuff Size Provider 07/30/2019 13:02 NYM 114/84 Left Arm Standing 07/30/2019 09:40 NYM 125/60 Right Arm Standing 07/30/2019 09:30 NYM 108/86 Left Arm Sitting SaO2: Dale lime Value(%) Air Provider 07/30/2019 09:30 NYM 98 Room Air Weight: Date Time Lbs Kg Waist Circum. Provider Generated 07/30/2019 14:05 by Bureau of Prisons - NYM Page 1 of 3 EFTA00073837 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: NYM Encounter Date: 07/30/2019 11:12 Provider: Unit: Z01 Date Time Lba Kg Waist Circum, Provider 07/30/2019 09:30 NYM 194.2 88.1 Exam: General Affect Yes: Cooperative Appearance Yes: Appears Well, Alert and Oriented x 3 No: Appears Distr ed. Dyspneic. Appears in Pain. Writhing in Pain, Pale. Pallor. Cyanotic, Diaphoretic. Disheveled, Unk cutely III Nutrition No: Appears O Pulmonary Auscultation Yes: Clear to Auscultation Cardiovascular Auscultation Yes: Regular Rate and Rhythm (RRR 1 and S2 No: Mil(G Musculoskeletal e 007 of 148 Tibia / Fibula Withheld exemption No: Edema Neurologic (b)(8). (b)(7) ( )(C) Cranial Nerves (CN) of the Freedom of Information Yes: Within Normal Limits Motor System-General Yes: Normal Exam Motor System-Strength Yes: Normal Muscular Strength ASSESSMENT: Body mass index (BMI) 27.0-27.9. adult. Z6827 - Current Constipation. unspecified, K5900 - Current Essential (primary) hypertension, 110 - Current - BY HX. Hyperlipidemia, unspecified, E785 - Current Low back pain, M545 - Current Neuralgia and neuritis, unspecified, M792 - Current Prediabeles, R7303 - Current Sleep apnea, G4730 - Current PLAN: New Medication Orders: R x# Medication Order Date Prescriber Order Generated 07/30.2019 14.05 by Bureau of Prisons - NYM Page 2 of 3 EFTA00073838 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: NYM Encounter Date: 07/30/2019 11:12 Provider Unit: Z01 New Medication Orders: Rx# Medication Order Date Prescriber Order Magnesium Hydroxide Susp conc 800 07/30/2019 11:12 10 CC Orally - Two Times a MG15ML Day PRN x 90 day(s) Indication: Constipation. unspecified INsulin REG - Human 07/30/2019 11:12 SLIDING SCALE Subcutaneously - Two Times a Day x 7 day(s) Pill Line Only Indication: Prediabetes Renew Medication Orders: Rxff Medication Order Date Prescriber Order 121836-NYM methylP ne 4 MG Tab ( 21 count 07/30/2019 11:12 Take the tablet by mouth as Pack) directed x 6 day(s) Indication: a and neuritis, unspecified New Laboratory Requests: Details Frequency Due Date Priority Lab Tests - Short List-General-CBC w diff ane Time 08/01/2019 00:00 Routine Lab Tests-P-PSA, Total Lab Tests-U-Uric Acid Lab Tests - Short List-General-Comprehensiv Metabolic Profile (CMP) Lab Tests-U-Urinalysis w/Reflex to Microscopic 008 of 148 New Radiology Request Orders: Withheld e emption Details Frequency Due Date Priority General Radiology-Spine / Cervical- One Ti(ix)(6); (b)( )(C) 08/29/2019 Routine General Specific reason(s) for request (ttfififtSiffigraei6 InfRnalje 66 YR OLD MALE WITH COMPLAITN OF RIGHT ARM NUI 2-3 MINUTES 3 DAYS AGO. PLEASE PERFORM C SPINE SERIES Disposition: Follow-up at Sick Call as Needed Patient Education Topics: Date initiated Format Handout/Topic Pipit l Outcome 07/30/2019 Counseling Access to Care Beaudo Robert Verbalizes Understanding 07/30/2019 Counseling Plan of Care Verbalizes Understanding Copay Required:No Cosign Required: No Telephone, Verbal Order: No Completed by on 07/30/2019 14:05 Generated 07 30'2019 14:05 by Bureau of Prisons - NYM Page 3 of 3 EFTA00073839 Bureau of Prisons Health Services Clinical Encounter Inmate Name: EPSTEIN. JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: NYM Encounter Date: 07/30/2019 11:12 Provider: Unit: Z01 Chronic Care - Chronic Care Clinic encounter performed at Health Services. SUBJECTIVE: COMPLAINT 1 Provider: Chief Complaint: Other Problem Subjective: PATIENT REFERRED BY THE WARDEN FOR EVALUATION. PATIE RTS HE HAS BEEN WITHOUT HIS MEDS FOR ABOUT 1 WEEK. HE ALS E S NUMBNESS IN HIS RIGHT ARM FOR A FEW MINUTES 3 DAYS AGO. STAT BNESS WENT AWAY ON ITS OWN, BUT WAS VERY CONCERNING. HE DEN HI SIDED WEAKNESS, DIPLOPIA, FACIAL DROOP, DIFFICULTY SPEAKING OWING. HE REPORT IA OF ABOUT 5 TIMES,. HE DENIES DYSURIA. HE REPORTS 'NEY STONES, HX OF HTN FOR WHICH HE WAS TAKING TOPROL. HE AHS A HX OF SLEEP AND STATED HE HAS NOT SLEPT FOR 3 WEEKS ISNCE HE HASB EEN CE HE DIE NOT HAVE ACCESS T HI CPAP MACHINE. I INFORME DHIM THAT WE EBED HIS CPAP MACHINE AND IT WILL BE GIVEN TO HIM TONIGHT.. HE REPORT OTHER NON-ME STATES HE FEELS OTHERWISEPIN Pain: Not Applicable Withhelddi o exemption Seen for clinic(s): Endocrine/Lipid, Orthopedic/Rheumatology, Respiratory (b)(6) (b)( )(C) OBJECTIVE: of the Freedom of Information Pulse: Date Time Rate Per Minute Location Provider 07/30/2019 13:02 07/30/2019 09:40 07/30/2019 09:30 94 88 87 Via Machine Via Machine e ouin. eaudouin, Robed MD Robed MD Robert MD Respirations: Date lime Rate Per Minute Provider 07/30/2019 09:30 NYM 12 Blood Pressure: Data Time Value Location Position Cuff Size Provider 07/30/2019 13:02 NYM 114/84 Left Arm Standing 07/30/2019 09:40 NYM 125/60 Right Arm Standing 07/30/2019 09:30 NYM 108/86 Left Arm Sitting SaO2: Date Time Value(%) Alt Provider 07/30/2019 09:30 NYM 98 Room Air Weight: Pale Time Lin Kg Waist Circum. Provider Generated 07/3012019 14:05 by Bureau of Prisons - NYM Page 1 of 3 EFTA00073840 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: NYM Encounter Date: 07/30/2019 11:12 Provider: Unit: Z01 Dale Time LIM Kg Waist Circum Provider 07/30/2019 09:30 NYM 194.2 88.1 Exam: General Affect Yes: Cooperative Appearance Yes: Appears Well, Alert and Oriented x 3 No: Appears Distr ed, Dyspneic, Appears in Pain, Writhing in Pain, Pale, Pallor, Cyanotic, Diaphoretic, Disheveled, Unk cutely III Nutrition No: Appears O Pulmonary Auscultation Yes: Clear to Auscultation Cardiovascular Auscultation Yes: Regular Rate and Rhythm (RRR 1 and S2 No: M•IG Musculoskeletal e 010 of 148 Tibia / Fibula exemption No: Edema Neurologic (b)( ) • (• (b)(6):le )(C) Cranial Nerves (CN) of the Freedom of Information Yes: Within Normal Limits Motor System-General Yes: Normal Exam Motor System-Strength Yes: Normal Muscular Strength ASSESSMENT: Body mass index (BMI) 27.0.27.9, adult, Z6827 - Current Constipation, unspecified, K5900 - Current Essential (primary) hypertension, 110 - Current - BY HX. Hyperlipidemia, unspecified, E785 - Current Low back pain, M545 - Current Neuralgia and neuritis, unspecified, M792 - Current Prediabetes, R7303 - Current Sleep apnea, G4730 - Current PLAN: New Medication Orders: Exit Medication Order Date Prescriber Order Generated 07/3012019 14:05 by Bureau of Prisons - NYM Page 2 of 3 EFTA00073841 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: NYM Encounter Date: 07/30/2019 11:12 Provider: Unit: Z01 New Medication Orders: BLit( Medication Order Date Prescriber Order Magnesium Hydroxide Susp conc 800 07/30/2019 11:12 10 CC Orally - Two Times a MG/5ML Day PRN x 90 day(s) Indication: Constipation, unspecified INsulin REG - Human 07/30/2019 11:12 SLIDING SCALE Subcutaneously Two Times a Day x 7 day(s) Pill Line Only Indication: Prediabetes Renew Medication Orders: &ft Medication Order Date Prescriber Order 121836-NYM methylP ne 4 MG Tab ( 21 count 07/30/2019 11:12 Take the tablet by mouth as Pack) directed x 6 day(s) Indication: a and neuritis, unspecified New Laboratory Requests: Details Frequency Due Date Priority Lab Tests - Short List-General-CBC w diff ane Time 08/01/2019 00:00 Routine Lab Tests-P-PSA, Total Lab Tests-U-Uric Acid Lab Tests - Short List-General-Comprehensiv Metabolic Profile (CMP) Lab Tests-U-Urinalysis w/Reflex to Microscopic e 011 of 148 New Radiology Request Orders: e emption Details Frequency Due Date Priority General Radiology-Spine / Cervical- One Ti0b)(6); (b )(C) 08/29/2019 Routine General Specific reason(s) for request ft 8ffirfffeftliekilfliRMISP 66 YR OLD MALE WITH COMPLAITN OF RIGHT ARM NUI 2-3 MINUTES 3 DAYS AGO. PLEASE PERFORM C SPINE SERIES Disposition: Follow-up at Sick Call as Needed Patient Education Topics: Date Initiated Format Handout/Topic Prov Outcome 07/30/2019 Counseling Access to Care Beaudo Robert Verbalizes Understanding 07/30/2019 Counseling Plan of Care Verbalizes Understanding Copay Required:No Cosign Required: No TelephoneNerbal Order: No Completed by on 07/30/2019 14:05 Generated 07130/2019 14:05 by Bureau of Prisons - NYM Page 3 of 3 EFTA00073842 Bureau of Prisons Health Services See Amendment Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Encounter Date: 07/30/2019 15:58 Facility: NYM Amendment made to this note by on 07/30/2019 16:12. Page 012 of 148 Withheld pursuant to exemption (b)(6) ; (b)(7)(A): (b)(7)(C) of the Freedom of Information and Privacy Act Bureau of Prisons - NYM EFTA00073843 Bureau of Prisons Health Services Clinical Encounter Inmate Name: EPSTEIN. JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: NYM Encounter Date: 07/28/2019 20:25 Provider RN Unit: H01 Nursing - Follow up encounter performed at Health Services. SUBJECTIVE: COMPLAINT 1 Provider: RN Chief Complaint: Neuropathy - Tingling/Numbness of Extremity(ies) Subjective: Inmate seen for F/U after returning from attorney conference offers no new complaints or worsening S/S stats My, hand still has pins and needles sometimes" No change in appearance from previous exam. Pain: No OBJECTIVE: Pulse: Date Time Rate Per Minute Location Rhythm Provider 07/28/2019 20:28 81 RN Respirations: Date Time Rate Per Minute Provider 07/28/2019 20:28 NYM 14 Blood Pressure: Withheld pursuant to exemption Date Time Value Location (b)WPO:jR9)(A): (b)Filk-PiZe Provider 07/28/2019 20:28 NYM 157/91 RN of the Freedom of Information and Privacy Act SaO2: Date Time yatue(%) Air Provider 07/28/2019 20:28 NYM 98 RN Exam: General Affect Yes: Cooperative Appearance Yes: Appears Well, Alert and Oriented x 3 Nutrition Yes: Within Normal Limits Skin General Yes: Within Normal Limits. Dry. Skin Intact ASSESSMENT: No Significant Findings/No Apparent Distress PLAN: Disposition: To be Evaluated by Provider Generated 0712812019 20:30 by RN Bureau of Prisons - NYM Page 1 of 2 EFTA00073844 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: NYM Encounter Date: 07/28/2019 20:25 Provider RN Unit: H01 Follow-up in 12-24 Hours Patient Education Topics: ttate_lnitiated Formal Handout/Topic Provider Outcome 07/28/2019 Counseling Plan of Care Verbalizes Understanding Copay Required:No Cosign Required: Yes Telephone/Verbal Order: No Completed by RN on 07/28/2019 20:30 Requested to be cosigned by Cosign documentation will be displayed on the following page. Page 014 of 148 Withheld pursuant to exemption (b)(6) (b)(7)(A): (b)(7)(C) of the Freedom of Information and Privacy Act Generated 07/28/2019 20:30 by RN Bureau of Prisons - NYM Page 2 of 2 EFTA00073845 Bureau of Prisons Health Services Cosign/Review Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Encounter Date: 07/28/2019 20:25 Provider: RN Facility: NYM Cosigned by on 07/28/2019 20:50. Page 015 of 148 Withheld pursuant to exemption (b)(6) ; (b)(7)(A) ; (b)(7)(C) of the Freedom of Information and Privacy Act Bureau of Prisons NYM EFTA00073846 Bureau of Prisons Health Services Clinical Encounter Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: NYM Encounter Date: 07/28/2019 06:51 Provider: RN Unit: H01 Nursing - Triage Note encounter performed at Health Services. SUBJECTIVE: COMPLAINT 1 Provider: RN Chief Complaint: Neuropathy - Tingling/Numbness of Extremity(ies) Subjective: " I woke up and I had no control over my Right arm for a few minutes it was just doing what it wanted to do" Pain: No OBJECTIVE: Pulse: Dale Time Rate Per Minute location Rhythm Provider 07/28/2019 06:57 82 RN Respirations: DAM lime Rate Per Minute Pr vider 07/28/2019 06:57 NYM 14 Blood Pressure: LocationWithhe0cPtlif8iint to extaidni(gize Dale Time Value Provider 07/28/2019 06:57 NYM 138/80 (b)(6) : (b)(7)(A): (b)(7)(C) RN SaO2: of the Freedom of Information and Privacy Act DAM Time ValuerY41 Alt Provider 07/28/2019 06:57 NYM 98 RN Exam: General Affect Yes: Cooperative Appearance Yes: Appears Well, Alert and Oriented x 3 Skin General Yes: Within Normal Limits, Dry, Skin Intact Head General Yes: Symmetry of Motor Function, AtraumaticlNormocephalic No: Facial Asymmetry, Battle's Sign, Raccoon Eyes, Deformity Eyes General Yes: , Extraocular Movements Intact Face General Yes: Symmetric Generated 07128;2019 07:22 by■ RN Bureau of Prisons - NYM Page 1 of 3 EFTA00073847 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: NYM Encounter Date: 07/28/2019 06:51 Provider RN Unit: H01 Exam: No: Ecchymosis, Numbness, Swelling. Periorbital Edema Neck General Yes: Abrasion(s) Pulmonary Observation/Inspection Yes: Within Normal Limits No: Respiratory Distress, Tachypnea, Hyperventilation Cardiovascular Observation Yes: Normal Rate Musculoskeletal Shoulder Yes: Full Range of Motion Symmetric, No: Swelling I, Inflammation' Humerus Yes: Within Normal Limits, Elbow Yes: Normal Exam I, Full Range of Motion', Nikkfie0tnicibrlifeilpation I Radius / Ulna Withhdd pursuant to exemption Yes: Normal Exam Full Range of Motion I Wrist/Hand/Fingers (b)(6); (b)(7)(A) ; (b)(7)(C) Yes: Full Range of Motion RoNtitio*HefRAAtigoog•Awitleiviic9 Act No: Inflammation I. Ecchymosis Erythema'. Tenderness Laceration(s) I, Abrasion(s) I, Contusion(s) I ROS Comments Received inmate AAOX3 in no acute distress, speaking in full sentenced ambulating independently C/O Right arm numbness after waking up from "sleeping on my side" that has since subsided. inmate interviewed in psyc obs through the slot. ViS noted WNL. RR even and unlabored, no neurological deficits noted, no facial droop slurred speech or dysphagia. Inmate with Full ROM to all extremities with 4/4 strength bilaterally • slight swelling noted to right phalanges when compared to left, no edema, erythema or ecchymosis noted. Denies an ain numbness or tingling at this time. Denies any Chest pain, Headache, Dizziness, SOB or Blurred vision. Eyes . MD on Call notified. Re-evaluate this evening or sooner if S/S persist. ASSESSMENT: Alteration in comfort PLAN: Disposition: Follow-up at Sick Call as Needed Notify Medical Duty Officer Patient Education Topics: Pate Initiated Format Handout/Topic Provider Outcome 07/28/2019 Counseling Plan of Care Verbalizes Understanding Generated 07/28/2019 07:22 by RN Bureau of Prisons - NYM Page 2 of 3 EFTA00073848 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: NYM Encounter Date: 07/28/2019 06:51 Provider: RN Unit: H01 Date Initiated Format Randoutagpic Provider Outcome Copay Required:No Cosign Required: Yes Telephone/Verbal Order: No Completed by RN on 07/28/2019 07:22 Requested to be cosigned by Cosign documentation will be displayed on the following page. Page 018 of 148 Withheld pursuant to exemption (b)(6) ; (b)(7)(A); (b)(7)(C) of the Freedom of Information and Privacy Act Generated 07/28/2019 07:22 by RN Bureau of Prisons - NYM Page 3 of 3 EFTA00073849 Bureau of Prisons Health Services Cosign/Review Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Encounter Date: 07/28/2019 06:51 Provider: RN Facility: NYM Cosigned by on 07/28/2019 20:51. Page 019 of 148 Withheld pursuant to exemption (b)(6) ; (b)(7)(A); (b)(7)(C) of the Freedom of Information and Privacy Act Bureau of Prisons NYM EFTA00073850 Bureau of Prisons Health Services Clinical Encounter - Administrative Note Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: Parr WHITE Facility: NYM Note Date: 07/26/2019 08:57 Provider: Unit: H01 Cosign Note - Clinical Encounter Cosign encounter performed at Health Services. Administrative Notes: ADMINISTRATIVE NOTE 1 Provider: THE MLP NOTIFIED THE OP LT OF THE INMATE STATEMENT REGARDING WHAT HAPPENED TO HIM 2 NIGHTS AGO. New Medication Orders: That Medication Order Date Prescriber Order Docusate Sodium Capsule 07/26/2019 08:57 TAKE ONE 100 MG CAP Orally - Two Times a Day x 180 day(s) Indication: Constipation, unspecified Copay Required:No Cosign Required: No Telephone Verbal Order: No Completed by on 07/26/2019 08:58 Page 020 of 148 Withheld pursuant to exemption (b)(6); (b)(7)(A) (b)(7)(C) of the Freedom of Information and Privacy Act Generated 07126,2019 08:58 by Bureau of Prisons NYM Page I of I EFTA00073851 Bureau of Prisons Health Services Clinical Encounter - Administrative Note Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318.054 Date of Birth: 01/20/1953 Sex: Rate WHITE Facility: NYM Note Date: 07/24/2019 16:10 Provider: Unit: H01 Cosign Note - Clinical Encounter Cosign encounter performed at Health Services. Administrative Notes: ADMINISTRATIVE NOTE 1 Provider: THE MLP NOTIFIED THE OP LT OF THE INMATE STATEMENT REGARDING WHAT HAPPENED TO HIM 2 NIGHTS AGO. Copay Required:No Cosign Required: No Telephone/Verbal Order: Completed by 24/2019 16:12 1 Withheld i.co e 021 of 148 exemption (b)(6) ; (b) ) ,( )(C) of the Freedom of Information Generated 07/24/2019 16:12 by Bureau of Prisons - NYM Page 1 of 1 EFTA00073852 Bureau of Prisons Health Services Clinical Encounter - Administrative Note Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318.054 Date of Birth: 01/20/1953 Sex: Rare-WHITE Facility: NYM Note Date: 07/24/2019 16:10 Provider: Unit: H01 Cosign Note - Clinical Encounter Cosign encounter performed at Health Services. Administrative Notes: ADMINISTRATIVE NOTE 1 Provider: THE MLP NOTIFIED THE OP LT OF THE INMATE STATEMENT REGARDING WHAT HAPPENED TO HIM 2 NIGHTS AGO. Copay Required:No Cosign Required: No Telephone/Verbal Order: Completed by 24/2019 16:12 1 e 022 of 148 Withheld ilp (b)(6) ; (b) o exemption ,( )(C) of the Freedom of Information Generated 07/24/2019 16:12 by Bureau of Prisons - NYM Page 1 of 1 EFTA00073853 Bureau of Prisons Health Services See Amendment Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Encounter Date: 07/26/2019 08:57 Facility: NYM Amendment made to this note by on 07/26/2019 08:58. Page 023 of 148 Withheld pursuant to exemption (b)(6) ; (b)(7)(A) ; (b)(7)(C) of the Freedom of Information and Privacy Act Bureau of Prisons - NYM EFTA00073854 Bureau of Prisons Health Services Clinical Encounter - Administrative Note Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318.054 Date of Birth: 01/20/1953 Sex: m Rare•WHITE Facility: NYM Note Date: 07/24/2019 15:10 Provider: Unit: H01 Admin Note - General Administrative Note encounter performed at Health Services. Administrative Notes: ADMINISTRATIVE NOTE 1 Provider: PATIENT WAS OFFERED TO HAVE AN OPTOMETRIST EVALUATION. HE REFUSED. REFUSAL FORM SIGNED. Copay Required:No Cosign Required: No TelephoneNerbal Order: No Completed by on 07/24/2019 15:17 Page 024 of 148 Withheld pursuant to exemption (b)(6) (b)(7)(A); (b)(7)(C) of the Freedom of Information and Privacy Act Generated 07/24/2919 15:17 by Bureau of Prisons - NYM Page 1 of 1 EFTA00073855 Bureau of Prisons Health Services Clinical Encounter Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: NYM Encounter Date: 07/24/2019 13:08 Provider: Unit: H01 Mid Level Provider Follow up Visit encounter performed at Receiving & Discharge. SUBJECTIVE: COMPLAINT 1 Provider: Chief Complaint: Other Problem Subjective: I still do not want to talk about. But, between you and me. I think my room mate had to do with what happened to me. Do not ask me. I am not going to say anything. Pain: No OBJECTIVE: Temperature: Date Tittle Fa_hienteit GetSiu_s LOCatiOn Provider 07/24/2019 13:12 NYM 97.8 36.6 Oral Pulse: Date Time Rate Per Minute Location Rhythm Provider 07/24/2019 13:12 83 Via Machine Regular Page 025 of 148 Blood Pressure: Time nWithheislamnt to extriiiiivze Provider Date Value Locatio 07/24/2019 13:12 NYM 132/89 Right Arm (b) jtirm(7)(A) : (b)Mayegular SaO2: of the Freedom of Information and Privacy Act Date Time Value(%) Air Provider 07/24/2019 13:12 NYM 96 Room Air Exam: General Affect Yes: Cooperative Appearance Yes: Appears Well, Alert and Oriented x 3 No: Appears Distressed. Appears in Pain Exam Comments Follow up evaluation done for inmate Epstein. He does not look in any pain or distress. He still has the erythema around his neck. Central part of this erythema has some abrasion. Patient does not complaint of any respiratory problem or distress. He still does not want to explain how the skin injury on his neck happed. he insinuates that injuries on his neck have to do with his room male. But does not want to talk about it. ASSESSMENT: Injury, unspecified. T1490 - Current PLAN: Disposition: Generated 07 24 2019 13.24 by Bureau of Prisons - NYM Page 1 of 2 EFTA00073856 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: NYM Encounter Date: 07/24/2019 13:08 Provider: Unit: H01 Follow-up at Sick Call as Needed Patient Education Topics: Date Initiated Format Handout/Topic Provider Outcome 07/24/2019 Counseling Access to Care Verbalizes Understanding 07/24/2019 Counseling Preventive Health Verbalizes Understanding Copay Required:No Cosign Required: Yes Telephone/Verbal Order: No Completed by on 07/2412019 13:24 Requested to be cosigned by Cosign documentation will be displayed on the following page. Page 026 of 148 Withheld pursuant to exemption (b)(6) ; (b)(7)(A) ; (b)(7)(C) of the Freedom of Information and Privacy Act Generated 07)242019 1324 by Bureau of Prisons • NYM Page 2 of 2 EFTA00073857 Bureau of Prisons Health Services Cosign/Review Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Encounter Date: 07/24/2019 13:08 Provider: Facility: NYM Cosigned with New Encounter Note by on 07/24/2019 16:10. Page 027 of 148 Withheld pursuant to exemption (b)(6) ; (b)(7)(A) ; (b)(7)(C) of the Freedom of Information and Privacy Act Bureau of Prisons NYM EFTA00073858 Bureau of Prisons Health Services Clinical Encounter Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: NYM Encounter Date: 07/23/2019 06:20 Provider: Unit: H01 Injury Assessment Non-work related encounter performed at Health Services. SUBJECTIVE: INJURY 1 Provider: 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 Page 028 of 148 OBJECTIVE: Withheld pursuant to exemption Temperature: u(b)aar tigr)i(A) ; (b)(71(C) . Date Time Fahrenheit Cglsi_s Provider 07 23 2019 06:30 NYM 91.Se FreeSOPA o(ynibrmation and PthsvOlip1Y. MLP Pulse: Dale Time Rate Per Minute Location Rhy►hm Provider 07723/2019 06:30 92 Via Machine Regular Respirations: Date Time Rate Per Minute Provider 07/23/2019 06:30 NYM 16 Blood Pressure: Date Time Value Location Position Cuff Size Provider 07/23/2019 06:30 NYM 140/85 Right Arm Sitting Adult-regular SaO2: Date Time Value(%) Air Provider 07/23/2019 06:30 NYM 96 Room Air Exam: General Affect Yes: Cooperative Appearance Yes: Appears Well, Alert and Oriented x 3 No: Appears Distressed, Lethargic. Dyspneic, Appears in Pain, Pallor, Cyanotic, Diaphoretic, Disheveled, Generated 0712312019 09.05 by Bureau of Prisons NYM Page 1 of 2 EFTA00073859 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M R : WHITE Facility: NYM Encounter Date: 07/23/2019 06:20 Provider: Unit: H01 Exam: Acutely III 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: Page 029 of 148 Injury, unspecified, T1490 - Current -'iO self inflicted injuries. Withheld pursuant to exemption PLAN: (b)(6). (b)(7)(A) (b)(7)(C) Disposition: of the Freedom of Information and Privacy Act 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 on 07`23 2019 09:05 Requested to be cosigned by Cosign documentation will be displayed on the following page. Generated 07/23/2019 09:05 by Bureau of Prisons - NYM Page 2 of 2 EFTA00073860 Bureau of Prisons Health Services Cosign/Review Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Encounter Date: 07/23/2019 06:20 Provider: Facility: NYM Cosigned by on 07/23/2019 15:44. Page 030 of 148 Withheld pursuant to exemption (b)(6) ; (b)(7)(A); (b)(7)(C) of the Freedom of Information and Privacy Act Bureau of Prisons NYM EFTA00073861 Bureau of Prisons Health Services Clinical Encounter Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: NYM Encounter Date: 07/14/2019 17:36 Provider Unit: Z05 Chronic Care 14 Day Physician Eval encounter performed at Health Services. SUBJECTIVE: COMPLAINT 1 Provider: Chief Complaint: ENDOLIPID Subjective: 66 YR OLD WHITE MALE WITH HX OF HYPERTRIGLYCERIDEMIA X 5 YEARS ON VASCEPA FOR 1 YEAR. STATES TRIGL WAS 800 , NOW 431. STATES HE COULD NOT TOLERATE OTHER ANTI-TRIGLYCERIDE MEDS DUE TO THEIR GI SIDE EFFECTS. HX OF OBSTRUCTUVE SLEEP APNEA X 5 YEARS FOR WHICH HE USED A CPAP MACHINE. STATES HE HAD HIS CPAP MACHINE WITH HIM WHEN HE ARRESTED. STATES THE FBI LOKELY HAS L4 - L5 SEVERE STENOSIS CASUING NUMBNESS AND SHOOTING PAIN IN THE LOWER EXTREMITIES. SURGICAL HX: NONE MENTAL HEALTH HX: NONE Pain: Yes Pain Assessment Date: 07/12/2019 13:25 Page 031 of 148 Location: Back-Middle Withheld pursuant to exemption Quality of Pain: Shooting Pain Scale: 5 (b)(6); (b)(7)(A); (b)(7)(C) Intervention: MEDRerl-take86‘616f Information and Privacy Act Trauma Date'Year: Injury: Mechanism: Onset: 5+ Years Duration: 5+ Years Exacerbating Factors: NO EXERCISE Relieving Factors: MEDROL DOSE PACK Reason Not Done: Comments: Seen for clinic(s): Orthopedic/Rheumatology, Pulmonary/Respiratory, Endocrine/Lipid Added to clinic(s): Orthopedic/Rheumatology, Pulmonary/Respiratory, Endocrine/Lipid OBJECTIVE: Exam: General Appearance Yes: Appears Well, Alert and Oriented x 3 No: Appears Distressed. Dyspneic. Appears in Pain, Writhing in Pain, Pale, Pallor, Cyanotic, Diaphoretic, Disheveled, Unkempt. Acutely III Nutrition No: Appears Obese Generated 07/1422019 18:11 by Bureau of Prisons - NYM Page 1 of 3 EFTA00073862 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: NYM Encounter Date: 07/14/2019 17:36 Provider: Unit: Z05 Exam: Eyes General Yes: , Extraocular Movements Intact Pulmonary Auscultation Yes: Clear to Auscultation Cardiovascular Auscultation Yes: Regular Rate and Rhythm (RRR), Normal S1 and S2 No: Milt Abdomen Auscultation Yes: Normo-Active Bowel Sounds Palpation Yes: Within Normal Limits Musculoskeletal Tibia / Fibula No: Edema Back Page 032 of 148 Yes: Tenderness Withheld pursuant to exemption Neurologic (b)(6) (b)(7)(A) , (b)(7)(C) Cranial Nerves (CN) Yes: Within Normal Limits of the Freedom of Information and Privacy Act Motor System-General Yes: Normal Exam ASSESSMENT: Constipation, unspecified, K5900 - Current Hyperlipidemia, unspecified, E785 - Current Low back pain, M545 - Current Neuralgia and neuritis, unspecified, M792 - Current Sleep apnea, G4730 • Current PLAN: New Medication Orders: RAE Medication Order Date Prescriber Order Omega 3 ( Vascepa) 1 GM Capsule 07/14/2019 17:36 TAKE 2 CAPS Orally - Two Times a Day x 180 day(s) -- TAKE WITH FOOD. Indication: Hyperlipidemia, unspecified New Laboratory Requests: Details Frequency Due Date Priority Lab Tests-H-Hemoglobin A1C One Time 10/10/2019 00:00 Routine Lab Tests-L-Lipid Profile Additional Information: Generated 07/14/2019 18:11 by Bureau of Prisons - NYM Page 2 of 3 EFTA00073863 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: NYM Encounter Date: 07/14/2019 17:36 Provider Unit: Z05 FASTING. Lab Tests-H-Hep B surface Ab One Time 08/08/2019 00:00 Routine Lab Tests-H-Hep B surface Ag Lab Tests-H-Hep C Ab Lab Tests-H-Hepatic Profile Schedule: Activity Date Scheduled Scheduled Provider Clinical Encounter 07/24/2019 00:00 Optometrist 66 YR OLD MALE FOR ROUTINE SCREENING. Chronic Care Visit 01/07/2020 00:00 Mid-Level Provider 6 MONTH F/U. Chronic Care Visit 07/01/2020 00:00 Physician 01 Other: PENDING EKG AND FOBT. CXR WAS REFUSED. Patient Education Topics: Qate_initiated Format Handout/Topic Provider Outcome 07/14/2019 Counseling Diagnosis Verbalizes Understanding Copay Required: No Cosign Required: N9age 033 of 148 Telephone Verbal Order: No Withheld pursuant to exemption Completed by 011 07 14.'2019 18:11 (b)(6); (b)(7)(A): (b)(7)(C) of the Freedom of Information and Privacy Act Generated 07/14/2019 18:11 by Bureau of Prisons - NYM Page 3 of 3 EFTA00073864 Bureau of Prisons Health Services Clinical Encounter Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: NYM Encounter Date: 07/12/2019 13:10 Provider Unit: Z05 Chronic Care 14 Day Physician Eval encounter performed at Health Services. SUBJECTIVE: COMPLAINT 1 Provider: Chief Complaint: ENDOiLIPID Subjective: 66 YR O HITE MALE WITH HX OF HYPER CERIDEMIA X 5 YEARS ON VASCEPA FOR 1 YEAR. STATES TRIGL WAS 800 . STATES HE COULD NOT TOLERATE OTHER ANTI-TRIGLYCERIDE MED EIR GI SIDE EFFECTS. HX OF UVE SLEEP APNEA X 5 YEARS FOR WHICH HE USED A CPAP MACHINE. HAD HIS CPAP MACHINE WITH HIM WHEN HE ARRESTED. STATES TH Y HAS L4 - L5 SEVERE SIS CASUING NUMBNESS AND SHOOTING PAIN IN THE LOWER EXTREM S. SURGICAL HX: NONE MENTAL HEALTH HX: Pain: Yes Pain Assessment Date: 07/1212019 13:25 C Se 034 of 148 Location: Back-Middle Withheld bt4o exemption Quality of Pain: Shooting Pain Scale: (b)(6): (b)(7) , (' - )(C) 5 Intervention: MEDRatlig:ISielaitWlef Information Trauma Date'Year: Injury: Mechanism: Onset: 5+ Years Duration: 5+ Years Exacerbating Factors: NO EXERCISE Relieving Factors: MEDROL DOSE PACK Reason Not Done: Comments: Seen for clinic(s): Endocrine/Lipid, Pulmonary/Respiratory, Orthopedic/Rheumatology Added to clinic(s): Endocrine/Lipid, Pulmonary/Respiratory, Orthopedic/Rheumatology OBJECTIVE: Exam: General Appearance Yes: Appears Well, Alert and Oriented x 3 No: Appears Distressed. Dyspneic. Appears in Pain, Writhing in Pain, Pale, Pallor, Cyanotic, Diaphoretic, Disheveled. Unkempt. Acutely III Nutrition No: Appears Obese Generated 07ft2/2019 14:20 by Bureau of Prisons - NYM Page 1 of 3 EFTA00073865 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: NYM Encounter Date: 07/12/2019 13:10 Provider: Unit: Z05 Exam: Eyes General Yes: , Extraocular Movements Intact Pulmonary Auscultation Yes: Clear to Auscultation Cardiovascular Auscultation Yes: Regular Rat Rhythm (RRR), Normal S1 and S2 No: Mit Abdomen Auscultation Yes: Normo-Active Palpation Yes: Within Normal Limits Musculoskeletal Tibia / Fibula No: Edema Back e 035 of 148 Yes: Tenderness o exemption Neurologic (b)(6) :le (b)( ) )(C) Cranial Nerves (CN) Yes: Within Normal Limits of the Freedom of Information Motor System-General Yes: Normal Exam ASSESSMENT: Constipation, unspecified, K5900 - Current Hyperlipidemia, unspecified, E785 - Current Low back pain, M545 - Current Neuralgia and neuritis, unspecified, M792 - Current Sleep apnea, G4730 - Current PLAN: New Medication Orders: Medication Order Date Prescriber Order Magnesium Hydroxide Susp 07/12/2019 13:10 30 CC Orally - Two Times a Day PRN x 2 day(s) Indication: Constipation, unspecified MethylPREDNISolone Tab 4 MG ( Dose 07/12/2019 13:10 AS DIRECTED Orally - daily x Pack 21 tab) 6 day(s) Indication: Neuralgia and neuritis, unspecified Disposition: Generated 07/12/2019 14:20 by Bureau of Prisons - NYM Page 2 of 3 EFTA00073866 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: NYM Encounter Date: 07/12/2019 13:10 Provider Unit: Z05 Follow-up at Sick Call as Needed Other: WILL CONTINUE NOTES TO ADDRESS THE NFDR AND FOLLOW-UP. Patient Education Topics: Date Initiated Format Handout/Topic Provider Outcome 07/12/2019 Counseling Diagnosis Verbalizes Understanding Copay Required:No Cosign Required: No Telephone/Verbal Order: Completed by Beaudouin, 07/12/2019 14:20 4 Withheld ullo e 036 of 148 exemption (b)(6) ; (b) ) ,( )(C) of the Freedom of Information Generated 07:12 2019 1420 by Bureau of Prisons - NYM Page 3 of 3 EFTA00073867 Bureau of Prisons Health Services Clinical Encounter Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: NYM Encounter Date: 07/12/2019 13:10 Provider Unit: Z05 Chronic Care 14 Day Physician Eval encounter performed at Health Services. SUBJECTIVE: COMPLAINT 1 Provider: Chief Complaint: ENDO/LIPID Subjective: 66 YR 0 HITE MALE WITH HX OF HYPER CERIDEMIA X 5 YEARS ON VASCEPA FOR 1 YEAR. STATES TRIGL WAS 800 . STATES HE COULD NOT TOLERATE OTHER ANTI-TRIGLYCERIDE MED EIR GI SIDE EFFECTS. HX OF UVE SLEEP APNEA X 5 YEARS FOR WHICH HE USED A CPAP MACHINE. HAD HIS CPAP MACHINE WITH HIM WHEN HE ARRESTED. STATES TH Y HAS L4 - L5 SEVERE SIS CASUING NUMBNESS AND SHOOTING PAIN IN THE LOWER EXTREM S. SURGICAL HX: NONE MENTAL HEALTH HX: Pain: Yes Pain Assessment Date: 07/12/2019 13:25 e 037 of 148 Location: Back-Middle Withheld o exemption Quality of Pain: Shooting Pain Scale: (b)(6): (b)( )(C) 5 Intervention: MEDRQ.tfAClb€e86Fil6f Information Trauma Date Year: Injury: Mechanism: Onset: 5+ Years Duration: 5+ Years Exacerbating Factors: NO EXERCISE Relieving Factors: MEDROL DOSE PACK Reason Not Done: Comments: Seen for clinic(s): Endocrine/Lipid, Pulmonary/Respiratory, Orthopedic/Rheumatology Added to clinic(s): Endocrine/Lipid, Pulmonary/Respiratory, Orthopedic/Rheumatology OBJECTIVE: Exam: General Appearance Yes: Appears Well, Alert and Oriented x 3 No: Appears Distressed. Dyspneic. Appears in Pain, Writhing in Pain, Pale, Pallor, Cyanotic, Diaphoretic, Disheveled. Unkempt. Acutely III Nutrition No: Appears Obese Generated 07/12/2019 14:20 by Bureau of Prisons - NYM Page 1 of 3 EFTA00073868 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: NYM Encounter Date: 07/12/2019 13:10 Provider: Unit: Z05 Exam: Eyes General Yes: , Extraocular Movements Intact Pulmonary Auscultation Yes: Clear to Auscultation Cardiovascular Auscultation Yes: Regular Rat Rhythm (RRR), Normal S1 and S2 No: Milt Abdomen Auscultation Yes: Normo-Active Palpation Yes: Within Normal Limits Musculoskeletal Tibia / Fibula No: Edema Back e 038 of 148 Yes: Tenderness exemption Neurologic (b)(6) ; (b)(7) ( )(C) Cranial Nerves (CN) Yes: Within Normal Limits of the Freedom of Information Motor System-General Yes: Normal Exam ASSESSMENT: Constipation, unspecified, K5900 - Current Hyperlipidemia, unspecified, E785 - Current Low back pain, M545 - Current Neuralgia and neuritis, unspecified, M792 - Current Sleep apnea, G4730 - Current PLAN: New Medication Orders: 8/iff Medication Order Date Prescriber Order Magnesium Hydroxide Susp 07/12/2019 13:10 30 CC Orally - Two Times a Day PRN x 2 day(s) Indication: Constipation, unspecified MethylPREDNISolone Tab 4 MG ( Dose 07/12/2019 13:10 AS DIRECTED Orally - daily x Pack 21 tab) 6 day(s) Indication: Neuralgia and neuritis, unspecified Disposition: Generated 07/12/2019 14:20 by Bureau of Prisons - NYM Page 2 of 3 EFTA00073869 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: NYM Encounter Date: 07/12/2019 13:10 Provider: Unit: Z05 Follow-up at Sick Call as Needed Other: WILL CONTINUE NOTES TO ADDRESS THE NFDR AND FOLLOW-UP. Patient Education Topics: Date Initiated Format Handout/Topic Provider Outcome 07/12/2019 Counseling Diagnosis Verbalizes Understanding Copay Required:No Cosign Required: No Telephone/Verbal Order: Completed by Beaudouin, 07/12/2019 14:20 4 Withheld L e e 039 of 148 o exemption (b)(6) , (b)( ) )(C) of the Freedom of Information Generated 07:12,2019 14:20 by Bureau of Prisons - NYM Page 3 of 3 EFTA00073870 Bureau of Prisons Health Services See Amendment Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Encounter Date: 07/14/2019 17:36 Facility: NYM Amendment made to this note by on 07/14/2019 18:11. Page 040 of 148 Withheld pursuant to exemption (b)(6) ; (b)(7)(A) ; (b)(7)(C) of the Freedom of Information and Privacy Act Bureau of Prisons - NYM EFTA00073871 Bureau of Prisons Health Services Clinical Encounter - Administrative Note Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318.054 Date of Birth: 01/20/1953 Sex: Rana. WHITF Facility: NYM Note Date: 07/12/2019 09:06 Provider: Unit: Z05 Admin Note - Orders encounter performed at Health Services. Administrative Notes: ADMINISTRATIVE NOTE 1 Provider: PATIENT REQUESTED TO HAVE A COLACE RX , INSTEAD OF TEH BISACODYL FOR CONSTIPATION. New Medication Orders: fixE Medication Order Date Prescriber Order Docusate Sodium Capsule 07/12/2019 09:06 TAKE ONE 100 MG CAP Orally - Two Times a Day x 30 day(s) Indication: Constipation, unspecified Discontinued Medication Orders: Bx# Medication Order Date Prescriber Order 121757-NYM Bisaoodyl E.C. 5 MG TAB 07/12./2019 09:06 Take one tablet (5 MG) by mouth at bedtime AS NEEDED for 10 days Discontinue Type: Di 148 When PharmacThicaises Discontinue Reason:discoggilhheld pursuant to exemption Indication: (b)(6) : (b)(7)(A), (b)(7)(C) Copay Required:No Cosign Required: No of the Freedom of Information and Privacy Act TelephoneNerbal Order: No Completed by on 07/12/2019 09:10 Generated 07/122019 09:10 by Bureau of Prisons NYM Page 1 of 1 EFTA00073872 Bureau of Prisons Health Services Clinical Encounter - Administrative Note Inmate Name: EPSTEIN, JEFFREY EDWARD Reg IS: 76318-054 Date of Birth: 01;201953 Sex: Rant, WHITE Facility: NYM Note Date: 07/07/2019 00:17 Provider: Unit: E06 Cosign Note - Intake Cosign encounter performed at Health Services. Administrative Notes: ADMINISTRATIVE NOTE 1 Provider: MED CL:1 NO CCC APPT. Discontinued Laboratory Requests: Details Frequency Due Date Priority Lab Tests-H-Hemoglobin AIC One Time 08/05/2019 00:00 Routine Lab Tests-C-CBC w/diff Lab Tests-L-Lipid Profile Lab Tests-C-Comprehensive Metabolic Profile (CMP) Lab Tests-U-Urinalysis w/Reflex to Microscopic Additional Information: 66 y/o male, elevated BP Labs requested to be reviewed by: BeauoCNC, Ckg*ti reflb New Laboratory Requests: Withheld pursuant to exemption Details Frequency Due Date Priority Chronic Care Clinics-Diabetic-CBC w/diff (KM; Tlip(f)(A) (b)(7)(C) 07/25/2019 00:00 Routine Chronic Care Clinics-Diabetic-Lipid Profile Chronic Care Clinics-Diabetic-HemObOgiffrAggpm of Information and Privacy Act Lab Tests-H-HIV 1/2 Lab Tests-I-RPR Chronic Care Clinics-Diabetic-Comprehensive Metabolic Profile (CMP) New Radiology Request Orders: Deals Frequency End Date Due Date Priority General Radiology-Chest-2 Views One Time 07/25/2019 Routine Specific reason(s) for request (Complaints and findings): 66 YR OLD MALE WITH NO PMHX REFERRED FOR ROUITNE CXR. Copay Required:No Cosign Required: No TelephoneNerbal Order: No Completed by on 07/07/2019 00:30 Generated 07/07/2019 00:30 by Bureau of Prisons NYM Page I of I EFTA00073873 Bureau of Prisons Health Services Health Screen Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Encounter Date: 07/06/2019 21:38 Provider: PA-C Facility: NYM Seizures: Denied Diabetes: Denied Cardiovascular: Denied CVA: Denied Hypertension: Denied Respiratory: Denied Sickle Cell Anemia: Denied Carcinomatymphoma: Denied Allergies: Denied PPD Administration: Date!lime: 07 06 2019 21:39 Provider: PA-C Location: Right Forearm Page 043 of 148 Drug Mfg: Sanofi Pasteur Withheld pursuant to exemption Lot Number: C5474BA (b)(6) (b)(7)(A): (b)(7)(C) Dosage: 0.1mL Route: ID of the Freedom of Information and Privacy Act Exp Dt: 1012020 Comments: Tuberculosis: Hx of Previous Disease: No Blood-tinged Sputum: No Night Sweats: No Weight Loss: No Fever: No Cough:No Comments: Generated 07i0612019 21:56 by PA C Bureau of Prisons NYM Page 1 of 6 EFTA00073874 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Encounter Date: 07/06/2019 21:38 Provider: PA-C Facility: NYM Infectious Disease Risk Factors: IV Drug Use: No IV Drug Use Needles: Sexual Partner IV Drug Use: No Sexual Partner IV Drug Use Needles: Female Sexual Partners (Last 5 Yrs): 10+ Male Sexual Partners (Last 5 Yrs): 0 Condom Use: Sometimes Sexual Contact With HIV+ Individual: No Blood Product Transfusion: No Travel Outside US: Yes Tattoos: No Comments: Born in US High school diploma Banker Traveled to Paris x 3 weeks up until arrest No tattoos HIV History: Page 044 of 148 When Tested: 2019 Withheld pursuant to exemption Test Result: Negative (b)(6); (b)(7)(A): (b)(7)(C) When Diagnosed AIDS: Last CD4: of the Freedom of Information and Privacy Act Comments: Hepatitis: Denied Other Infectious Diseases: Syphilis: No Syphilis Last Treatment: N/A Genital Warts: No Chlamydia: Yes Gonorrhea: No Herpes: No Chicken Pox: Yes Other: No Comments: Chlamydia in 2015, treated Chicken pox in childhood Abuse History: Denied Physical: No Emotional: No Sexual: No Comments: Denies Generated 07/06/2019 21:56 by PA-C Bureau of Prisons NYM Page 2 of 6 EFTA00073875 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Encounter Date: 07/0672019 21:38 Provider: PA-C Facility: NYM Mental Health: Level of Consciousness: Alert and Oriented Psychomotor Activity: Normal General Appearance: Normal Behavior: Cooperative Mood: Appropriate to Content Thought Process: Goal Directed Thought Content: Normal Hx of Mental Health Treatment: None Hx of Head Injury: None Current Mental Health Treatment: No Current Mental Health Complaint: No Hx of Loss of Consciousness: No Hx of Hearing Voices: No Past History of Suicide Attempt: No Current Suicide Ideation: No Suicide Prevention Initiated:No Page 045 of 148 Comments: Withheld pursuant to exemption Substance Use History: Denied (b)(6); (b)(7)(A): (b)(7)(C) Current Painful Condition: Denied of the Freedom of Information and Privacy Act Other Health Issues: Current Medical Conditions: Other Current Treatments: Pregnant: NA Dental Condition: Denied Generated 07,06/2019 21:56 by PAC Bureau of Prisons NYM Page 3 of 6 EFTA00073876 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: Race: WHITE Encounter Date: 07/06/2019 21:38 Provider: PA-C Facility: NYM Observations: Draining Skin Lesions: No Signs of Lice: No Signs of Scabies: No Signs of Recent Trauma: No Recent Tattoos: No Needle Marks: No Signs of Rash: No Open Sores: No Wounds: No Body Deformities: No Tremors: No Sweating: No Comments: Pulse: Date Time Rate Per Minute Location Rhythm Provider 07/06/2019 21:43 90 Via Magbi006 of 148 PA-C Respirations: Withheld pursuant to exemption Date Dme Rate Per Minute Provider 07/06/2019 21:43 NYM (b)SW ;41C7 g,)(ObblibRE ) Blood Pressure: of the Freedom of Information and Privacy Act Date Time Value Location Position Cuff Size Provider 07/06/2019 21:45 NYM 164/90 Right Arm Sitting Adult-regular PA-C 07/06/2019 21:43 NYM 155/83 Left Arm Sitting Adult-regular PA-C SaO2: Date Time Value(%) Air Provider 07/06/2019 21:43 NYM 95 Room Air PA-C Height: Date dm Inches Cm Provider 07/06/2019 21:43 NYM 72.0 182.9 PA-C Weight: Date Time the Kg Waist Circum Provider 07/06/2019 21:43 NYM 200.0 90.7 PA-C Prosthetic Devices/Equipment: Denied Potential Items For Follow-up: Item Travel Outside US Other Infectious Disease History Comments: I have reviewed 0 pages of intake paperworks Generated 07'06,2019 21:56 by PA-C Bureau of Prisons NYM Page 4 of 6 EFTA00073877 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Encounter Date: 07/06/2019 21:38 Provider: PA-C Facility: NYM Health Problems Newly Identified During This Encounter: HeatthEroblem Medication Reconciliation. The patient's known medication list including OTC items was compiled and compared to new and changed BOP orders. Reconciled Medications: Source Action Type Rx# Medication Order Detail OTC No known OTCs New Laboratory Requests: Details Frequency Due Date Priority Lab Tests-H-Hemoglobin A1C One Time 08/05/2019 00:00 Routine Lab Tests-C-CBC w/diff Lab Tests-L-Lipid Profile Lab Tests-C-Comprehensive Metabolic Profile (CMP) Lab Tests-U-Urinalysis w/Reflex to Microscopic Additional Information: 66 ylo male, elevated BP Labs requested to be reviewed by: New Non-Medication Orders: Page 047 of 148 Order Frequency .._Dumlloo Details . Ordered By withherb pursuant to exemption EKG One Time 66 yio male PA-C Order Date: 07'0612OO); (b)(7)(A); (b)(7)(C) Fecal Occult Blood One Time . 3 different stools PA-C of the Freedom of Information ana vrivacy ACT Order Date: 07/06,2019 Schedule: Activity Date Scheduled Scheduled Provider Vision Screen 07/06/2019 00:00 Optometrist 66 y/o male PPD Reading 07/08/2019 00:00 Nurse Follow-up 07/09/2019 00:00 Mid-Level Provider BP check Other: BP noticed to be elevated. IM denies Hx of HTN or any significant chronic medical conditions. He is currently asymptomatic and denies any bodily complaints at this time. Will recheck BP in 2-3 days. Disposition: Follow-up at Sick Call as Needed To be Evaluated by Provider Instructed inmate how to obtain medical, dental, and mental health care. Copay Required:No Cosign Required: Yes Telephone/Verbal Order: No Generated 07'06:2019 21:56 by PA,C Bureau of Prisons NYM Page 5 of 6 EFTA00073878 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Encounter Date: 07/06/2019 21:38 Provider: PA-C Facility: NYM Completed by PA-C on 07/06/2019 21:56 Requested to be cosigned by Cosign documentation will be displayed on the following page. Page 048 of 148 Withheld pursuant to exemption (b)(6) ; (b)(7)(A) ; (b)(7)(C) of the Freedom of Information and Privacy Act Generated 07/06/2019 21:56 by PA•C Bureau of Prisons - NYM Page 6 of 6 EFTA00073879 Bureau of Prisons Health Services Cosign/Review Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Encounter Date: 07/06/2019 21:38 Provider: PA-C Facility: NYM Cosigned with New Encounter Note by on 07/07/2019 00:17. Page 049 of 148 Withheld pursuant to exemption (b)(6); (b)(7)(A) ; (b)(7)(C) of the Freedom of Information and Privacy Act Bureau of Prisons NYM EFTA00073880 Bureau of Prisons Health Services History & Physical Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/201953 Sex: M R e: WHITE Facility: NYM Encounter Date: 07/09/2019 12:35 Provider Unit: H01 Seizures: Denied Diabetes: Denied Cardiovascular: Denied CVA: Denied Hypertension: Denied Respiratory: Denied Sickle Cell Anemia: Denied Carcinoma/Lymphoma: Denied Allergies: Denied Tuberculosis: Hx of Previous Disease: No Blood-tinged Sputum: No Night Sweats: No Page 050 of 148 Weight Loss: No Withheld pursuant to exemption Fever: No (b)(6); (b)(7)(A); (b)(7)(C) Cough:No of the Freedom of Information and Privacy Act Comments: Infectious Disease Risk Factors: IV Drug Use: No IV Drug Use Needles: Sexual Partner IV Drug Use: No Sexual Partner IV Drug Use Needles: Female Sexual Partners (Last 5 Yrs): 10+ Male Sexual Partners (Last 5 Yrs): 0 Condom Use: Sometimes Sexual Contact With HIV+ Individual: No Blood Product Transfusion: No Travel Outside US: Yes Tattoos: No Comments: Born in US High school diploma Banker Traveled to Paris x 3 weeks up until arrest No tattoos Generated 07,09/2019 13:03 by Bureau of Prisons - NYM Page 1 of 13 EFTA00073881 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: NYM Encounter Date: 07/09/2019 12:35 Provider: Unit: H01 HIV History: When Tested: 2019 Test Result: Negative When Diagnosed AIDS: Last CD4: Comments: Hepatitis: Denied Other Infectious Diseases: Syphilis: No Syphilis Last Treatment: N/A Genital Warts: No Chlamydia: Yes Gonorrhea: No Herpes: No Chicken Pox: Yes Other: No Page 051 of 148 Comments: Chlamydia in 2015, treated Chicken pox in childhood Withheld pursuant to exemption Abuse History: Denied (b)(6) (b)(7)(A); (b)(7)(C) Physical: No Emotional: No of the Freedom of Information and Privacy Act Sexual: No Comments: Denies Generated 07,09/2019 13:03 by Bureau of Prisons - NYM Page 2 of 13 EFTA00073882 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: NYM Encounter Date: 07/09/2019 12:35 Provider: Unit: H01 Mental Health: Level of Consciousness: Alert and Oriented Psychomotor Activity: Normal General Appearance:Normal Behavior: Cooperative Mood: Appropriate to Content Thought Process: Goal Directed Thought Content: Normal Hx of Mental Health Treatment: None Hx of Head Injury: None Current Mental Health Treatment: No Current Mental Health Complaint: No Hx of Loss of Consciousness: No Hx of Hearing Voices: No Past History of Suicide Attempt: No Current Suicide Ideation: No Page 052 of 148 Suicide Prevention Initiated:No Withheld pursuant to exemption Comments: Substance Use History: Denied (b)(6); (b)(7)(A); (b)(7)(C) Current Painful Condition: DEtifiltib Freedom of Information and Privacy Act Other Health Issues: Current Medical Conditions: Other Current Treatments: Pregnant: NA Dental Condition: Denied Generated 07,09/2019 13:03 by Bureau of Prisons - NYM Page 3 of 13 EFTA00073883 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: NYM Encounter Date: 07/09/2019 12:35 Provider: Unit: H01 Observations: Draining Skin Lesions: No Signs of Lice: No Signs of Scabies: No Signs of Recent Trauma: No Recent Tattoos: No Needle Marks: No Signs of Rash: No Open Sores: No Wounds: No Body Deformities: No Tremors: No Sweating: No Comments: Page 053 of 148 Withheld pursuant to exemption (b)(6) ; (b)(7)(A): (b)(7)(C) of the Freedom of Information and Privacy Act Generated 07/09/2019 13:03 by Bureau of Prisons - NMI Page 4 of 13 EFTA00073884 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: NYM Encounter Date: 07/09/2019 12:35 Provider: Unit: H01 Immunizations: Hepatitis A and B (TwinRx) Series Administration: History Unknown, Not Administered Documented Date: 0709/2019 12:51 EST Immunization Date: Provider: Location: Drug Mfg: Lot Number: Dosage: Route: Exp Dt: Comments: Measles:Mumps,'Rubella Series Administration: History Unknown, Not Administered Documented Date: 07/09/2019 12:51 EST Immunization Date: Provider: Page 054 of 148 Location: Withheld pursuant to exemption Drug Mfg: (b)(6) (b)(7)(A); (b)(7)(C) Lot Number: of the Freedom of Information and Privacy Act Dosage: Route: Exp Dt: Comments: Smallpox Series Administration: History Unknown, Not Administered Documented Date: 07/09/2019 12:51 EST Immunization Date: Provider: Location: Drug Mfg: Lot Number: Dosage: Route: Exp Dt: Comments: Tetanus Administration: History Unknown, Not Administered Documented Date: 07/09/2019 12:51 EST Generated 07,09/2019 13:03 by Bureau of Prisons - NYM Page 5 of 13 EFTA00073885 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: NYM Encounter Date: 07/09/2019 12:35 Provider: Unit: H01 Immunization Date: Provider: Location: Drug Mfg: Lot Number: Dosage: Route: Exp Dt: Comments: Varicella Series Administration: History Unknown, Not Administered Documented Date: 07/09/2019 12:51 EST Immunization Date: Provider: Location: Drug Mfg: Lot Number: Page 055 of 148 Dosage: Withheld pursuant to exemption Route: (b)(6): (b)(7)(A); (b)(7)(C) Exp Dt: of the Freedom of Information and Privacy Act Comments: Temperature: Date Time Fahrenheit Celsius Location Provider 07/09/2019 12:49 NYM 97.3 36.3 Oral Pulse: PAW lime Rate Per Minute Location Rhythm Provider 07/09/2019 12:49 82 Via Machine Regular Respirations: Date Time Rate Per Minute Provider 07/09/2019 12:49 NYM 16 Blood Pressure: Date lime Value Location Position Cuff Size Provider 07/09/2019 12:49 NYM 117/66 Right Arm Sitting Adult-regular SaO2: Date Time Value(%) Air Provider 07/09/2019 12:49 NYM 97 Room Air Height: Date Time Inches Cm Provider 07/09/2019 12:49 NYM 70.0 177.8 Generated 07/09(2019 13:03 by Bureau of Prisons • NYM Page 6 of 13 EFTA00073886 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: NYM Encounter Date: 07/09/2019 12:35 Provider: Unit: H01 Date Time inches Cm Provider Weight: Date Time iLt s Kg Waist Circum. Provider 07/09/2019 12:49 NYM 194.4 88.2 Prosthetic Devices1Equipment: Denied Tobacco Usage: Denied General Social History: Foreign Travel: Born in USA: Yes Country of Birth: USA Patient Education Assessments: Date Ed Yrs Occupation Learns Best By Primary Language Barriers to Education 07/09/2019 12 Banker Speaking/Listening English None Family History - Father: Age at Death: 74 Cause of Death: Diabetes complications Significant Illnesses: Page 056 of 148 Diabetes Withheld pursuant to exemption Heart Disease (b)(6) (b)(7)(A): (b)(7)(C) Comments: Family History - Mother: of the Freedom of Information and Privacy Act Age at Death: 81 Cause of Death: Kidney Failure Significant Illnesses: Heart Disease Comments: Family History - Sibling: Number of Siblings: 1 Significant Illnesses: Comments: Past Hospitalization: Reason Location When Acute Appendicitis Mount Sinai Hospital 1990 Complications: None Comments: Head: Normal: Yes Comments: Generated 07/09(2019 13:03 by Bureau of Prisons - NYM Page 7 of 13 EFTA00073887 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: NYM Encounter Date: 07/09/2019 12:35 Provider: Unit: H01 Eyes: EOMI: Yes Icterus:No Conjunctival Inflammation: No Pupils Yes Pupil Size Rt: Pupil Size Lt: Pupils Comments: Fundi Vessels Nicking: No Fundi Vessels Discs Flat:Yes Fundi Vessels Discs Sharp Margins: Yes Fundi Vessels Grounds Abnormal: No Eyes Comments: Vision Screen 07/09/2019 12:52 Blindness: With Corrective Distance Vision: OD: 100 OS: 70 OU: OD: OS OU: Near Vision: OD: OS: OU: OD: OS: OU: Page 057 of 148 Ishihara Color Test: Withheld pursuant to exemption Tonometry: L: (b)(6). (b)(7)(A). (b)(7)(C) Comments: Needs evaluation with optometrist. Ears: of the Freedom of Information and Privacy Act Right Ear: Canal patent Left Ear: Canal patent Ears Comments: Nose: Nares Patent: Yes Septum Midline: Yes Septum Intact: Yes Drainage,Discharge: No Polyps: No Nose Comments: Generated 07,09/2019 13:03 by Bureau of Prisons - NYM Page 8 of 13 EFTA00073888 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: HITE Facility: NYM Encounter Date: 07/09/2019 12:35 Provider: Unit: H01 Mouth Lesions:No Oral/Buccal Mucosa:Yes Gums Normal: Yes Tonsils Present:Yes Tonsils Normal: Yes Pharynx: Normal Color Teeth Poor Dentition: No Teeth Count:Mostly Present Dentures: No Mouth Comments: Cranial Nerves: Intact Yes Cranial Nerves Comments: Neck: Full ROM:Yes Page 058 of 148 Masses Nodes: No Withheld pursuant to exemption Trachea: Midline (b)(6); (b)(7)(A); (b)(7)(C) Thyroid: Normal Size Comments: of the Freedom of Information and Privacy Act Breasts: Normal: Yes Masses:No Tenderness:No Scars: No Dimpling:No Nipple Discharge: No Nipple Retraction:No Instructions for Self Breast Exam Given: No Comments: Generated 07,09/2019 13:03 by Bureau of Prisons - NYM Page 9 of 13 EFTA00073889 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M R : WHITE Facility: NYM Encounter Date: 07/09/2019 12:35 Provider Unit: H01 Thorax: Contour Normal:Yes Increased AP Diameter: No Asymmetrical Expansion:No Lungs Clear: Yes Wheezes: No Crackles: No Rhonchi: No Rates: No Accessory Muscle Use: No Comments: Spine: Deformity: No Full ROM:Yes Tenderness: No Comments: Cardiovascular: Page 059 of 148 RRR: Yes Withheld pursuant to exemption Normal S1/S2: Yes (b)(6); (b)(7)(A): (b)(7)(C) Murmurs: No Carotid Bruits: No of the Freedom of Information and Privacy Act JVD: No Arteries: Right Left Radial: Femoral: Dorsalis Pedis: Post. Tibialis: Comments: Generated 07,0912019 13:03 by Bureau of Prisons - NYM Page 10 of 13 EFTA00073890 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg 4: 76318-054 Date of Birth: 01/20/1953 Sex: HITS Facility: NYM Encounter Date: 07/09/2019 12:35 Provider Unit: H01 Abdomen: Normal Contour:Yes Scaphoid: No Obese: No Gravid: No Hernias: No Bruits: No Masses:No Scars: No Tenderness: No Organomegaly: No Active Bowel Sounds: Yes Comments: Extremities: Nails Clubbing: No Nails Cyanosis: No Lower Extremity Edema - Right: None Page 060 of 148 Lower Extremity Edema - Left: None Atrophy: No Withheld pursuant to exemption Amputations: No (b)(6) ; (b)(7)(A); (b)(7)(C) Other Deformities: No Varicosities:No of the Freedom of Information and Privacy Act Calf Tenderness:No Pulse Deficit: No Strength: Right Left Arm: Leg: Full ROM: Right Left Arm: Yes Yes Leg: Yes Yes Comments: Generated 07,09/2019 13:03 by Bureau of Prisons - NYM Page 11 of 13 EFTA00073891 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M R : WHITE Facility: NYM Encounter Date: 07/09/2019 12:35 Provider Unit: H01 Reflexes: Right ken Biceps: Patellar: Brachioradialis: Achilles: Sensation: Vibratory: Yes Light Touch: Yes Pin Prick: Yes Comments: GU: Chaperoned By: Rectum: Not Done Comments: Refused. Page 061 of 148 Male Genitalia: Not Done Withheld pursuant to exemption Comments: Refused. (b)(6); (b)(7)(A), (b)(7)(C) Skin: of the Freedom of Information and Privacy Act Normal:Yes Rash: No Redness:No Abnormal Pigmentation: No Abnormal Lesions Growths: No Comments: Lymphatics: Adenopathy: No Comments: Potential Items For Follow-up: Item Travel Outside US Other Infectious Disease History Rectum Not Done Male Genitalia Not Done PPD Administration Not Performed Comments: Patient has a history of constipation. Generated 07,0912019 13:03 by Bureau of Prisons Page 12 of 13 EFTA00073892 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: NYM Encounter Date: 07/09/2019 12:35 Provider: Unit: H01 Cleared For Food Services: Yes Health Problems Newly Identified During This Encounter: Health Problem Constipation, unspecified - Current - New Medication Orders: Rx# MedicaliO_n Order Date PreS.Criber Ogler Bisacodyl E.C. Tablet 07/09/2019 12:35 5 mg Orally at bedtime PRN x 10 day(s) Indication: Constipation, unspecified Disposition: Follow-up at Sick Call as Needed Instructed inmate how to obtain medical, dental, and mental health care. Copay Required:No Cosign Required: Yes TelephoneNerbal Order: No Completed by on 07 09 2019 13:03 Requested to be cosigned by Cosign documentation will be displayed on the following 062 of 148 Withheld pursuant to exemption (b)(6); (b)(7)(A): (b)(7)(C) of the Freedom of Information and Privacy Act Generated 07,09/2019 13:03 by Bureau of Prisons - NYM Page 13 of 13 EFTA00073893 Bureau of Prisons Health Services Cosign/Review Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Encounter Date: 07/09/2019 12:35 Provider: Facility: NYM Cosigned by on 07/11/2019 22:41. Page 063 of 148 Withheld pursuant to exemption (b)(6) ; (b)(7)(A) ; (b)(7)(C) of the Freedom of Information and Privacy Act Bureau of Prisons NYM EFTA00073894 Bureau of Prisons Health Services Inmate Local Hospital Reg #: 76318-054 Inmate Name: EPSTEIN. JEFFREY EDWARD SENSITIVE BUT UNCLASSIFIED — This information is confidential and must be appropriately safeguarded. Transfer To: Transfer Date: 08/10/2019 Health Problems Health Problem Status Hyperlipidemia, unspecified Current HYPERTRIGLYCERIDEMIA Sleep apnea Current Essential (primary) hypertension Current BY HX. Constipation. unspecified Current Low back pain Current Neuralgia and neuritis, unspecified Current No Diagnosis Current Prediabetes Current Injury, unspecified Current RIO self inflicted injuries. Body mass index (BMI) 27.0-27.9, adult Current Medications: All medications to be continued until evaLuate d Joyoaphysician unless otherwise indicated. Bolded drugs required for transport. Page °tw ? Docusate Sodium 100 MG Cap Exp: 08/11/264M-AO.pTiSafietbcattroilftia00 MG) by mouth twice daily for 30 days Docusate Sodium 100 MG Cap Exp: 01/22/2020 SIG: Take one capsule (100 MG) twice daily by mouth with plenty of water (b)(6), (b)(7)(A), (b)(7)(C) Milk of Magnesia Susp (OTC) (473ML) 400MG/5ML Exp: 10/28/2019 SIG: shake well take 10ml by mouth twice daily AS NEEDED of the Freedom of Information and Privacy Act Omega 3 (Vascepa) 1 GM Capsule Exp: 01/13/2020 SIG: Take two capsules (2 GM) twice daily by mouth with food OTCs: Listing of all known OTCs this inmate is currently taking. None Pending Appointments Dale Time Activity Provider 07/24/2019 00:00 Clinical Encounter Optometrist 01/07/2020 00:00 Chronic Care Visit Mid-Level Provider 07/01/2020 00:00 Chronic Care Visit Physician 01 07/09/2020 00:00 PPD Administration Nurse Pending Non-Medication Orders: Order Order Date Frequency Duration Details EKG 07/06/2019 One Time 66 y/o male Fecal Occult Blood 07/06/2019 One Time 3 different stools TB Clearance: Yes Last PPD Date: 07/09/2019 Induration: 0mm Last Chest X-Ray Date: Results: TB Treatment: Sx free for 30 days: Yes TB Follow-up Recommended: No Sickle Cell: Sickle Cell Trait/Disease: No Generated 08..10;2019 07:00 by RN Bureau of Prisons NYM Page 1 of 2 EFTA00073895 Reg #: 76318-054 Inmate Name: EPSTEIN, JEFFREY EDWARD SENSITIVE BUT UNCLASSIFIED - This information is confidential and must be appropriately safeguarded. Limitations/Restrictions/Diets: Cell: lower bunk --- 10/09/2019 Cleared for Food Service: Yes Other diet restrictions: FISH ALLERGIES. --- 07/30/2020 Comments: Allergies No Known Allergies Devices / Equipment C-Pap Travel: Direct Travel: No Travel Restrictions: None UNIVERSAL PRECAUTIONS OBSERVED WHEN TRANSPORTING ANY INMATE: Transfer From Institution: NEW YORK MCC Phone Number: Address 1: Address 2: City/State/Zip: NEW YORK. New York 10007 Name/Title of Person Completing Form: RN Date: 08/10/2019 Inmate Name: EPSTEIN, JEFFREY EDWARD Re DOB: 01/20/1953 Sex: M ag deglf-P134 Withheld pursuant to exemption (b)(6); (b)(7)(A): (b)(7)(C) of the Freedom of Information and Privacy Act Generated 08r10/2019 07:00 by RN Bureau of Prisons NYM Page 2 of 2 EFTA00073896 Bureau of Prisons Health Services Vitals All Begin Date: 07/06/2019 End Date: 05/11/2020 Reg #: 76318-054 Inmate Name: EPSTEIN, JEFFREY EDWARD Temperature: Date Time Fahrenheit Celsius Location Provider 07/24/2019 13:12 NYM 97.8 36.6 Oral Orig Entered: 07/24/2019 13:14 EST 07/23/2019 06:30 NYM 97.5 36.4 Oral Orig Entered: 07/23/2019 08:33 EST 07/09/2019 12:49 NYM 97.3 36.3 Oral Orig Entered: 07/09/2019 12:51 EST Pulse: Date Time Rate Per Minute Location Rhythm Provider 07/30/2019 13:02 94 Orig Entered: 07/30/2019 13:04 EST 07/30/2019 09:40 88 Via Machine Orig Entered: 07/30/2019 13:04 EST 07/30/2019 09:30 87 Via Machine Orig Entered: 07/30/2019 12:59 EST Beaul349014%thhieD 07/28/2019 20:28 RN pursuant to "'remotion Orig Entered: 07/28/2019 20:29 EST L RN 07/28/2019 06:57 82 (b)(6): (b)(7)(A): (b)(7)(C) RN Orig Entered: 07/28/201:#04:flet4Tm gfzibielCi9atikthstiRti lacy Act 07/24/2019 13:12 83 Via Machine Regular Orig Entered: 07/24/2019 13:14 EST 07/23/2019 06:30 92 Via Machine Regular Orig Entered: 07/23/2019 08:33 EST 07/09/2019 12:49 82 Via Machine Regular Orig Entered: 07/09/2019 12:51 EST 07/06/2019 21:43 90 Via Machine PA-C Orig Entered: 07/06/2019 21:48 EST PA-C Respirations: Date Time Rate Per Minute Provider 07/30/2019 09:30 NYM 12 Orig Entered: 07/30/2019 12:59 EST 07/28/2019 20:28 NYM 14 RN Orig Entered: 07/28/2019 20:29 EST RN 07/28/2019 06:57 NYM 14 RN Orig Entered: 07/28/2019 06:58 EST RN 07/23/2019 06:30 NYM 16 Orig Entered: 07/23/2019 08:33 EST • 07/09/2019 12:49 NYM 16 Generated 05/11/2020 09:57 by OGC Bureau of Prisons • DAN Page 1 of 3 EFTA00073897 Begin Date: 07/06/2019 End Date: 05/11/2020 Reg #: 76318.054 Inmate Name: EPSTEIN, JEFFREY EDWARD Date Time Rate Per Minute Provider Orig Entered: 07/09/2019 12:51 EST 07/06/2019 21:43 NYM 15 PA-C Orig Entered: 07/06/2019 21:48 EST PA-C Blood Pressure: Date lime Value Location Position Cuff Size Provider 07/30/2019 13:02 NYM 114/84 Left Arm Standing Orig Entered: 07/30/2019 13:04 EST 07/30/2019 09:40 NYM 125/60 Right Arm Standing Orig Entered: 07/30/2019 13:04 EST 07/30/2019 09:30 NYM 108/86 Left Arm Sitting Orig Entered: 07/30/2019 12:59 EST 07/28/2019 20:28 NYM 157/91 RN Orig Entered: 07/28/2019 20:29 EST RN 07/28/2019 06:57 NYM 138/80 RN Orig Entered: 07/28/2019 06:58 EST RN 07/24/2019 13:12 NYM 132/89 Right Arm Sitting Adult-regular Orig Entered: 07/24/2019 13:14 EST 07/23/2019 06:30 NYM 140/85 Right Arm 067 of 148"un-regular Orig Entered: 07/23/2019 08:33 EST %lair o exenli8n. 07/09/2019 12:49 NYM 117/66 Right Pre regular Orig Entered: 07/09/2019 12:51 ESTO:464g(Ii0(704914b)(7)(C) 07/06/2019 21:45 NYM 164/90 RiVt Arm Sitting. Adult-regular PA-C $an8Privacy Act Orig Entered: 07/06/201)9 t21:41;egtr 07/06/2019 21:43 NYM 155/83 Left Arm Sitting Adult-regular PA-C Orig Entered: 07/06/2019 21:48 EST PA-C Blood Glucose: Date Time Value (mg/dO type Regular Insulin Provider 08/04/2019 08:30 156 Non-Fasting RN Orig Entered: 08/04/2019 09:08 EST RN 08/02/2019 06:30 97 Non-Fasting Orig Entered: 08/02/2019 08:16 EST 08/01/2019 06:30 103 Non-Fasting Orig Entered: 08/01/2019 09:00 EST 07/31/2019 06:15 108 Non-Fasting Orig Entered: 07/31/2019 08:36 EST Sa02: Date lime Value(%) Air Provider 07/30/2019 09:30 NYM 98 Room Air Orig Entered: 07/30/2019 12:59 EST 07/28/2019 20:28 NYM 98 RN Orig Entered: 07/28/2019 20:29 EST RN 07/28/2019 06:57 NYM 98 RN Generated 05/11/2020 09:57 by OGC Bureau 01 Prisons • DAN Page 2 of 3 EFTA00073898 Begin Date: 07/06/2019 End Date: 05/11/2020 Reg #: 76318.054 Inmate Name: EPSTEIN, JEFFREY EDWARD Date Time Value(%) Air Provider Orig Entered: 07/28/2019 06:58 EST RN 07/24/2019 13:12 NYM 96 Room Air Orig Entered: 07/24/2019 13:14 EST 07/23/2019 06:30 NYM 96 Room Air Orig Entered: 07/23/2019 08:33 EST 07/09/2019 12:49 NYM 97 Room Air Orig Entered: 07/09/2019 12:51 EST 07/06/2019 21:43 NYM 95 Room Air PA-C Orig Entered: 07/06/2019 21:48 EST PA-C Height: Date lime Inches Cm Provider 07/09/2019 12:49 NYM 70.0 177.8 Orig Entered: 07/09/2019 12:51 EST 07/06/2019 21:43 NYM 72.0 182.9 PA-C Orig Entered: 07/06/2019 21:48 EST PA-C Weight: Date Time the Kg Waist Circum. Provider 07/30/2019 09:30 NYM 194.2 88.1 Page 068 oinadouin, Robert MD Orig Entered: 07/30/2019 12:59 Reahhaelamaiscial RobleMpffibn 07/09/2019 12:49 NYM 194.4 88.2 (b)(6 Ha 7 A; Orig Entered: 07/09/2019 12:51 EST 07/06/2019 21:43 NYM 266.81e FroWyrn o ormation angeritaiMWA-C Orig Entered: 07/06/2019 21:48 EST PA-C Generated 05/11/2020 09:57 by OGC Bureau of Prisons • DAN Page 3 of 3 EFTA00073899 Bureau of Prisons Health Services PPDs Reg #: 76318-054 Inmate Name: EPSTEIN, JEFFREY EDWARD Admin: Location Provider Reading• Induration Provider 07/06/2019 21:39 Right Forearm PA-C 07/09/2019 12:47 0 mm Orig Entered: 07/06/2019 21:43 EST PA-C Orig Entered: 07/09/2019 12:47 EST Total: 1 Page 069 of 148 Withheld pursuant to exemption (b)(6) ; (b)(7)(A) ; (b)(7)(C) of the Freedom of Information and Privacy Act Generaled 05/11/2020 09:57 by OGC Bureau of Prisons DAN Page 1 of 1 EFTA00073900 76316054 EPSTEIN. JEFFREY Medication Administration Record JULY 2019 Medication Orders Time 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Ord. Date 0730'19 inIN I4 21 Inject regular insulin subcutaneously per Exp. Dale sliding scale: twice daily "'pill 'Inc— for 7 0731/9 days '0.01 NYM 122148- NYM Insulin Rog (10 ML) 100 UNITSML Ws Ord. Date 07/31/19 1111N '0:00 Inject regular insulin subcutaneously per Exp. Date sliding scale: each morning for 7 days "'pill 08.07/9 Ilne— • 09 59 NYM 122160- NYM InSoto Reg (10 ML) 100 UNITSSAL In1 Panp 0T0 of US Withheld pursuant to exemption (b)(6) ; (b)(7)(A) : (b)(7)(C) of the Freedom of Information and Privacy Act Providers: YJ Documentation Codes: ORD = Order I NI = Dose Not Indicated Registration F. 76318-054 Pt. Name: EPSTEIN. JEFFREY DOB: 01/20153 Report information is current as of the date and time of printing: 05,11-2020 09:57 EST EFTA00073901 76318-054 EPSTEIN. JEFFREY Medication Administration Record AUGUST 2019 Medication Orders Time 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Ord. Date 0731,19 PAN 10 00 Inject regular insulin subcutaneously per Exp. Dale sliding scale: each morning for 7 days —pill 08,07,19 line— 09:59 NYM 122160 NYM Insuim Rog (10 ML) 100 UNITS ML Iq Page 071 of 148 Withheld pursuant to exemption (b)(6); (b)(7)(A) : (b)(7)(C) of the Freedom of Information and Privacy Act Providers: Y..1 = Documentation Codes: ORD = Order I NI = Dose No1 Indicated Registration 4. 76318-054 Pt. Name: EPSTEIN. JEFFREY DOB: 01:20:53 Report information is current as of the date and time of printing: 05:11,2020 09:57 EST EFTA00073902 Bureau of Prisons Health Services Devices and Equipment Start Date: 07/06/2019 Stop Date: 05/11/2020 Reg #: 76318-054 Inmate Name: EPSTEIN, JEFFREY EDWARD Device/Equipment Stan Date Stop Date Date Returned Obtained From Comments C-Pap 07/30/2019 14:05 EST 07/30/2019 Personal PHILIPS RESPIRONICS SYSTEM ONE CPAP MACHINE. SERIAL #: P11312813B1ED. Total: 1 Page 072 of 148 Withheld pursuant to exemption (b)(6); (b)(7)(A); (b)(7)(C) of the Freedom of Information and Privacy Act Generated 05/11/2020 09:57 by OGG Bureau of Prisons - DAN Page 1 of 1 EFTA00073903 Bureau of Prisons Health Services Pain Management Begin Date: 07/06/2019 End Date: 05/11/2020 Reg #: 76318-054 Inmate Name: EPSTEIN. JEFFREY EDWARD Date Intervention Pain Quality Location Pre Post Provider 07/12/2019 13:25 MEDROL DOSE PACK Shooting Back-Middle 5 Orig Entered: 07/12/2019 13:28 EST Page 073 of 148 Withheld pursuant to exemption (b)(6) : (b)(7)(A) : (b)(7)(C) of the Freedom of Information and Privacy Act Generals 0511;2020 0937 by OGG Bureau of Prisons DAN Page 1 of 1 EFTA00073904 Bureau of Prisons Health Services Modified Diet Request Types of Diets: Clear Liquid Exp Date: Low Fat Exp Date: Mechanical Soft Exp Date: Low Cholesterol Exp Date: Low Triglyceride Exp Date: Renal Exp Date: Full Liquid Exp Date: Sodium Controlled Exp Date: Snack Exp Date: Diabetic Exp Date: Calorie Controlled Exp Date: X Other: FISH ALLERGIES. Exp Date: 07/30/2020 Comments: Page 074 of 148 Withheld pursuant to exemption (b)(6); (b)(7)(A): (b)(7)(C) Health Service Staff EPSTEIN. JEFFREY EDWARD of the Freedom of Ini&AH;4and Privacy Act 07/30/2019 Inmate Name Reg# Date Generated 07/30/2019 14:57 by Bureau of Prisons NYM Page 1 of 1 EFTA00073905 Bureau of Prisons Health Services Allergies Reg #: 76318-054 Inmate Name: EPSTEIN, JEFFREY EDWARD Alleray Date Noted Reaction No Known Allergies 07/06/2019 Orig Entered: 07/06/2019 21:40 EST PA-C Total: 1 Page 075 of 148 Withheld pursuant to exemption (b)(6) ; (b)(7)(A) ; (b)(7)(C) of the Freedom of Information and Privacy Act Generated 05/11/2020 09:57 by OGC Bureau of Prisons - DAN Page 1 of 1 EFTA00073906 Bureau of Prisons Health Services Patient Education Assessments & Topics Reg #: 76318-054 Inmate Name: EPSTEIN. JEFFREY EDWARD Assessments Assessment Learns Best By Primary Language Years of Education Barriers To Education Provider 07/09/2019 Speaking/Listening English 12 None Orig Entered: 07/09/2019 12:52 EST Total: 1 Topics Date Initiated Form Handout/Topic Outcome Provider 07/30/2019 Counseling Access to Care Verbalizes Understanding Page 076 of 148 Orig Entered: 07/30/2019 13:33 EST 07/30/2019 Counseling Plan of Care Withheld pursuant to exempliobalizes Understanding Orig Entered: 07/30/2019 13:34 EST (b)(6); (b)(7)(A) : (b)(7)(C) 07/28/2019 Counseling Plan of Verbalizes Understanding Orig Entered: om of Information and Privacy Act 07/28/2019 07:22 EST 07/28/2019 Counseling Plan of Care Verbalizes Understanding Orig Entered: 07/28/2019 20:30 EST 07/24/2019 Counseling Access to Care Verbalizes Understanding Orig Entered: 07/24/2019 13:23 EST 07/24/2019 Counseling Preventive Health Verbalizes Understanding Orig Entered: 07/24/2019 13:23 EST 07/23/2019 Counseling Access to Care Verbalizes Understanding Orig Entered: 07/23/2019 09:04 EST 07/23/2019 Counseling Plan of Care Verbalizes Understanding Orig Entered: 07/23/2019 09:04 EST 07/14/2019 Counseling Diagnosis Verbalizes Understanding Orig Entered: 07/14/2019 18:11 EST 07/12/2019 Counseling Diagnosis Verbalizes Understanding Generated 05'1112020 09:57 by OGC Bureau of Prisons DAN Page 1 of 2 EFTA00073907 Reg #: 76318-054 Inmate Name: EPSTEIN. JEFFREY EDWARD Topics Date Initiated Format Handout/Topic Outcome Provider Orig Entered: 07/12/2019 13:33 EST Total: 10 Page 077 of 148 Withheld pursuant to exemption (b)(6); (b)(7)(A); (b)(7)(C) of the Freedom of Information and Privacy Act Generated 0511 2020 0937 by OGC Bureau of Prisons DAN Page 2 ol 2 EFTA00073908 Bureau of Prisons Health Services Blood Glucose Begin Date: 07/06/2019 End Date: 05'11:2020 Reg #: 76318-054 Inmate Name: EPSTEIN. JEFFREY EDWARD (Reference Range: Random or Fasting 70 - 100.2 hour post-prandial 70 - 140) Date Time Value Type Comments 08/0412019 08:30 NYM 156 Non-Fasting Orig Entered: 08/04/2019 09:08 EST RN 08/02/2019 06:30 NYM 97 Non-Fasting Orig Entered: 08/02/2019 08:16 EST 08/01:2019 06:30 NYM 103 Non-Fasting Orig Entered: 08/01/2019 09:00 EST 07:31:2019 06:15 NYM 108 Non-Fasting Orig Entered: 07/31/2019 08:36 EST Page 078 of 148 Total: 4 Withheld pursuant to exemption (b)(6): (b)(7)(A) : (b)(7)(C) of the Freedom of Information and Privacy Act Generated 05(11/2020 09:57 by OGC Bureau of Prisons DAN Page I of 1 EFTA00073909 Bureau of Prisons Health Services Health Problems Reg #: 76318-054 Inmate Name: EPSTEIN, JEFFREY EDWARD Description Axis Code Type Code Diag. Date Status Status Date Current Hyperlipidemia, unspecified 07/12/2019 13:48 EST ICD-10 E785 07/12/2019 Current HYPERTRIGLYCERIDEMIA Sleep apnea 07/12/2019 13:56 EST ICD-10 G4730 07/12/2019 Current Essential (primary) hypertension 07/30/2019 13:13 EST ICD-10 110 07/30/2019 Current BY HX. Constipation, unspecified Page 079 of.1! 07/09/2019 12:58 EST iuu 10 K5900 07/09/2019 Current Withheld pursuant to exemption Low back pain 07/12/2019 13:30 EST (b)(6); (b)(7)(A): (WA M545 07/12/2019 Current Neuralgia and neuritis, unspecified of the Freedom of Information and Privacy Act 07/12/2019 13:30 EST ICD-10 M792 07/12/2019 Current No Diagnosis 07/09/2019 10:28 EST PhD/Chief I DSM-IV No Dx 07/09/2019 Current Psychologist Prediabetes 07/30/2019 13:26 EST ICD-10 R7303 07/30/2019 Current Injury, unspecified 07/23/2019 09:04 EST ICD-10 T1490 07/23/2019 Current to self inflicted injuries. Body mass index (BMI) 27.0.27.9, adult 07/30/2019 13:14 EST ICD-10 Z6827 07/30/2019 Current Total: 10 Generated 05/11/2020 09:57 by OGC Bureau of Prisons - DAN Page 1 of EFTA00073910 Bureau of Prisons Health Services Vision Screens Reg #: 76318-054 Inmate Name: EPSTEIN. JEFFREY EDWARD Vision Screen on 07/09/2019 12:52 Blindness: Distance Vision: OD: 20/100 OS: 20/70 OU: Near Vision: OD: OS: OU: With Corrective Distance Vision: OD: OS: OU: Near Vision: OD: OS: OU: Present Glasses - Distance Refraction - Distance Sphere Cylinder Axis Add Sphere Cylinder Axis Add L: L: Color Test: Tonometry: L: Comments: Needs evaluation with optometrist. Orig Entered: 07/09/2019 12:54 EST e 080 of 148 Withheld pursuant to exemption (b)(6) (b)(7)(A); (b)(7)(C) of the Freedom of Information and Privacy Act Generated 05/11/2020 09:57 by OGC Bureau of Prisons • DAN Page 1 of 1 EFTA00073911 Bureau of Prisons Health Services Immunizations Begin Date: 07/06/2019 End Date: 05'11:'2020 Reg It: 76318-054 Inmate Name: EPSTEIN, JEFFREY EDWARD immunization Immunization Date Administered Location Dosage Drug Mfg Lot # Exp Date Hepatitis A and B (TwinRx) History Unknown Orig Entered: 07/09/2019 12:51 EST Measles/Mumps,Rubella Series History Unknown Orig Entered: 07/09/2019 12:51 EST Smallpox Series History Unknown Orig Entered: 07/09/2019 12:51 EST Tetanus History Unknown Orig Entered: 07/09/2019 12:51 EST Varicella Series History Unknown Page 081 of 148 Orig Entered: 07/09/2019 12:51 EST Total: 5 Withheld pursuant to exemption (b)(6) : (b)(7)(A) : (b)(7)(C) of the Freedom of Information and Privacy Act Generated 05111/2020 09:57 by OGC Bureau of Prisons DAN Page 1 of I EFTA00073912 Bur ^. Prisons i-lea:`!I Services iCqc .cal Duty Status Reg #: 76318-054 in :ate Name: EPSTEIN. JEFFREY EDWARD Housing Status _ confined to the living quarter: t. ', ept _meals pill line treatments Exp. Date: _ on complete bed rest: _ bathroom privileges only Exp. Date: X cell: _cell on fir . floc, single cell X lower bunk airborne infection isolation Exp. Date: 19: 019 other: Exp. Date: Physical Limila: 1/Restriction all spc s Exp. L. le: Hill.4 : upper body lower body F .n. Date: CP die ascular exercise: running _jogging walking softball Eap. Date: football basketball handball stationary er ..-ment other: Exp. Date: May have the following equipment in his / her possession: Equipment Start C ite End Date Return Date C-Pap 07 ni 19 PHILIPS RESPIRONICS SYSTEM ONE CPAP MACHINE. SERIAL #: P11312813B1ED. Page 082 of 148 Work Restriction / Limitation: Withheld pursuant to exemption Cleared for Food Service: Yes (b)(6) (b)(7)(A) (b)(7)(C) X No Restrictions Comments: N/A of the Freedom of Information and Privacy Act 07/30/2019 Health Services Staff Date Inmate Name: EPSTEIN, ."3-. -WY EDWARD Reg #: 76318-054 Quarters: null ALL EXPIRATION DATES ctt .F 24:00 Generated 05/11/2020 09:57 by OGC C of Prisons - DAN Page I of 1 EFTA00073913 Bur :Lit ^. Prisons l-lea:`!I Services ih'qc .cal Duty Status Reg #: 76318-054 in. :ate Name: EPSTEIN. JEFFREY EDWARD Housing Status confined to the living quarter:. t., ept _meals pill line treatments Exp. Date: on complete bed rest: bathroom privileges only Exp. Date: X cell: cell on fir' floc, single cell X lower bunk airborne infection isolation Exp. Date: 4 0.19/ :019 other: Exp. Date: Physical Limlio: VRestriction all spc s Exp. L. le: wr 4h upper body lower body F • n. Date: ca dic ascular exercise: _running _jogging walking softball Eat.). Date: football basketball handball stationary er ..-ment other: Exp. Date: May have the following equipment in his / her possession: Work Restriction / Limitation: Cleared for Food Service: Yes X No Restrictions Page 083 of 148 Comments: N/A Withheld pursuant to exemption 07/09/2019 Health Services Staff (b)1b). (b)(/)(A), (b)( O(L) Date Inmate Name: EPSTEIN, JEFFREDYtEEPtieed6M of lifferation alf3318#0&14Act Quarters: null ALL EXPIRATION DATES ARE ATI' ,..01 Generated 05/11/2020 09:57 by OGC Eure;i:i of Prisons - DAN Page I of 1 EFTA00073914 Bureau of Prisons Health Services Medication Summary Historical Complex: NYM--NEW YORK MCC Begin Date: 07/06:2019 End Date: 05/11/2020 Inmate: EPSTEIN. JEFFREY EDWARD Reg #: 76318.054 Quarter: ???-???? Medications listed reflect prescribed medications from the begin date to end date on this report. Allergies: Denied Active Prescriptions Bisacodyl E.C. 5 MG TAB Take one tablet (5 MG) by mouth at bedtime AS NEEDED for 10 days Rx#: 121757-NYM Doctor: Start: 07/09/19 Exp: 0719119 D/C: 07/12/19 Pharmacy Dispensings: 10 TAB in 307 days Docusate Sodium 100 MG Cap Take one capsule (100 MG) by mouth twice daily for 30 days Rx#: 121823-NYM Doctor: Start: 07/12/19 Exp: 08/11/19 D/C: 08/10/19 Pharmacy Dispensings: 60 CAP in 304 days Page 084 of 148 Docusate Sodium 100 MG Cap Take one capsule (100 MG) twice daily by moutkVittthet&PU9s0lAktcteexemption Rx#: 122084-NYM Doctor: Beaudouin. RobwW (b)(7)(A); (b)(7)(C) Start: 07/26/19 Exp: 01/22/20 D/C: 0810119 Pharmacy Dispensings: 30 CAP in 290 days of the Freedom of Information and Privacy Act Milk of Magnesia Susp (OTC) (473ML) 400MG/5ML shake well take 2 tablespoonful twice daily by mouth Rx#: 121835-NYM Doctor: Start: 07/12/19 Exp: 07/14/19 Pharmacy Dispensings: 473 ML in 304 days Milk of Magnesia Susp (OTC) (473ML) 400MG/5ML shake well take 10ml by mouth twice daily AS NEEDED Rx#: 122150-NYM Doctor: Start: 07/30/19 Exp: 10/28/19 D/C: 08/10/19 Pharmacy Dispensings: 473 ML in 286 days methylPREDNISolone 4 MG Tab [ 21 count Pack] Take the tablet by mouth as directed Rx#: 121836-NYM Doctor: Start: 07/12/19 Exp: 07/18/19 Pharmacy Dispensings: 21 tab in 304 days methylPFIEDNISolone 4 MG Tab [ 21 count Pack] Take the tablet by mouth as directed Rx#: 122149-NYM Doctor: Start: 07/30/19 Exp: 08/05/19 Pharmacy Dispensings: 21 tab in 286 days Generated 05:11)2020 09:57 by OGC Bureau of Prisons DAN Page 1 of 2 EFTA00073915 Complex: NYM--NEW YORK MCC Begin Date: 07/06/2019 End Date: 05/11/2020 Inmate: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Quarter: ???-???? Active Prescriptions Omega 3 (Vascepa) 1 GM Capsule Take two capsules (2 GM) twice daily by mouth with food Rx#: 121885-NYM Doctor: Start: 07/17/19 Exp: 01/13/20 D/C: 08/10/19 Pharmacy Dispensings: 180 Cap in 299 days Insulin Reg (10 ML) 100 UNITS/ML Inj Inject regular insulin subcutaneously per sliding scale: twice daily "'pill line"' for 7 days —pill line— Rx#: 122148-NYM Doctor: Start: 07/30/19 Exp: 08/06/19 D/C: 07/31/19 Pharmacy Dispensings: 0 ML in 286 days Insulin Reg (10 ML) 100 UNITS/ML Inj Inject regular insulin subcutaneously per sliding scale: each morning for 7 days "'pill line"' "'pill line*" Rx#: 122160-NYM Doctor: Start: 07/31/19 Exp: 08/07/19 Pharmacy Dispensings: 0 ML in 285 days Page 085 of 148 Withheld pursuant to exemption (b)(6); (b)(7)(A); (b)(7)(C) of the Freedom of Information and Privacy Act Generated 05/11/2020 09:57 by OGC Bureau of Prisons - DAN Page 2 of 2 EFTA00073916 Bureau of Prisons Health Services Dental Health History Screen Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: NYM Encounter Date: 07/26/2019 07:54 Provider: DDS Unit: H01 ASSESSMENTS: Health Problems as of Dental Health History Encounter date: 07/26/2019 07:54 Health Problems Health Problem Status Hyperlipidemia, unspecified Current HYPERTRIGLYCERIDEMIA Sleep apnea Current Constipation, unspecified Current Low back pain Current Neuralgia and neuritis, unspecified Current No Diagnosis Current Injury, unspecified Current RIO self inflicted injuries. Medical History as of Dental Health History Encounter date: 07/26/2019 07:54 Medical History: Allergies: Denied Page 086 of 148 Seizures: Denied Withheld pursuant to exemption Diabetes: Denied Cardiovascular: Denied (b)(6); (b)(7)(A); (b)(7)(C) CVA: of Ehefeeledom of Information and Privacy Act Hypertension: Denied Respiratory: Denied Sickle Cell Anemia: Denied Carcinoma/Lymphoma: Denied HIV History: When Tested: 2019 Test Result: Negative When Diagnosed AIDS: Last CD4: Comments: Hepatitis: Denied Generated 07,26/2019 07:59 by DDS Bureau of Prisons NYM Page 1 of 3 EFTA00073917 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: NYM Encounter Date: 07/26/2019 07:54 Provider: DDS Unit: H01 Other Infectious Diseases: Syphilis: No Syphilis Last Treatment: N/A Genital Warts: No Chlamydia: Yes Gonorrhea: No Herpes: No Chicken Pox: Yes Other: No Comments: Chiamydia in 2015. treated Chicken pox in childhood Other Health Issues: Other Medical Conditions And Treatment:sleep apnea Current Medical Conditions: Other Current Treatments: Pregnant: N A Dental Observations as of Dental Health History EncouRglecRARO/R/2019 07:54 HiStinWVithheld pursuant to exemption Alcohol: No (b)(6) ; (b)(7)(A): (b)(7)(C) Methamphetamine: No Tobacco products: of the Freedotm of Information and Privacy Act Other drugs: No Sensitive teeth: No Bleeding gums: Yes Food impaction: Yes Pain around ear: No Toothache: No Wear partial dentures: No Unusual sounds while eating: No Snoring: Yes Blisters on lips or mouth: No Clenching or grinding: Yes Swelling or lumps in mouth throat: No Burning tongue: No Bad breath: No Decayed teeth: No Loose teeth: No Wear dentures: No None: No Comments: Generated 07,26 20 t 9 07:59 by ODS Bureau of Prisons NYM Page 2 of 3 EFTA00073918 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: NYM Encounter Date: 07/2672019 07:54 Provider: DDS Unit: H01 Cardiac Condition Requiring Prophylaxis: No Prosthetic joint(s): No Radiation history of head or neck: No Excessive bleeding: No Bisphosphonates: No Comments: Medications as of Dental Health History Encounter date: 07/26/2019 07:54 Medications: Docusate Sodium 100 MG Cap Exp: 08/11/2019 SIG: Take one capsule (100 MG) by mouth twice daily for 30 days Omega 3 (Vascepa) 1 GM Capsule Exp: 01/13/2020 SIG: Take two capsules (2 GM) twice daily by mouth with food OTCs: Listing of all known OTCs this inmate is currently taking. Instructed inmate how to obtain medical, dental, and mental health care. Copay Required:No Cosign Required: No Telephone/Verbal Order: No Completed by DDS on 07726:2019 07:59. rage 088 of 148 Withheld pursuant to exemption (b)(6); (b)(7)(A): (b)(7)(C) of the Freedom of Information and Privacy Act Generated 07,26/2019 07:59 by DDS Bureau of Prisons NYM Page 3 of 3 EFTA00073919 Bureau of Prisons Health Services Dental A&O Exam Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: NYM Encounter Date: 07/26,2019 07:47 Provider: DDS Unit: H01 Reviewed Health Status: Yes Occlusion: Class I Oral Hygiene: Fair CPITN: 3 2 3 3 2 3 Hard and soft tissue examination performed and documented on BP618 form: Yes Head & Neck/Soft Tissue within normal limits? No Comments: moderate to advanced upper posterior gingival recession Decayed: Missing: Filled: 0 14 Comments: Lower anterior crowding Approved for hygiene appointment and radiographs: Yes Instructed inmate how to obtain routine and emergendie4e089 01O08 Oral hygiene instructions given: Yes Dental A&O Screening Exam findings entered onActhtelltilDttrSIW0UREeXeDfcAlArRD by DOS on 0726/2019 07:47. (b)(6). (b)(7)(A), (b)(7)(C) of the Freedom of Information and Privacy Act Generated 07,262019 08:00 by DDS Bureau of Prisons NYM Page 1 of 1 EFTA00073920 Bureau of Prisons Health Services Dental Soap/Admin Encounter Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Facility: NYM Encounter Date: 07/18/2019 13:48 Provider: Dental Asst Unit: Z05 Screening encounter at Dental Clinic. Reason Not Done: Unavailable Comments: Patient has had several call outs for his Dental A & O screening but has not been escorted to the dental clinic. Cosign Required: No Completed by Dental Asst on 07/19/2019 13:49. Page 090 of 148 Withheld pursuant to exemption (b)(6) ; (b)(7)(A) ; (b)(7)(C) of the Freedom of Information and Privacy Act Generated 07/19/2019 13:49 by Dental Bureau of Prisons NYM Page 1 of 1 EFTA00073921 Bureau of Prisons -SENSITIVE BUT UNCLASSIFIED** Psychology Services Clinical Intervention - Clinical Contact Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Facility: NYM Unit Team: 5 Date: 08/08/2019 10:02 Provider: PhD/Chief Focus of Session Inmate Epstein was seen today for a follow-up session in SHU. Subjective/Objective Presentation Inmate Epstein stated he is feeling okay and has been eating his meals. He reported his sleep as "fair" and would like to go the general population. He denied any mental health symptoms at this time and denied any feelings of depression and/or anxiety. Inmate Epstein denied any suicidal ideation, intention, or plan. He currently has a cellmate and appears to interact with him. Inmate Epstein continues to spend his days and evening with his attorney's in the attorney conference room. He told this writer he received his PAC number to make phone calls. Inmate Epstein indicated he has only had a couple of phone calls over the speaker phone and wondered "if that counted" as his monthly phone contact. He also reported he his missing some books he was reading in the suicide watch area prior to returning to the SHU. Other than complaints about the prison and concerns regarding his housing, he had no mental health concerns today. He did not appear to be in any distress and the SHU Staff have not reported any unusual behaviors on his part. Intervention(s) Inmate EPSTEIN was provided with brief supportive interventions and psychoeducation regarding additional coping strategies. Inmate EPSTEIN was receptive to these interventions rage 091 of 148 Progress/Plan Inmate EPSTEIN was educated about both routifiglilOienteetytM eat ig for contacting Psychology staff. He was reminded of the self-help books and audiotapes avaif~ Ate s g§fejogy department. There appears to be no need for follow up at this time. He will be seen in weekly rtj Oirn itnd ?n6ritfily for SHU reviews. of the Freedom of Information and Privacy Act Completed by PhD/Chief Psychologist on 08/08/2019 10:09 Generated 0810812019 10:09 by PhD/Chief Bureau of Prisons NYM Page 1 of 1 EFTA00073922 Bureau of Prisons "SENSITIVE BUT UNCLASSIFIED'. Psychology Services Suicide Risk Assessment Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Facilit : NYM Unit Team: 5 Date: 08/01/2019 13:29 Provider: PsyD Type of Housing: SHU- Administrative Segregation Cell Accommodation: Double-Cell FINDINGS This assessment and the resulting recommendations are based on the following sources of information: Clinical Interview. Medical Record. Psychology Data System, Sentry R ea sQ0.10.LEteterral & D staff reported to this writer this morning at about 8:30 AM on 8/01/19 that yesterday when Mr. Epstein was brought back from court the US Marshals asked him to sign a form that noted Mr. Epstein has "suicidal tendencies." Mr. Epstein was seen for a Suicide Risk Assessment at about 1:00 PM on 8101/19 in Attorney Conference. This note is being entered at about 4:20 PM on 8/01/19. Mental Health History According to a Suicide Risk Assessment dated 7/09/19 by Dr. "Inmate Epstein denied any history of mental health treatment, either on an inpatient or outpatient basis. Inmate Epstein denied any treatment in the past or present with psychotropic medication. He also denied any acute mental health symptoms at this time." Self-Harm History Pag of 148 According to a Suicide Risk Assessment dated 7/09/19 by Dr. , "Inmate Epstein denied any past or present suicidal ideation, intention or plan. He denied eAtitbh§lnitoPt**josettfatPtiliftmpts or self-injurious behavior in the past." (b)(6), (b)(7)(A), (b)(7)(C) According to this writer's Suicide Risk i C his time if he had placed the string pa,Pgibig adMiadidr;144 WM( around his neck or if someone else di Current Problem & D staff reported to this writer this morning at about 8:30 AM on 8/01/19 that yesterday when Mr. Epstein was brought back from court the US Marshals asked him to sign a form that noted Mr. Epstein has "suicidal tendencies." This is likely due to the incident on 7/23/19, but as a precaution another Suicide Risk Assessment was conducted. Mr. Epstein seemed surprised that there was a form noting suicidal tendencies. He denied stating he was suicidal. He said he saw the DHO today and he said his incident report for the marks on his neck was expunged. He stated even though he has his cpap machine now, he said his cellmate talks at night and he stated this keeps him up. This writer offered to talk to the SHU Lt. to have him housed with a different cellmate. but he stated he wants to give it 3 to 4 days to see if he wants a different cellmate. He complained about the noise in SHU. Current Mental Status Level of Consciousness: Alert and Oriented Psychomotor Activity: Normal General Appearance: Normal Behavior: Cooperative Mood: Appropriate to Content Thought Process: Goal Directed Thought Content: Normal Current Mental Status: He exhibited a neutral mood with a mildly restricted range of affect. His speech was logical and Generated 08101t2019 16:21 by Imeri, Darlene PsyD Bureau of Prisons NYM Page 1 of 3 EFTA00073923 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Facilit : NYM Unit Team: 5 Date: 08/01/2019 13:29 Provider: PsyD coherent. with no loosening of associations or tangential, circumstantial or irrelevant speech. Auditory and visual hallucinations were denied, and delusions were not elicited. He did not engage in any bizarre or inappropriate behavior. He denied current suicidal or self harm ideation and he agreed to immediately tell staff if he starts to have suicidal or self harm thoughts. He was future oriented. He does not appear to be an immediate danger to self. He denied thoughts of hurting others and he agreed to tell staff if he has these thoughts. RISK AND PROTECTIVE FACTORS ASSESSED: This writer screened the inmate for a variety of empirically validated factors commonly associated with risk for self-harm and suicide. The following STATIC risk factors were assessed to be present and increase the inmate's risk for engaging in suicide related behaviors: High Profile Crime, Lack of family connections, Sex offender status The following DYNAMIC risk factors were assessed to be present and increase the inmate's risk for engaging in suicide related behaviors: Current physical pain. Sleep problems The following PROTECTIVE factors were assessed to be present and may decrease the inmate's risk of suicide:Able to identify reasons to live, Denial of suicidal ideation/intention/plans, Future orientation, Religious beliefs against suicide, Supportive family relationships. View of death as negative, Willingness to engage in treatment Risk Factors: He was found by staff in his cell in SHU on 7/23/19 with a string loosely tied around his neck, which Mr. Epstein stated he did not remember anything about. It is still unclear at this time if Mr. Epstein had placed the string around his own neck or if someone else did. He has a high profile sex offense case. He stated his lower back hurts and he stated Medical is aware of this. He stated he has difficulty sleeping even with his cpap machine because he stated his cellmate talks at night. Protective Factors: He denied current suicidal or self harm thoughts and agreed to tell staff if he starts to have these thoughts. He had denied a history of self harm and suicide attempts. He had denied a family history of suicidal and self harm attempts. He had denied having any chronic medical conditions. He denied leVPQrStIM. He had denied a history of childhood abuse. He denied fearing for his safety at this time. He denied MiNiwsigassiqg pigtails" He stated he lives for and plans to finish this case and to go back to his normal life. He said his friends and Lawyers are erhotionally supportive. He said he is Jewish and he said in his religion suicide is against the religion. (b)(6) : (b)(7)(A) ; (b)(7)(c) Overall, his current protective factors overatitlibignesIdetattatinforroatiOaMyl Priwataitently psychologically stable. He denied feeling hopeless. He is reporting positive future plans and reasons to live for. He said he has social supports in the community and his Lawyers visit him often. He denied any current suicidal or self harm ideation, intention or plan. Suicide Watch is not indicated at this time. DIAGNOSIS- No Diagnosis. No Dx - Current CONCLUSIONS The Overall Acute Suicide Risk for this Inmate is: Low Overall Chronic Suicide Risk for this Inmate is: Absent RECOMMENDATIONS 1. Suicide Watch is not indicated at this time. 2. Supportive and educative interventions were provided. 3. He was educated about both routine and emergency procedures for contacting Psychology staff. 4. He will be seen in follow up by Psychology next week to monitor his mental status and to provide further intervention if needed. 5. In the meantime, he was encouraged to self-refer to Psychology if needed to which he agreed and seems capable of doing. 6. If he remains in SHU. he will be seen by Psychology in SHU Rounds and in SHU Reviews. Suicide Watch: A suicide watch is not warranted at this time Generated 08/01/2019 16:21 by PsyD Bureau of Prisons - NYM Page 2 of 3 EFTA00073924 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Facilit : NYM Unit Team: 5 Date: 08/01/2019 13:29 Provider: PsyD Completed by PsyD on 08/01/2019 16:21 Page 094 of 148 Withheld pursuant to exemption (b)(6) (b)(7)(A): (b)(7)(C) of the Freedom of Information and Privacy Act Generated 08/01/2019 16:21 by PsyD Bureau of Prisons NYM Page 3 of 3 EFTA00073925 Bureau of Prisons -SENSITIVE BUT UNCLASSIFIED. * Psychology Services Clinical Intervention - Clinical Contact Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01.20/1953 Sex: M Facility: NYM Unit Team: 5 Date: 07/31/2019 10:35 Provider: BsyCi/DAPC Focus of Session Mr. EPSTEIN was seen today by this writer for a follow up appointment after he was removed from Psychological Observation yesterday. Subjective/Objective Presentation Mr. EPSTEIN presented in a pleasant mood and reported he is generally doing well. He stated, "I could be better." but acknowledged he is doing as well as can be expected given his circumstances. He reported he is going to court today for a status hearing. He stated he generally slept well last night and is readjusting to being placed back in SHU. He reported getting along well with his cell mate. He was informed of appropriate procedures for contacting Psychology staff while he is in SHU, if needed. Current Mental Status: Mr. EPSTEIN was alert and oriented, He was polite. calm, and cooperative in demeanor. He exhibited a neutral affect with appropriate range. Eye contact and hygiene were appropriate. He spoke with normal rate. tone, and volume. His thoughts were organized and coherent, with no loosening of associations or tangential, circumstantial, or irrelevant content. There was no evidence of perceptual disturbance. delusional ideation, or a formal thought disorder. He did not engage in any bizarre or inappropriate behavior. He noted having normal sleeping and eating habits. Mr. EPSTEIN explicitly denied recent and current suicidal ideation. planning, and intent. He was future- oriented and expressed a commitment to life and safety, agreeing to contact staff immediately should he experience suicidal ideation or psychological distress. He also denied tlpgfl89(liaQging others. Intervention(s) Withheld pursuant to exemption Supportive interventions and cognitive behavioral therapeutic techniques were utilized. Mr. EPSTEIN was receptive to all interventions. (b)(6); (b)(7)(A); (b)(7)(C) RtMeaSinan of the Freedom of Information and Privacy Act Mr. EPSTEIN was educated about both routine and emergency procedures for contacting psychology. There appears to be no need for follow-up at this time and he expressed willingness to self refer to psychology staff if needed. He will continue to be seen during routine SHU rounds and SHU reviews while he is housed in SHU. He was encouraged to reach out for PRN services should he experience any psychological distress. Completed by PsyD/DAPC on 07/31/2019 10:56 Generated 07/31/2019 10:56 by PsyD(DAPC Bureau of Prisons NYM Page 1 ol 1 EFTA00073926 Bureau of Prisons -SENSITIVE BUT UNCLASSIFIED- Psychology Services Clinical Intervention - Clinical Contact Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Facility: NYM Unit Team: 5 Date: 07130(2019 12:01 Provider: PsyD Focus of Session He was seen by writer while he was on Psych Observation. Subjective/Objective Presentation He stated he hasn't slept well at MCC-NY because he hasn't had his cpap machine. He stated it is here and he will be able to start using it tonight. He discussed how he does not think he will able to sleep in SHU and how he does not like SHU because of the noise. He discussed issues on not getting some medication with Medical today. The "Eating/Shower Chart" indicated yesterday he ate breakfast and dinner, drank liquids, and took a shower when offered and so far today it noted he ate breakfast and drank liquids. The Psych Observation Log noted he slept, drank water, went to legal, and talked to an Inmate Companion about investments. Current Mental Status: He exhibited a neutral mood with a full range of affect. His speech was logical and coherent, with no loosening of associations or tangential, circumstantial or irrelevant speech. Auditory and visual hallucinations were denied, and delusions were not elicited. He did not engage in any bizarre or inappropriate behavior. There was no indication of disturbed thought process or content. Intellectual ability appeared to be above average. Personal hygiene was adequate. He denied current suicidal or self harm ideation and he agreed to immediately tell staff if he starts to have suicidal or self harm thoughts. He was future oriented. He does not appear to be an immediate danger to self. He denied thoughts of hurting others and he agreed to tell stafffitalge 088 tifebit3thoughts. Intervention(s) Withheld pursuant to exemption Supportive and educative interventions were provided. When asked about the Turning Point handouts for coping in SHU, he stated he already knows these strategies beb)(13)blb)MAftie(bk70(gtts and had tried them when he was in SHU the last time. He stated with the noise in SHU, he said the strategies will not work. He was encouraged to try them. Progress/Plan of the Freedom of Information and Privacy Act The Chief Psychologist was consulted. Psych Observation will be discontinued. Mr. Epstein was educated about both routine and emergency procedures for contacting Psychology staff. He will be seen in follow up by Psychology tomorrow to monitor his mental status and to provide further intervention if needed and he was informed that he will be seen by Psychology tomorrow. In the meantime. he was encouraged to self-refer to Psychology if needed to which he agreed and seems capable of doing. If he remains in SHU, he will be seen by Psychology in SHU Rounds and in SHU Reviews. The SHU Lt. was informed that Mr. Epstein needs to be housed with an appropriate cellmate. Completed by PsyD on 07/30/2019 13:54 Generated 07)30,2019 13:54 by PsyD Bureau of Prisons NYM Page I of 1 EFTA00073927 Bureau of Prisons "SENSITIVE BUT UNCLASSIFIED- Psychology Services Institution Disciplinary Process Report Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01)2011953 Sex: M Facility: NYM Unit Team: 5 Date: 07/30/2019 12:01 Provider: PsyD Reason for Referral and Identifying Information Inmate Epstein was referred by Unit Manager for an evaluation of competency to proceed with the disciplinary process for actions resulting in an incident report. On 7/23/19, inmate Epstein was charged with code 228 (Tattooing or Self-Mutilation). These infractions were assigned incident report number 3282555. Background Information According to a Suicide Risk Assessment dated 7/09/19 by Dr. "Inmate Epstein denied any history of mental health treatment, either on an inpatient or outpatient basis. Inmate Epstein denied any treatment in the past or present with psychotropic medication. He also denied any acute mental health symptoms at this time." According to a Suicide Risk Assessment dated 7/09/19 by Dr. "Inmate Epstein denied any past or present suicidal ideation. intention or plan. He denied ever engaging in any suicide attempts or self-injurious behavior in the past." According to this writer's Suicide Risk Assessment dated 7/23/19, "It is unclear at this time if he had placed the string around his neck or if someone else did." Clinical Interview and Mental Status Exam Inmate Epstein still does not remember how he obtained the marks around his neck. Page 097 of 148 Current Mental Status: He exhibited a neutral momitAigii4. ,tsfitrii. Rprot egg b speech was logical and coherent, with l no loosening of associations or tangential. circumstantial irrelevant speec . uditory and visual hallucinations were denied, and delusions were not elicited. He did not eibogp terx,1041.ErypqMappropriate behavior. There was no indication of disturbed thought process or content. Intellectual ability appeared to be above average. Personal hygiene was adequate. He denied current suicditer&Sdamrofdatatalatiod bedierigactytAtrinmediately tell staff if he starts to have suicidal or self harm thoughts. He was future oriented. He does not appear to be an immediate danger to self. He denied thoughts of hurting others and he agreed to tell staff if he has these thoughts. Clinical Impression According to his last Diagnostic and Care Level Formulation Note dated 7/09/19 by Dr. "No Diagnosis, No Dx - Current." Findings The determination of whether an inmate is competent to proceed with the disciplinary process is based on a clinical assessment of the inmate's (1) ability to understand the nature of the proceedings, and (2) their ability to assist in their own defense. Depending on the outcome of the assessment. one of three findings can be made: (1) the inmate is COMPETENT to proceed with the disciplinary process: (2) the inmate is NOT PRESENTLY COMPETENT but could be restored to competence with treatment: or (3) the inmate is NOT COMPETENT and is unlikely to become competent. Recommendations Regarding Sanctions In the case of inmate Epstein. after a review of available psychological and psychiatric records as well as information pertaining to the offense conduct, it is determined that this inmate is: (X) COMPETENT to proceed with the disciplinary process. ( ) NOT PRESENTLY COMPETENT, but could become competent with treatment; it is recommended that the inmate for an updated competency assessment in 30 days. ( ) NOT COMPETENT and not likely to become competent. Generated 07130/2019 12:33 by PsyD Bureau of Prisons NYM Page 1 of 2 EFTA00073928 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Facility: NYM Unit Team: 5 Date: 07/30/2019 12:01 Provider: Imeri, Darlene PsyD Completed by PsyD on 07/30/2019 12:33 Page 098 of 148 Withheld pursuant to exemption (b)(6) (b)(7)(A): (b)(7)(C) of the Freedom of Information and Privacy Act Generated 07/30,2019 12:33 by PsyD Bureau of Prisons NYM Page 2 of 2 EFTA00073929 Bureau of Prisons **SENSITIVE BUT UNCLASSIFIED** Psychology Services General Administrative Note Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Facility: NYM Unit Team: 5 Date: 07/30/2019 12:01 Provider: PsyD Comments Psych Observation Discontinuation Note: Please see "Clinical Contact" dated today. Completed by PsyD on 07/30/2019 12:33 Page 099 of 148 Withheld pursuant to exemption (b)(6) ; (b)(7)(A) ; (b)(7)(C) of the Freedom of Information and Privacy Act Generated 07/30/2019 12:33 by PsyD Bureau of Prisons - NYM Page 1 of 1 EFTA00073930 Bureau of Prisons -SENSITIVE BUT UNCLASSIFIED" Psychology Services Clinical Intervention - Clinical Contact Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01)201953 Sex: M Facility: NYM Unit Team: 5 Date: 07129/2019 10:01 Provider: PhD/Chief Focus of Session Inmate Epstein was seen while on psychological observation today in the hospital area. Subjective/Objective Presentation Same presentation today, but he said he thinks his memory for the incident (injury to his neck) may be impaired because of his sleep apnea. He is supposed to get his CPAP machine today. He is aware he will be returning to SHU, but said he is feeling unwell due to his inability to sleep and numbness in his arm. He requested to have one good night of sleep with his CPAP and will return to SHU with a cellmate tomorrow. He then asked if he could remain down here where it is "safe" for the entire week. I told him he can stay down one more night to receive his CPAP and a good night's sleep, but that he would be returned to SHU tomorrow. It was explained that there is no mental health issues precluding him from returning to SHU tomorrow and that we could not house him in the SW/Hospital area because he felt safe or more comfortable for him. It was explained to him that he would be placed in a safe situation in the SHU. According to his log book and eating/shower chart, he has been eating and drinking when not in his legal visits. He has also been writing and attending his legal visits. Intervention(s) Inmate EPSTEIN was provided with brief supportive interventions and psychoeducation regarding additional coping strategies. Inmate EPSTEIN was somewhat receptive to thvg isitmeoritipas, but appears more concerned about getting his various needs in the prison (phone calls. recreation. housir% placeme-a concerns. etc.) Progress/Plan Withheld pursuant to exemption He will remain on psychological observation today a9g l.tiNiligc.t.R.,1 4U tomorrow. He will be seen by psychology daily to assess his mental status and pskliblb§afttnefia. of the Freedom of Information and Privacy Act Completed by PhD/Chief Psychologist on 07/29/2019 10:26 Generated 07)29,2019 10:26 by Phathiel Bureau of Prisons NYM Page 1 of 1 EFTA00073931 Bureau of Prisons -SENSITIVE BUT UNCLASSIFIED" Psychology Services Clinical Intervention - Clinical Contact Inmate Name: EPSTEIN. JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01)201953 Sex: M Facility: NYM Unit Team: 5 Date: 07/28/2019 08:33 Provider: PsyD Focus of Session He was seen by writer while he was on Psych Observation. Subjective/Objective PresentaisIn The "Eating/Shower Chart" noted that yesterday he ate breakfast. He is not in the Psych Observation cell for about 12 hours per day because of being in Attorney Conference with his Attorneys, so the "Eating/Shower Chart" may not reflect all of his meals. He stated he was served one meal in Attorney Conference yesterday. He stated he drinks a lot water at night. The Psych Observation log noted he talked about life in general population and he slept. Earlier he had complained that his right arm was numb and hanging. Nurse from Medical had seen him for this. When this writer was interviewing him, he said his right arm still feels somewhat numb and he said he cannot make a fist with that hand. He also said he has numbness on his neck. This writer notified Nurse He stated last night when he flushed the toilet it kept flushing for 45 minutes. He stated he found it so aversive and upsetting that he said he sat in the corner and held his ears. He said because of this he was agitated for hours and was not able to sleep. The Lt. will be moving him to a different cell and he was informed of this. He stated the feeling he got with the noise of the toilet was similar to when he was in SHtitgelikEtaid thigrmay have something on the Autism spectrum. He said in the movie "Rain Man," the person with Autism had an aversion to noise. He stated he is also really good with numbers. Withheld pursuant to exemption Current Mental Status: He exhibited a mildly anxious(Pai MPS! affect. His speech was logical and coherent, with no loosening of associa4irinehtgaiAttAli fikiffifinaw rica speech. Auditory and visual hallucinations were denied. and delusions were not elicited. He did not engage in any bizarre or inappropriate behavior. He denied current suicidal or self harm ideation and he agreed to immediately tell staff and Inmate Companions if he starts to have suicidal or self harm thoughts. He was future oriented. He does not appear to be an immediate danger to self. He denied thoughts of hurting others and he agreed to tell staff and Inmate Companions if he has these thoughts. Interventions) Supportive and educative interventions were again provided. He had not been given the Turning Point handouts yesterday that were on his cell door, so they were handed to him by staff today. Progress/Plan He will remain on Psych Observation in an abundance of caution and pending housing arrangements to be made on Monday. While on Psych Observation, he will be seen daily by Psychology. Completed by PsyD on 07/28/2019 09:24 Generated 07/28,2019 09:24 by PsyD Bureau of Prisons NYM Page 1 ol 1 EFTA00073932 Bureau of Prisons -SENSITIVE BUT UNCLASSIFIED- Psychology Services Clinical Intervention - Clinical Contact Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/201953 Sex: M Facility: NYM Unit Team: 5 Date: 07;27/2019 07:14 Provider: PsyD Focus of Session He was seen by writer while he was on Psych Observation. Subjective/Objective Presentation The "Eating/Shower Chart" indicated yesterday he ate dinner, drank liquids, and took a shower when offered. The Psych Observation Log noted he brushed his teeth, went to a Legal visit, talked about business and investing to an Inmate Companion, ate. and slept. When interviewed, he stated he still cannot remember what happened in SHU that caused the marks on his neck. He stated that for the 5 days before that he had only slept about 30 minutes each night because of noise in SHU. He stated he is anxious about going back to SHU because he stated he is going back to a place where he had gotten marks on his neck and he does not know why it happened. He said he has an appetite and is eating. He said he is waking up every 1 1/2 hours. He stated he feels dehydrated because he is not drinking enough water because he stated he feels he is not given enough bathroom breaks while with his Attorney. Medical was e-mailed with his complaint of feeling dehydrated. He said his Lawyers and friends are all emotionally supportive. Current Mental Status: He exhibited a neutral mood with a fFillgenljtaaffIllect. His speech was logical and coherent, with no loosening of associations or tangential, circumstantial or irrelevant speech. Auditory and visual hallucinations were denied, and delusions were not elicited. He did nWIntIgh€14f§tiA9ttifiRrettnaRiffieppropriate behavior. He denied current suicidal or self harm ideation. He stated "I'm a cowaWl'attqa hviimirckot like pain and even does not like when he has to give blood. He agreed to immediately tell VAtflar1difeuV)ale t'65iVriions if he starts to have suicidal or self harm thoughts. He was future orientedoillfiediermatnaeiRmrpAWilrimiglanger to self. He denied thoughts of hurting others and he agreed to tell staff and Inmate Companions if he has these thoughts. Intervention(s) Supportive and educative interventions were provided. Turning Points handouts on stress management, sleep, and building a routine in SHU were placed on his cell door to be given to him when his food slot is opened. He stated he wants it noted in his chart that he is being given a pamphlet on sleep, but that is not going to help because of the noise in SHU that prevents him from sleeping. Progress/Plan He will remain on Psych Observation in an abundance of caution and pending housing arrangements to be made on Monday. While on Psych Observation, he will be seen daily by Psychology. Completed by PsyD on 07/28/2019 09:19 Generated 07/28,2019 09:19 by PsyD Bureau of Prisons NYM Page 1 of 1 EFTA00073933 Bureau of Prisons **SENSITIVE BUT UNCLASSIFIED** Psychology Services Clinical Intervention - Clinical Contact Inmate Name EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Facility: NYM Unit Team: 5 Date: 07127/2019 07:14 Provider: PsyD Focus of Session He was seen by writer while he was on Psych Observation. Subjective/Objective Presentation The "Eating/Shower Chart" indicated yesterday he ate dinner, drank liquids, and took a shower when offered. The Psych Observation Log noted he brushed his teeth, went to a Legal visit, talked about business and investing to an Inmate Companion, ate. an When interviewed, he st II cannot remember what happened in SHU that caused the marks on his neck. He stated that for the 5 days b e had only slept about 30 minutes each night because of noise in SHU. He stated he is anxious about going bac because he stated he is going back to a place where he had gotten marks on his neck and he does not know why He said he has an appetite and is eati Heidsa is waking up every 1 1/2 hours. He stated he feels dehydrated because he is not drinking enough water bec tated he feels he is not given enough bathroom breaks while with his Attorney. Medical was e-mailed with his t •f feeling dehydrated. He said his Lawyers and friends are all emotionally supportive. Current Mental Status: He exhibited a neutral mood 1O8Parn§t6of affect. His speech was logical and coherent, with no loosening of associations or tangential ial or irrelevant speech. Auditory and visual hallucinations were denied, and delusions were fr4e4heifb WicYliffin any bizarre or inappropriate behavior. He denied current suicidal or self harm ideation. He Mg -Ip added he does not like pain and even does not like when he has to give blood. IIe agreed:1'6nm al"and Inmate Companions if he starts to have suicidal or self harm thoughts. Htflik fygeop,sigpiAriA be an immediate danger to self. He denied thoughts of hurting others and he agreed to tell staff and Inmat= 0 1Qns if he has these thoughts. Intervention(s) Supportive and educative interventions were provided. He was given Turnin douts on stress management, sleep, and building a routine in SHU. He stated he wants it noted in his chart th given a pamphlet on sleep, but that is not going to help because of the noise in SHU that prevents him f rung Progress/Plan He will remain on Psych Observation in an abundance of caution and pending housing arr be made on Monday. While on Psych Observation, he will be seen daily by Psychology. Completed by PsyD on 07/27/2019 08:16 Generated 07/27/2019 08:16 by PsyD Bureau of Prisons NYM Page 1 of 1 EFTA00073934 Bureau of Prisons -SENSITIVE BUT UNCLASSIFIED- Psychology Services Clinical Intervention - Clinical Contact Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01)2011953 Sex: M Facility: NYM Unit Team: 5 Date: 07/27/2019 07:14 Provider: PsyD Focus of Session He was seen by writer while he was on Psych Observation. Subjective/Objective Presentatism The "Eating/Shower Chart" indicated yesterday he ate dinner, drank liquids, and took a shower when offered. The Psych Observation Log noted he brushed his teeth, went to a Legal visit, talked about business and investing to an Inmate Companion, ate. an When interviewed, he st II cannot remember what happened in SHU that caused the marks on his neck. He stated that for the 5 days b e had only slept about 30 minutes each night because of noise in SHU. He stated he is anxious about going bac because he stated he is going back to a place where he had gotten marks on his neck and he does not know why He said he has an appetite and is eatiNr Heidsa is waking up every 1 1/2 hours. He stated he feels dehydrated because he is not drinking enough water bec tated he feels he is not given enough bathroom breaks while with his Attorney. Medical was e-mailed with his t •f feeling dehydrated. He said his Lawyers and friends are all emotionally supportive. Current Mental Status: He exhibited a neutral mood tellninpt8of affect. His speech was logical and coherent, with no loosening of associations or tangential ial or irrelevant speech. Auditory and visual hallucinations were denied, and delusions were PIMA WiliYilffin any bizarre or inappropriate behavior. He denied current suicidal or self harm ideation. He atopi -ce added he does not like pain and even does not like when he has to give blood. IIe agreedterm a and Inmate Companions if he starts to have suicidal or self harm thoughts. Fit* #448o siviA%rci be an immediate danger to self. He denied thoughts of hurting others and he agreed to tell staff and Inmat s if he has these thoughts. Intervention(s) Supportive and educative interventions were provided. He was given Turnin douts on stress management, sleep, and building a routine in SHU. He stated he wants it noted in his chart th given a pamphlet on sleep, but that is not going to help because of the noise in SHU that prevents him f ring Progress/Plan He will remain on Psych Observation in an abundance of caution and pending housing arr be made on Monday. While on Psych Observation, he will be seen daily by Psychology. Completed by PsyD on 07/27/2019 08:16 Generated 07/27;2019 08:16 by PsyD Bureau of Prisons NYM Page 1 of 1 EFTA00073935 Bureau of Prisons Health Services See Amendment Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Encounter Date: 07/27/2019 07:14 Facility: NYM Amendment made to this note by PsyD on 07/28/2019 09:19. Page 105 of 148 Withheld pursuant to exemption (b)(6) (b)(7)(A) ; (b)(7)(C) of the Freedom of Information and Privacy Act Bureau of Prisons - NYM EFTA00073936 Bureau of PriSonS -SENSITIVE BUT UNCLASSIFIED** Psychology Services Clinical Intervention - Clinical Contact Inmate Name: EPSTEIN. JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/201953 Sex: M Facility: NYM Unit Team: 5 Date: 07/26/2019 09:09 Provider: PhD/Chief Focus of Session Inmate Epstein was seen while on psychological observation in our hospital area. Subjective/Objective Presentation Prior to this writer's contact with him, Inmate Epstein showered and dressed himself for his legal visit today. He was smiling and did crack some jokes during the interview. He did elucidate some complaints and suggested being disappointed with this writer as he wants "to trust me and for me to trust him." He stated he remains unhappy with legal visiting procedures as he cannot go to the bathroom as frequently as he would like to since he has a "weak bladder." Inmate Epstein also reported since coming to the psychological observation area, he has felt constipated and needs his Colace. He had self-carry Colace in SHU, but since coming to the observation area, he has not had his medication. This writer immediately notified medical and his pills were being processed during the interview. Inmate Epstein also continues to complain about the conditions of SHU confinement (i.e.. feeling punished. smells. noise, and restrictions). With regard to the events which lead to his initial placement on suicide watch, inmate Epstein stated he has no memory of the event. He asked to speak with his old cellmate "Nick" to see if he can tell him what happened or see if his memory could be triggered. He remarked. 1 am still trying to figure out how I got this (pointing to the scab around his neck)." Inmate Epstein denies remembering harming himself and/or being harmed by his cellmate. He does not exhibit symptoms of any cognitive disorder, seizure disorder, psychotic disorder, or dissociative disorder at this time or in the past. Inmate Epstein denied any current suicidal ideation, irltigtiot0toplt48 He reported wanting to be alive to fight his legal case and go back and live life. He referred to himself as "a coward" and "I'm Jewish." He said he is not the type who likes pain or would ever attempt to harm hirrWO.held pursuant to exemption While on psychological observation, inmate Epstein (PanleA)67dilkAPAPh9s. sleeping and interacting with the inmate companions. He is in legal visiting the aiiifil itya8,9, yhyrtiewridsgrycgpightAVog book and eating/shower chart reflect the same. He has been speaking to inmate companions about investment strategies and about prison adjustment. Correctional Staff report during his legal visits. he is interacting with his attorney, animated. laughing. and joking. interventioks) Inmate Epstein was provided with supportive and coping skills interventions today. He was receptive to them, but mostly wanted to express his complaints about his current prison confinement status and needs. He wanted this writer to address them. Progress/Plan Inmate Epstein will remain on psychological observation in an abundance of caution and pending housing arrangements to be made on Monday. He continues to be vague and reports memory deficits regarding the events which lead to a piece of sheet being placed loosely around his neck and marks with scabs around his neck. Completed by PhD/Chief Psychologist on 07/26/2019 10:05 Generated 07/26;2019 10:05 by PhD/Chief Bureau of Prisons NYM Page 1 of 1 EFTA00073937 Bureau of Prisons -SENSITIVE BUT UNCLASSIFIED- Psychology Services Clinical Intervention - Clinical Contact Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01)2011953 Sex: M Facility: NYM Unit Team: 5 Date: 07/25/2019 10:14 Provider: PhD/Chief Focus of Session Inmate Epstein was seen by this writer this morning while on psychological observation in the hospital area of the prison. Subjective/Objective Presentation Inmate Epstein was in good spirits today and engaged in reciprocal conversation with this writer this morning. He smiled and remarked. "welcome back" when this writer arrived. He continues to assert he does not remember how he received marks around his neck, remarking "I do not remember anything, maybe you can give me some cues." He stated he just remembers going for a drink of water and the next thing he knew he woke up to the sound of his own snoring. When this writer attempted to get a more detailed account from him, indicating that it would be rare to have such impairments in memory as he does not suffer from an acute cognitive disorder, he smiled and said he understood my position. Inmate Epstein did reveal he is unhappy with his current confinement in Special Housing (SHU) as he considers it "a punishment cell." He said he finds the restrictions up there unfair as he has not done anything wrong. Inmate Epstein stated he feels it is dangerous in the SHU, he cannot sleep well up there due to noise from the other inmates, it smells, and it is difficult for him to work on his legal case up there. He stated he has not received the phone calls he was promised nor has he been able to receive recreation. It was explained to him that he spends the entire day in the attorney conference room and it is likely that he has missedpl tingsdelme staff members have attempted to give him phone calls and recreation. Inmate Epstein also reported complaints about the attorney conference room, stating they do not take him to the bathroom frequently enoupithheld pursuant to exemption Inmate Epstein adamantly denied any suicidality at tAMPOri4,bailet) '1Wlevested in my case to fight it, I have a life and I want to go back to living my life."46i gt.%egjAyoiiig rusogogki ttrgUpwa. According to his log book, he has been eating, drinking, sleeping, and interacting with the inmate companions. He has also been attending his daily legal visits. Intervention(s) Inmate EPSTEIN was provided with brief supportive interventions and psychoeducation regarding additional coping strategies. Inmate EPSTEIN was mostly receptive to these interventions. He requested to be housed in general population rather than the SHU and stated he wanted to remain on psychological observation due to his concerns with being in the SHU. Progress/Plan In an abundance of caution, inmate Epstein will remain on psychological observation. He has yet to give an account of how he sustained the marks around his neck, is not revealing much about his mental status. and there are concerns about his adjustment at this time to being housed in the SHU. Inmate Epstein will be seen daily by psychology while on psychological observation. Completed by PhD/Chief Psychologist on 07/25/2019 10:43 Generated 07;25,2019 10:43 by PhDiChiel Bureau of Prisons NYM Page 1 of 1 EFTA00073938 Bureau of Prisons "SENSITIVE BUT UNCLASSIFIED— Psychology Services Post Suicide Watch Report Inmate Name: EPSTEIN, JEFFREY EDWARD Reg It: 76318-054 Date of Birth: 01/20/1953 Sex: M Facility: NYM Unit Team: 5 Date: 07/24/2019 09:23 Provider: Ph.D. Watch Start Date: 07)23/2019 01:40 Watch Stop Date: 07'24,2019 08:45 Total Time on Watch: 31 hrs 5 minutes Watch Conducted By: Both inmates and staff Transfered to Medical Center: No Current Mental Status Level of Consciousness: Alert and Oriented Psychomotor Activity: Normal General Appearance: Normal Behavior: Cooperative Mood: Appropriate to Content Thought Process: Goal Directed Thought Content: Normal Current Mental Status: Mr. EPSTEIN was alert and oriented. He was polite, calm. and cooperative in demeanor. He exhibited a neutral affect with appropriate range. Eye contact and hygiene were appropriate. The inmate spoke with normal rate, tone, and volume. His thoughts were organized and coherent, with no loosening of associations or tangential, circumstantial, or irrelevant content. There was no evidence of perceptual disturbance, delusional ideation, or a formal thought disorder. He did not engage in any bizarre or inappropriate behavior. He noted pagifigggiotiaoleeping and eating habits. Mr. EPSTEIN explicitly denied recent and current suicidal ideation. planning, and intent. He was future-oriented and expressed a commitment to life and safety. agreeing to contact stWiffhnftOttlarEOPIOniclnefOl4k95brience suicidal ideation or psychological distress. He also denied thoughts of harming others. (b)(6) ; (b)(7)(A); (b)(7)(C) Risk Factors Assessed- This writer screened the inmate for a variety0efrfrfifItititgiaeteteffiefee0erthowikstsociated with risk for self harm. The following STATIC risk factors were assessed to be present and increase the inmate's risk for engaging in suicide related behaviors: High Profile Crime. Lack of family connections, Sex offender status The following DYNAMIC risk factors were assessed to be present and increase the inmate's risk for engaging in suicide related behaviors: Current physical pain. Fear for own safety The following PROTECTIVE factors were assessed to be present and may decrease the inmate's risk of suicide:Able to identify reasons to live, Adequate problem solving skills, Denial of suicidal ideation/intention/plans, Future orientation, View of death as negative, Willingness to engage in treatment Risk Factors: Mr. EPSTEIN has a significant scar around his neck. which is now scabbing over. He reported swelling in this area but denied experiencing any related pain. Mr. EPSTEIN continues to claim a lack of memory for the incident resulting in this scar. The story he provided was vague, such that this writer challenged him a couple of times, but he insisted he was being honest about his lapse in memory. The nature of the incident remain unclear. Mr. EPSTEIN is incarcerated for a very high profile crime with media attention. He was recently denied bail. He also reported difficulty managing his time in the SHU. He reported being fearful for his safety if he is to return to the cell with his previous cell mate. Protective Factors: Mr. EPSTEIN adamantly denied current suicidal ideation or intent or a history of suicide attempts. He stated, "I have no interest in killing myself." He explained. although his situation is "not perfect" due to his being incarcerated. he noted he has "lots to do for [his] legal case." He described having a "wonderful life," to include interactions with "interesting people and projects." He said "it would be crazy" to take his life. He furthered. "I would not do that to myself: He denied feelings of hopelessness, although did report being "depressed" and "unhappy" about his current legal situation. He previously denied a history of childhood abuse. He reported he is sleeping adequately now that he is no longer in the SHU. He appear future-oriented as he endorsed an interest in being housed in general population. Weighing of Risk and Protective Factors: Mr. EPSTEIN adamantly denied sucidality. However, in light of his vague self-report regarding the incident which precipitated his placement on Suicide Watch, combined with his fear for his own safety, reported Generated 07124/2019 12:09 by Ph.D. Bureau of Prisons NA/ Page 1 of 3 EFTA00073939 Inmate Name: EPSTEIN. JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Facility: NYM Unit Team: 5 Date: 07/24/2019 09:23 Provider: Ph.D. difficulty managing his time in the SHU. and the high profile nature of his alleged offense. Mr. EPSTEIN will be stepped down from Suicide Watch to Psychological Observation. Changes in Risk Factors Assessed Upon a review of the log book, it was indicated Mr. EPSTEIN has been speaking to the inmate companions about having previously taught mathematics and physics. He has been observed pacing the cell as well as sleeping. eating. and drinking within normal limits. Upon interview today. Mr. EPSTEIN requested he be provided a toothbrush as well as a shower. His requests were made known to the lieutenants and he was provided a shower prior to attending his legal visit. This writer also provided him a toothbrush, toothpaste, and hygiene products. Asked about the alleged incident which transpired yesterday resulting in his placement on Suicide Watch. Mr. EPSTEIN said he is frustrated he has been placed in a "punishment cell for no reason." Specifically, Mr. EPSTEIN was referring to his placement in the SHU. Asked to recall the events surrounding the alleged incident. Mr. EPSTEIN said his cell mate was "playing with a bed sheet" and he claimed he does not recall the events thereafter. He said he recalled eating meat and drinking water and claimed the next event for which he has memory is his hearing himself snore and waking up on a stretcher. Mr. EPSTEIN claimed he does not recall himself or his cell mate tying a string or rope around his neck. He said he has "been trying to remember" and "wracking his mind." Asked if he experienced any interpersonal issues with his cell mate. Mr. EPSTEIN described his cell mate as "agitated" and claimed his cell mate called him a "pedophile" for the first time yesterday. His cell mate was also reportedly reading a newspaper article about Mr. EPSTEIN, which bothered him and it was something he believed to be "strange" for their to lignonout him in his cell. Mr. EPSTEIN recalled throwing away the newspaper photograph of himself by trump i it and flushing it down the toilet. Asked if his cell mate ever threatened to harm him, he denied this Withfiekercum antiiptaton told the inmate companions yesterday his cell mate tried to kill him, while also claiming no memory of the incident, Mr. EPSTEIN again said he did not recall the incident and further stated. "I don't know if he put Iteifilecito(a)AelbX4)(EPSTEIN explained he had been experiencing difficulty sleeping in his SHU cell due to his inmate peers banging on the cell door and window, but has not been experiencing any other acute issu4 81SirrciORWIf. Information and Privacy Act Reason for Removal from Watch Mr. EPSTEIN stated, "I have no interest in killing myself." He explained although his situation is "not perfect" due to his being incarcerated, he noted he has "lots to do for ihisl legal case." He described having a "wonderful life," to include interactions with "interesting people and projects." He said "it would be crazy" to take his life. He furthered. "I would not do that to myself." Mr. EPSTEIN did express a feeling of safety being housed on Psychological Observation rather than in the SHU. He asked if he could remain on this status for a couple of days. he was advised his housing situation will be re-evaluated on a day-to-day basis. He expressed a desire to be housed in general population rather than in the SHU and asked if there were a "safer" unit for him to be housed in comparison to the one where he was initially placed. Mr. EPSTEIN claimed there were many MS-13 gang members on the initial unit. He was advised he will be maintained on Psychological Observation in the near future, but his long-term housing situation will be revisited. as it is not ideal for one to remain in isolation on Psychological Observation for extended periods of time. Mr. EPSTEIN acknowledged this information and thanked this writer for her explanation and time. Diagnosis: No Diagnosis, No Dx - Current Conclusions The Overall Acute Suicide Risk for this Inmate is: Low Overall Chronic Suicide Risk for this Inmate is: Absent Recommendations 1. Mr. EPSTEIN will be removed from Suicide Watch and stepped down to Psychological Observation. 2. While on Psychological Observation, he will be continuously observed by Inmate Companions. 3. While on Psychological Observation. he will be seen daily by Psychology. 4. Supportive and educative interventions were provided. 5. Mr. EPSTEIN was provided novels and a request was made for his legal paperwork to be provided to him on Psychological Generated 07124/2019 12:09 by Ph.D. Bureau of Prisons Page 2 of 3 EFTA00073940 Inmate Name: EPSTEIN. JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Facility: NYM Unit Team: 5 Date: 07/24/2019 09:23 Provider: Ph.D. Observation. 6. This writer contacted the Pharmacy to indicate Mr. EPSTEIN has not been receiving his medication used to alleviate his constipation. 7. Mr. EPSTEIN attended a legal visit today. after having been provided a shower. 8. Mr. EPSTEIN was educated about both routine and emergency procedures for contacting psychology. 9. The inmate was encouraged to reach out for PRN services should he experience any psychological distress. Completed by Ph.D. on 07/24/2019 12:09 Page 110 of 148 Withheld pursuant to exemption (b)(6) (b)(7)(A) ; (b)(7)(C) of the Freedom of Information and Privacy Act Generated 07/24/2019 12:09 by Ph.D. Bureau of Prisons NYM Page 3 of 3 EFTA00073941 Bureau of Prisons "SENSITIVE BUT UNCLASSIFIED'. Psychology Services Suicide Risk Assessment Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Facilit : NYM Unit Team: 5 Date: 07/23/2019 10:09 Provider: PsyD Type of Housing: SHU- Administrative Segregation Cell Accommodation: Double-Cell FINDINGS This assessment and the resulting recommendations are based on the following sources of information: Clinical Interview. Medical Record. Psychology Data System, Sentry EteassaLtQLEtetertal The On Call Psychologist. Dr. had been contacted by the Operations Lt. at about 2 AM on 7/23/19 to inform her that Mr. Epstein was being placed on Suicide Watch because he was found with a string around his neck. Mr. Epstein was seen by this writer for a Suicide Risk Assessment at about 9:10 AM on 7/23/19. This note is being entered at about 3:35 PM on 7/23/19. Mental Health History According to a Suicide Risk Assessment dated 7/09/19 by Dr. "Inmate Epstein denied any history of mental health treatment, either on an inpatient or outpatient basis. Inmate Epstein denied any treatment in the past or present with psychotropic medication. He also denied any acute mental health symptoms at this time." Self-Harm History Page 111 of 148 According to a Suicide Risk Assessment dated 7/09/19 by Dr. vii. , "Inmate Epstein denied any past or present suicidal ideation, intention or plan. He denied ev*VinicA frY8Smpts or self-injurious behavior in the past." (b)(6) ; (b)(7)(A) ; (b)(7)(C) Substance Abuse History According to a Suicide Risk Assessm6gtttitkre tiA9691(401547.10ffirrihF4tAceOthin denied any alcohol or substance abuse. He said it is well-known that he does not even drink alcohol." Current Problem Earlier this morning Mr. Epstein was found by SHU staff in his cell with a string loosely tied around his neck. It is unclear at this time if Mr. Epstein had placed the string around his own neck. When Mr. Epstein was asked by this writer how he ended up on Suicide Watch, he denied remembering. He stated he got a drink of water last night in his cell and went back to bed. He said the next thing he remembered is hearing himself snore. He said he wants to know why he is on Suicide Watch. He was informed that staff stated he was found in his cell with a string on his neck. According to Medical records, he had been seen by Medical for this and had a rule out of self inflicted injuries. When this writer reviewed the Staff Suicide Watch Log. it noted that Mr. Epstein told the staff watching him that his cellmate tried to kill him. which Mr. Epstein did not tell this writer when this writer had interviewed Mr. Epstein. This writer was not able to ask Mr. Epstein about this. since Mr. Epstein was now in Legal. The Captain was notified about this notation and the Captain stated they were already aware of this statement. CstrientMental Status Level of Consciousness: Alert and Oriented Psychomotor Activity: Normal General Appearance: Normal Behavior: Cooperative Mood: Appropriate to Content Generated 07/23/2019 15:38 by PsyD Bureau of Prisons NYM Page 1 of 3 EFTA00073942 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Facilit : NYM Unit Team: 5 Date: 07/23/2019 10:09 Provider: PsyD Thought Process: Goal Directed Thought Content: Normal Current Mental Status: He exhibited a neutral mood with a full range of affect. His speech was logical and coherent, with no loosening of associations or tangential. circumstantial or irrelevant speech. Auditory and visual hallucinations were denied. and delusions were not elicited. He did not engage in any bizarre or inappropriate behavior. He denied current suicidal or self harm ideation and he agreed to immediately tell staff if he starts to have suicidal or self harm thoughts. He was future oriented. He does not appear to be an immediate danger to self. He denied thoughts of hurting others and he agreed to tell staff if he has these thoughts. RISK AND PROTECTIVE FACTORS ASSESSED: This writer screened the inmate for a variety of empirically validated factors commonly associated with risk for self-harm and suicide. The following STATIC risk factors were assessed to be present and increase the inmate's risk for engaging in suicide related behaviors: High Profile Crime, Lack of family connections. Sex offender status The following DYNAMIC risk factors were assessed to be present and increase the inmate's risk for engaging in suicide related behaviors: Current physical pain The following PROTECTIVE factors were assessed to be present and may decrease the inmate's risk of suicide:Able to identify reasons to live. Adequate problem solving skills. Denial of suicidal ideation/intention/plans, Future orientation, View of death as negative. Willingness to engage in treatment Risk Factors: He was found by staff in his cell in SHU with a string loosely tied around his neck, which Mr. Epstein stated he did not remember anything about. It is unclear at this time if Mr. Epstein had placed the string around his own neck or if someone else did. According to Medical, he had a circular line around the base of his neck, which he denied knowing how he obtained. He stated his throat hurts which was reported to Medical. He 1PaligS tlibWrlili% sex offense case and recently was denied bail. When asked if he has any friends or family that are motionallv sKortive. he stated he does not know what that means. When nneio DUES nt to exemption emotional supports were explained to him and then again asked e as any tamiiy or friends that are emotionally supportive. he was vague and said he has a lot of people. (b)(6): (b)(7)(A); (b)(7)(C) Protective Factors: He denied current suiciblbefealtIbirof eadiRntreimAkiese thoughts. He denied a history of self harm and suicide attempts. He denied a family history of suicidal and self harm attempts. He denied having any chronic medical conditions. He denied feeling hopeless. He denied a history of childhood abuse. He denied fearing for his safety. He denied feeling like a burden to anyone. He reported he is sleeping adequately. He stated he lives to have fun, to enjoy life, and to learn. He said his future plans include fighting his case and going back to his normal life. Whereas, he is denying suicidal and self harm thoughts and has a lot of protective factors, he is denying that he remembers how he ended up on Suicide Watch and has marks encircling his neck. It is unclear at this time if he had placed the string around his neck or if someone else did. He will remain on Suicide Watch for further observation and safekeeping. DIAGNOSIS: No Diagnosis, No Dx - Current CONCLUSIONS The Overall Acute Suicide Risk for this Inmate is: Moderate Overall Chronic Suicide Risk for this Inmate is: Absent RECOMMENDATIONS 1. Mr. Epstein will remain on Suicide Watch for further observation and safekeeping. 2. While on Suicide Watch, he will be continuously observed by Inmate Companions. 3. While on Suicide Watch, he will be seen daily by Psychology. 4. Supportive and educative interventions were provided. 5. Medical was informed that he reported his throat hurts. Suicide Watch: A suicide watch was initiated by non-clinical staff and continues to be warranted Suicide Watch was initiated on: 07/23/2019 01:40 Generated 07/23/2019 15:38 by PsyD Bureau of Prisons NYM Page 2 of 3 EFTA00073943 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Facilit : NYM Unit Team: 5 Date: 07/23/2019 10:09 Provider: PsyD Completed by PsyD on 07/23/2019 15:38 Page 113 of 148 Withheld pursuant to exemption (b)(6) ; (b)(7)(A); (b)(7)(C) of the Freedom of Information and Privacy Act Generated 07/23/2019 15:38 by PsyD Bureau of Prisons NYM Page 3 of 3 EFTA00073944 Bureau of Prisons - SENSITIVE BUT UNCLASSIFIED** Psychology Services General Administrative Note Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01;20,1953 Sex: M Facility: NYM Unit Team: 5 Date: 07;23/2019 07:56 Provider: PhD/Chief Comments This On-Call Psychologist was contacted by the Operations Lt. at about 2 AM on 7/23/19 to inform Mr. Epstein was being placed on Suicide Watch because he was found with a string loosely hanging around his neck. Mr. Epstein will be seen today by the duty psychologist for a Suicide Risk Assessment. Completed by PhD/Chief Psychologist on 07/24/2019 07:59 Page 114 of 148 Withheld pursuant to exemption (b)(6); (b)(7)(A): (b)(7)(C) of the Freedom of Information and Privacy Act Generated 07/24/2019 07:59 by PhD/Chief Bureau of Prisons NYM Page 1 of 1 EFTA00073945 Bureau of Prisons "SENSITIVE BUT UNCLASSIFIED" Psychology Services SHU Review Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Facility NYM Unit Team: A&O Date: 07/18/2019 07:21 Provider: PhD Chef Placed in SHU: 07/10/2019 Type: SHU Status: ADMIN.DETENTION Threat to Self: Low Basis of Review: Inmate was interviewed Adjustment: Satisfactory, segregation not detrimental Mental Status: No significant mental health issues. Threat to Others: Low Comments Monthly SHU Review Note Inmate Epstein was meeting with his legal team today and has a court hearing. He was not able to be seen for a SHU review. Another attempt to interview him for a SHU review will be done in the near future. Completed by PhD/Chief Psychologist on 07/18/2019 12:06 Page 115 of 148 Withheld pursuant to exemption (b)(6); (b)(7)(A) (b)(7)(C) of the Freedom of Information and Privacy Act Generated 07/1812019 12:06 by PhD/Chief Bureau of Prisons NYM Page 1 of 1 EFTA00073946 Bureau of Prisons -SENSITIVE BUT UNCLASSIFIED** Psychology Services Clinical Intervention - Clinical Contact Inmate Name: EPSTEIN. JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01)201953 Sex: M Facility: NYM Unit Team: MO Date: 07116/2019 12:48 Provider: PhD!Chief Focus of Session Inmate Epstein called for this writer in attorney conference today. The officer in attorney conference notified this writer that he was asking to be seen. Subjective/Objective Presentation Inmate Epstein reported he has not received a spoon or soap in SHU. nor did he receive the phone calls that were "promised to him." He told this writer we need to have mutual trust that his needs are met in the prison. This writer told inmate Epstein that she would address his concerns. On the way out, a staff member told this writer she witnessed inmate Epstein receive two phone calls from the Lt. Nonetheless, this writer informed the SHU lieutenant of his concerns and he said he would ensure that he had soap, a spoon, and his initial SHU phone call. Inmate Epstein did not have any psychological concerns today. He denied any mental health symptoms or suicidality. He has been eating as best as he can and has requested a Kosher diet. Intervention(a) Inmate EPSTEIN was provided with brief supportive and psychoeducation regarding additional coping strategies. Inmate EPSTEIN was receptive to these interventions. He continued with his legal visit. Progress/Plan Inmate EPSTEIN was educated about both routine and emergency procedures for contacting Psychology staff. He was reminded of the self-help books and audiotapes available ttPagghlifeoP90ehology department. There appears to be no need for follow up at this time. He will be seen in SHU for rounds and monthly SHU reviews. Withheld pursuant to exemption Completed by PhD/Chief Psychologist on dia.){§)26WM5(b)(7)(C) of the Freedom of Information and Privacy Act Generated 07118/2019 13:05 by PhD/Chief Bureau of Prisons NYM Page 1 of 1 EFTA00073947 Bureau of Prisons -SENSITIVE BUT UNCLASSIFIED" Psychology Services Clinical Intervention - Clinical Contact Inmate Name: EPSTEIN, JEFFREY EDWARD Reg St: 76318-054 Date of Birth: 01120,1953 Sex: M Facility: NYM Unit Team: MO Date: 07111/2019 15:21 Provider: PhD/Chief Focus of Session Inmate Epstein was seen for his psychological observation follow-up in attorney conference this afternoon. Subie_ctive/Objective Presentation Inmate Epstein reported he has been consulting with his attorney most of the day. He elucidated concerns about his incarceration including not receiving his property yet in SHU, feeling cold in his cell, not receiving his Colace, not having enough water in attorney conference. and a desire to recreate in SHU." Inmate Epstein was also upset about wearing an orange jumpsuit and being treated like "a bad guy" when he did not do anything wrong in the prison. Custody and security concerns were addressed with inmate Epstein including why he has to wear his orange jumpsuit (due to his being housed in SHU). He requested that he be placed in a brown uniform during his legal visits. He was told his concerns would be addressed in the SHU meeting. Inmate Epstein stated he is not having any current problems with his cellmate and indicated he at bran cereal for breakfast and took a shower yesterday. He did not sleep well last night. Inmate Epstein continues to deny any suicidal ideation, intention or plan. He did not appear to be in any distress at this time. Intervention(s) Inmate EPSTEIN was provided with brief supportive interventions, CBT-based interventions, and psychoeducation regarding additional coping strategies. Inmate EPSTEIN waoaraatitivef tfaese interventions. Progress/Plan ...... Inmate EPSTEIN was educated about both rout/ lYgV elgien@retnrtt egrd lEi for contacting Psychology staff. He was reminded of the self-help books and audiotapes avaiiBlialt% Aye(gfr)6tiology department. He will be seen next week after his bail hearing to assess his mental status 'and syc °logical sea /lily. of the Freedom of Information and Privacy Act Completed by PhD/Chief Psychologist on 07/12/2019 07:51 Generated 07/12/2019 07:51 by PhD/Chief Bureau of Prisons NYM Page 1 ol 1 EFTA00073948 Bureau of Prisons **SENSITIVE BUT UNCLASSIFIED** Psychology Services General Administrative Note Inmate Name: EPSTEIN, JEFFREY EDWARD Reg St: 76318-054 Date of Birth: 01/20r1953 Sex: M Facility: NYM Unit Team: MO Date: 07;11/2019 14:28 Provider: PsyD Comments This writer attempted to see Mr. Epstein in the morning and then again in the afternoon for a Psych Observation Follow Up. but he was in Attorney Conference. Completed by Imen Darlene PsyD on 07/11/2019 15:51 Page 118 of 148 Withheld pursuant to exemption (b)(6) (b)(7)(A); (b)(7)(C) of the Freedom of Information and Privacy Act Generated 07/11/2019 15:51 by PsyD Bureau of Prisons NYM Page 1 of 1 EFTA00073949 Bureau of Prisons "SENSITIVE BUT UNCLASSIFIED- Psychology Services Clinical Intervention - Clinical Contact Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01)201953 Sex: M Facility: NYM Unit Team: MO Date: 07;10,2019 08:38 Provider: PhD/Chief Focus of Session Inmate Epstein was seen today for a psychological observation contact in the hospital area by this writer. Subjective/Obj€ctive Presentation Inmate Epstein appeared well and it was noted in his log book and eating/sleeping chart that he has been eating his meals, sleeping, interacting with the inmate companions, and pacing in his cell. Today, he presented this writer with numerous concerns and requests. He stated he does not want to be housed in the SHU because he is not comfortable there: he wants to be single-celled if he goes to the SHU: he wants Colace. not the Ducolex he received from medical yesterday; he wants to be able to walk around and go to recreation; he does not want to wear an orange uniform to his legal visits because he is treated "like a punished inmate:" he wants a phone call before he leaves the psychological observation area: he wants a shower and towel: he would like to be housed in the cadre (5S) unit; and would like his property. paper. and a pen. Inmate Epstein's concerns were addressed by this writer and it was explained to him he will not be single-celled or placed in a housing unit for safety and security concerns. His medical concerns (constipation) were discussed with health services as well as his desire to be placed on Colace. Inmate Epstein was provided a shower this morning. Intervention(s) Inmate Epstein was provided with supportive intervention aglco4i4 styostrategies today. He was receptive to interventions and was able to elucidate his various needs. Hand noPpresent with any acute psychopathology and continues to deny any suicidal ideation. intentionAftiNglatki6iftrthigwdRoywii to his bail hearing on Monday but stated he is aware that even if he gets bail, it will take at least two weeks to sort things out so he can leave the jail. Progress/Plan (b)(6), (b)(7)(A), (b)(7)(C) Inmate Epstein is not in any psychologi 443F@€EOFIPiSfIRf2SrRf8 )3wdh°f7Pjfcgla@tat health symptoms or complaints. and is denying any suicidality. He appears psychologically stable at this time and can be released from the psychological observation area. Inmate Epstein will be housed in the 9S area with a cellmate. He will be seen again tomorrow by psychology to evaluate his mental status and psychological stability. Completed by PhD/Chief Psychologist on 07/10/2019 09:09 Generated 07/10/2019 09:09 by PhD/Chief Bureau of Prisons NYM Page I of I EFTA00073950 Bureau of Prisons -SENSITIVE BUT UNCLASSIFIED- Psychology Services Diagnostic and Care Level Formulation Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 0112011953 Sex: M Facility: NYM Unit Team: A&O Date: 07109(2019 10:13 Provider: PhD/Chief Relevant Historical Information Inmate Epstein is a 66-year-old Caucasian male, currently incarcerated on sex trafficking charges. He denied any history of mental health treatment, either on an inpatient or outpatient basis. Inmate Epstein denied any treatment in the past or present with psychotropic medication. He also denied any acute mental health symptoms at this time. Inmate Epstein denied any past or present suicidal ideation, intention or plan. He denied ever engaging in any suicide attempts or self-injurious behavior in the past. Inmate Epstein denied any alcohol or substance abuse. He said it is well-known that he does not even drink alcohol. Presenting Problem/Symptom Inmate Epstein was seen by this writer for suicide risk assessment today, 7/9/19 at 7:30 a.m. for precautionary reasons. He returned from court yesterday evening. He did not mark any mental health items or symptoms on his Psychology Questionnaire (PSIQ) when he entered the institution. Nonetheless. Inmate Epstein has various risk factors for suicidality including a high profile case with media attention, sex offense/trafficking charges, pre-trial status, and he had a court proceeding yesterday which could have given him bad news regarding his legal situation. Inmate Epstein returned from court after duty hours yesterday evening and staff notified the on-call psychologist. Inmate Epstein was placed on a precautionary psychological observation status until psychology could interview him this morning to conduct a formal suicide risk assessment in order to determine whether he is currently at-risk for suicidality. Diagnostic Formulation Inmate Epstein has no history of mental health problems anP dSWetPoifelihtit suicidality at this time. He has never received inpatient or outpatient mental health treWiNgorAyagg4AKANaof suicidality. Currently, he does not exhibit any acute psychopathology, is currently psychologically stable and is in no psychological distress. As such, he is being classified as a CC1-MH inmate at this time. CO%) AfhttiNje)iffigekytychan inmate who either has no identifiable mental illness (Axis I "No Diagnosis") or is mildly ill and requires clinical intervention on an as-needed basis. Care Level Formulation of the Freedom of Information and Privacy Act CARE1-MH is indicative of an inmate who shows no significant level of functional impairment associated with a mental illness and demonstrates no need for regular mental health intervention. Diagnosis: No Diagnosis. No Dx - Current Completed by PhD/Chief Psychologist on 07/09/2019 10:40 Generated 07109,2019 10:40 by PhD/Chief Bureau of Prisons NYM Page 1 of 1 EFTA00073951 Bureau of Prisons "SENSITIVE BUT UNCLASSIFIED** Psychology Services Diagnostic and Care Level Formulation Inmate Name EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Facility: NYM Unit Team: A&O Date: 07109/201910:13 Provider: PhD/Chief Relevant Historical Information Inmate Epstein is a 66-year-old Caucasian male, currently incarcerated on sex trafficking charges. He denied any history of mental health treatment, either on an inpatient or outpatient basis. Inmate Epstein denied any treatment in the past or present with psychotropic medication. He also denied any acute mental health symptoms at this time. Inmate Epstein denied any past or present suicidal ideation, intention or plan. He denied ever engaging in any suicide attempts or self-injurious behavior in th,past. Inmate Epstein denied any alcohol or substance abuse. He said it is well-known that he does not even drink Inmate Epstein was seen .sk assessment today for precautionary reasons. He did not mark any mental health items or symptoms on h ology Questionnaire (PSIQ) when he entered the institution. Nonetheless, Inmate Epstein has various risk factors y including a high profile case with media attention, sex offense/trafficking charges, pre-trial status, and he had proceeding yesterday which could have given him bad news regarding his legal situation. Inmate Epstein return om courtier duty hours yesterday evening and staff notified the on-call psychologist. Inmate Epstein was placed on onary psychological observation status until psychology could interview him this morning to conduct a fo risk assessment to determine whether he is currently at-risk for suicidality. Diagnostic Formulation Inmate Epstein has no history of mental health proble i felAbit suicidality at this time. He has never received inpatient or outpatient mental health tre gaahof suicidality. Currently, he does not exhibit any acute psychopathology, is currently pt icittg c nd is in no psychological distress. As such, he is being classified as a CC1-MH inmate at this time. WM: (gan inmate who either has no identifiable mental illness (Axis I "No Diagnosis") or is mildly ill and requires ention on an as-needed basis. Care Level Formulation of the Freedom of Information CARE1-MH is indicative of an inmate who shows no significant level of airment associated with a mental illness and demonstrates no need for regular mental health intervention. Diagnosis: No Diagnosis. No Dx - Current Completed by PhD/Chief Psychologist on 07/09/2019 10:32 Generated 07109,2019 10:32 by PhOiChiel Bureau of Prisons NYM Page 1 ol 1 EFTA00073952 Bureau of Prisons **SENSITIVE BUT UNCLASSIFIED" Psychology Services Diagnostic and Care Level Formulation Inmate Name EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01)201953 Sex: Facility: NYM Unit Team: MO Date: 07109/201910:13 Provider: PhD/Chief Relevant Historical Information Inmate Epstein is a 66-year-old Caucasian male, currently incarcerated on sex trafficking charges. He denied any history of mental health treatment, either on an inpatient or outpatient basis. Inmate Epstein denied any treatment in the past or present with psychotropic medication. He also denied any acute mental health symptoms at this time. Inmate Epstein denied any past or present suicidal ideation, intention or plan. He denied ever engaging in any suicide attempts or self-injurious behavior in th,past. Inmate Epstein denied any alcohol or substance abuse. He said it is well-known that he does not even drink Presenting Problem/ Inmate Epstein was seen sk assessment today for precautionary reasons. He did not mark any mental health items or symptoms on h ology Questionnaire (PSIQ) when he entered the institution. Nonetheless, Inmate Epstein has various risk factors ' y including a high profile case with media attention, sex offense/trafficking charges, pre-trial status, and he had proceeding yesterday which could have given him bad news regarding his legal situation. Inmate Epstein return om court ter duty hours yesterday evening and staff notified the on-call psychologist. Inmate Epstein was placed on onary psychological observation status until psychology could interview him this morning to conduct a for risk assessment to determine whether he is currently at-risk for suicidality. Diagnostic Formulation Inmate Epstein has no history of mental health proble 12-ao9felikit suicidality at this time. He has never received inpatient or outpatient mental health tre gagiyisfiof suicidality. Currently. he does not exhibit any acute psychopathology, is currently pt ictiog c nd is in no psychological distress. As such, he is being classified as a CC1-MH inmate at this time. CMS): Man inmate who either has no identifiable mental illness (Axis I "No Diagnosis") or is mildly ill and requires ention on an as-needed basis. Care Level Formulation of the Freedom of Information CARE1-MH is indicative of an inmate who shows no significant level of airment associated with a mental illness and demonstrates no need for regular mental health intervention. Diagnosis: No Diagnosis. No Dx - Current Completed by PhD/Chief Psychologist on 07/09/2019 10:32 Generated 07/09/2019 10:32 by PhD/Chief Bureau of Prisons NYM Page 1 of 1 EFTA00073953 Bureau of Prisons Health Services See Amendment Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Encounter Date: 07/09/2019 10:13 Facility: NYM Amendment made to this note by PhD/Chief Psychologist on 07/09/2019 10:40. Page 123 of 148 Withheld pursuant to exemption (b)(6) ; (b)(7)(A); (b)(7)(C) of the Freedom of Information and Privacy Act Bureau of Prisons NYM EFTA00073954 Bureau of Prisons "SENSITIVE BUT UNCLASSIFIED'. Psychology Services Suicide Risk Assessment Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Facilit : NYM Unit Team: A&O Date: 07/09/2019 08:41 Provider: PhD/Chief Psychologist Type of Housing: Other Psychological Observation Cell Accommodation: Single Cell EltiifiNaS This assessment and the resulting recommendations are based on the following sources of information: Medical Record. Clinical Interview Inmate Epstein was placed on psychological observation when he returned from court yesterday evening 7/8/19 for precautionary reasons. He is not on a suicide watch at this time. He was seen this morning for a psychological observation contact and suicide risk assessment this morning, 7/9/19. at 7:30 a.m. as it was determined he possessed some at-risk factors for suicidality. Reason for Referral Inmate Epstein is being seen for suicide risk assessment today for precautionary reasons. Inmate Epstein has various risk factors for suicidality at this time including a high profile case with media attention. sex offense/trafficking charges, pre-trial status. and he had a court proceeding yesterday which could have given him bad news regarding his legal situation. As such, this writer instructed IIII staff, as well as the Lieutenant's Office, to immediately notify the psychology department when he returned from court. Inmate Epstein returned from court after duty hours and denied suicidality. The aforementioned staff notified the on-call psychologist and inmate Epstein was placed on a precautionary psychological observation status until psychology could intprekjievitaittlikanorning to conduct a suicide risk assessment. Developmental History Withheld pursuant to exemption Inmate Epstein denied any history of being the victim and/or perpetrator or physical or sexual abuse. Educational History/Cognitive Impairment (b)(6) ; (b)(7)(A); (b)(7)(C) Inmate Epstein reported he obtained V kigtetApiRf8a-affie,RtMollictfgefttoraduate classes in the area of mathematics. Arrest History_and_EXPerience olJacar_caration Inmate Epstein reported he has served time in Palm Beach County jail on sex offense charges (soliciting prostitution) in the past. He is now being charged with sex trafficking, on a federal level. Mental Health History Inmate Epstein denied any history of mental health treatment, either on an inpatient or outpatient basis. Inmate Epstein denied any treatment in the past or present with psychotropic medication. He also denied any acute mental health symptoms at this time. SatItUiblQnt Inmate Epstein denied any past or present suicidal ideation, intention or plan. He denied ever engaging in any suicide attempts or self-injurious behavior in the past. Substance Abuse History Inmate Epstein denied any alcohol or substance abuse. He said it is well-known that he does not even drink alcohol. Medical Concerns Inmate Epstein denied any significant medical problems, other than a history of high triglycerides. He reported feeling constipated at this time. Current Problem Inmate Epstein is currently on psychological observation due to his having multiple risk factors associated with suicidality. He denies any suicidality at this time and has no mental health or suicide history. He is being seen for a suicide risk assessment in an abundance of caution. Current Mental Status Generated 07/10/2019 09:20 by Miller, Elissa PhD/Chief Bureau of Prisons - NYM Page 1 of 3 EFTA00073955 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Facilit : NYM Unit Team: A&O Date: 07/09/2019 08:41 Provider: PhD/Chief Psychologist Level of Consciousness: Alert and Oriented Psychomotor Activity: Normal General Appearance: Normal Behavior: Cooperative Mood: Appropriate to Content Thought Process: Goal Directed Thought Content: Normal Inmate Epstein did not exhibit any acute psychopathology and exhibited a clear mental status. Current Mental Status: Mr. EPSTEIN was alert and oriented. He was polite, calm. and cooperative in demeanor. He exhibited a neutral affect with appropriate range. Eye contact and hygiene were appropriate. The inmate spoke with normal rate, tone, and volume. His thoughts were organized and coherent, with no loosening of associations or tangential, circumstantial, or irrelevant content. There was no evidence of perceptual disturbance. delusional ideation, or a formal thought disorder. He did not engage in any bizarre or inappropriate behavior. He noted having normal sleeping and eating habits. Mr. EPSTEIN explicitly denied recent and current suicidal ideation. planning. and intent. He was future-oriented and expressed a commitment to life and safety, agreeing to contact staff immediately should he experience suicidal ideation. RISK AND PROTECTIVE FACTORS ASSESSED: This writer screened the inmate for a variety of empirically validated factors commonly associated with risk for self-harm and suicide. The following STATIC risk factors were assessed to be preserIbiawlimmitre inmate's risk for engaging in suicide related behaviors: Sex offender status. Lack of family connections. High Profile Crime Of the DYNAMIC risk factors assessed, none were Wiihttel;f4 NrwaArip. exemption The following PROTECTIVE factors were assessed to tokeyppiymAyNtafc)twase the inmate's risk of suicide:Willingness to engage in treatment, View of death as negative. Future orientation, Denial of suicidal ideation/intention/plans, Adequate problem solving skills. Able to identify reasons to liGtthe Freedom of Information and Privacy Act As noted above. Inmate Epstein is a 66-year-old Caucasian male. He has various risk factors for suicidality at this time including a high profile case with extensive media attention, sex offense/trafficking charges, pre-trial status, and he had a court proceeding yesterday which may have given him bad news regarding his legal situation. Inmate Epstein also informed this writer that his only family at this time is his brother. with whom he does not have a close relationship with. Despite these risk factors, inmate Epstein possesses a number of protective factors at this time. Inmate Epstein adamantly denied any suicidal ideation, intention or plan. He was very future oriented and requested a phone call, to meet with his attorney, to take a shower. and to brush his teeth. He was eating his cereal when this writer arrived and said "I have my paper spoon here." He reported he is going to have a bail hearing on Monday and believes he is going to be released from jail. Inmate Epstein reported he is a Banker and has a "big business" in the community and that "being alive is fun." He also revealed he enjoys learning and teaching. He has confidence in his attorney and described him as "competent." Inmate Epstein denied any mental health history or history of suicidality. He also reported none of his family members have mental health histories. Inmate Epstein stated he is a mathematician and took post graduate classes in this area of study. Inmate Epstein stated he has a support system in the community. including friends and other associates. Finally, inmate Epstein demonstrated a good sense of humor and did not appear dysphoric, agitated or anxious. No acute psychopathology was noted. Overall, inmate Epstein has numerous protective factors at this time that outweigh his risk factors for suicidality. He has a positive outlook regarding his legal case. demonstrates no psychiatric symptoms, has no psychiatric or suicide history, and verbalized a desire to be alive at this time and future orientation. DIAGNOSIS: No Diagnosis, No Dx - Current Generated 07/10/2019 09:20 by PhaChiet Bureau of Prisons NYM Page 2 of 3 EFTA00073956 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg 11: 76318-054 Date of Birth: 01/20/1953 Sex: M Fa ilit : NYM Unit Team: A&O Date: 07/09/2019 08:41 Provider: PhD/Chief Psychologist CONCLUSIONS The Overall Acute Suicide Risk for this Inmate is: Low Overall Chronic Suicide Risk for this Inmate is: Absent RECOMMENDATIONS Inmate Epstein is currently on psychological observation pending suitable housing placement. In light of his current sex offense charges and extensive media coverage on the television, he will need to be confined in a suitable housing unit. Inmate Epstein will be seen daily while on psychological observation and will be seen for a psychological observation follow-up session once he is released from observation. Inmate Epstein denied the need for psychological intervention, self-help materials, or follow-up. He has been classified as a CC1-MH inmate at this time. CARE1-MH is indicative of an inmate who shows no significant level of functional impairment associated with a mental illness and demonstrates no need for regular mental health intervention. Suicide Watch: A suicide watch is not warranted at this time Completed by PhD/Chief Psychologist on 07/10/2019 09:20 Page 126 of 148 Withheld pursuant to exemption (b)(6) (b)(7)(A) (b)(7)(C) of the Freedom of Information and Privacy Act Generated 07/10/2019 09:20 by PhD/Chief Bureau of Prisons - NYM Page 3 of 3 EFTA00073957 Bureau of Prisons "SENSITIVE BUT UNCLASSIFIED'. Psychology Services Suicide Risk Assessment Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Facilit : NYM Unit Team: MO Date: 07/09/2019 08:41 Provider: PhD/Chief Psychologist Type of Housing: Other Psychological Observation Cell Accommodation: Single Cell FINDINGS This assessment and the resulting recommendations are based on the following sources of information: Clinical Interview, Medical Record Inmate Epstein was placed on chological observation when he returned from court yesterday evening 7/8/19 for precautionary reasons. He i a suicide watch at this time. Reason for Referral Inmate Epstein is being seen f e risk assessment today for precautionary reasons. Inmate Epstein has various risk factors for suicidality at thi ' ing a high profile case with media attention, sex offense/trafficking charges. pre-trial status, and he had a court o ing yesterday which could have given him bad news regarding his legal situation. As such, this writer instruc &D staff s well as the Lieutenant's Office, to immediately notify the psychology department when he returned fro Inmate Epstein returned from court after duty hours and denied suicidality. The aforementioned staff notifi -call psychologist and inmate Epstein was placed on a precautionary psychological observation status until psycholo ,terview him this morning to conduct a suicide risk assessment. Developmental History Inmate Epstein denied any history of being the victim Ma? physical or sexual abuse. Educational History/Cognitive Impairment Withheld o exemption Inmate Epstein reported he obtained his high scho%citgl4 drme graduate classes in the area of mathematics. Arrest History and Experience of toMatheedom of Information Inmate Epstein reported he has served time in Palm Beach County jail apse charges (soliciting prostitution) in the past. He is now being charged with sex trafficking, on a federal level. Mental Health History Inmate Epstein denied any history of mental health treatment, either on an inpat O tient basis. Inmate Epstein denied any treatment in the past or present with psychotropic medication. He also d I acute mental health symptoms at this time. Self-Harm History Inmate Epstein denied any past or present suicidal ideation, intention or plan. He denied ever a ging in any suicide attempts or self-injurious behavior in the past. Substance Abuse History Inmate Epstein denied any alcohol or substance abuse. He said it is well-known that he does not even drink alcohol. Medical Canaeini Inmate Epstein denied any significant medical problems, other than a history of high triglycerides. He reported feeling constipated at this time. Current Problem Inmate Epstein is currently on psychological observation due to his having multiple risk factors associated with suicidality. He denies any suicidality at this time and has no mental health or suicide history. He is being seen for a suicide risk assessment in an abundance of caution. Current Mental Status Level of Consciousness: Alert and Oriented Generated 07/09/2019 10:36 by PhD/Chief Bureau of Prisons - NYM Page 1 of 3 EFTA00073958 Inmate Name EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Facilit : NYM Unit Team: A&O Date: 07/09/2019 08:41 Provider: PhD/Chief Psychologist Psychomotor Activity: Normal General Appearance: Normal Behavior: Cooperative Mood: Appropriate to Content Thought Process: Goal Directed Thought Content: Normal Inmate Epstein did not exhibit any acute psychopathology and exhibited a clear mental status. Current Mental Status: Mr. EP IN was alert and oriented. He was polite, calm, and cooperative in demeanor. He exhibited a neutral affect with appropri e. Eye contact and hygiene were appropriate. The inmate spoke with normal rate, tone, and volume. His thoughts nized and coherent, with no loosening of associations or tangential. circumstantial. or irrelevant content. There ce of perceptual disturbance, delusional ideation, or a formal thought disorder. He did not engage in any bizarre or ina e behavior. He noted having normal sleeping and eating habits. Mr. EPSTEIN explicitly denied recent and curre eation, planning, and intent. He was future-oriented and expressed a commitment to life and safety, agree' act staff immediately should he experience suicidal ideation. RISK AND PROTECTIVE FACTORS SSED• This writer screened the inmate for a variety of validated factors commonly associated with risk for self-harm and suicide. The following STATIC risk factors were assessed t and increase the inmate's risk for engaging in suicide related behaviors: High Profile Crime, Lack of family connect ender status Of the DYNAMIC risk factors assessed, none were foun g of 148 The following PROTECTIVE factors were assessed\41.0 Ilse the inmate's risk of suicide:Able to identify reasons to live. Adequate problem solving skills. Denial of suici. ntion/plans. Future orientation, View of death as negative. Willingness to engage in treatment (b)(6): ( As noted above, Inmate Epstein is a 66-yeartotcrraddtaieAt trgolen factors for suicidality at this time including a high profile case with extensive media attention, sex offense/tr- rges. pre-trial status. and he had a court proceeding yesterday which may have given him bad news regarding his leg Inmate Epstein also informed this writer that his only family at this time is his brother, with whom he does not hav Cl ationship with. Despite these risk factors, inmate Epstein possesses a number of protective factors atRii Inmate Epstein adamantly denied any suicidal ideation, intention or plan. He was very future oriented and requeste call, to meet with his attorney. to take a shower, and to brush his teeth. He was eating his cereal when this writ d said "I have my paper spoon here." He reported he is going to have a bail hearing on Monday and believes he is go g t sed from jail. Inmate Epstein reported he is a Banker and has a "big business" in the community and that "bei fun." He also revealed he enjoys learning and teaching. He has confidence in his attorney and described him as mpetent." Inmate Epstein denied any mental health history or history of suicidality. He also reported none of his family members have mental health histories. Inmate Epstein stated he is a mathematician and took post graduate classes in this area of study. Inmate Epstein stated he has a support system in the community, including friends and other associates. Finally. inmate Epstein demonstrated a good sense of humor and did not appear dysphoric, agitated or anxious. No acute psychopathology was noted. Overall, inmate Epstein has numerous protective factors at this time that outweigh his risk factors for suicidality. He has a positive outlook regarding his legal case, demonstrates no psychiatric symptoms, has no psychiatric or suicide history, and verbalized a desire to be alive at this time and future orientation. DIAGNOSIS- No Diagnosis. No Dx - Current CONCLUSIONS The Overall Acute Suicide Risk for this Inmate is: Low Overall Chronic Suicide Risk for this Inmate is: Absent Generated 07109i2019 10:36 by PhaChiel Bureau of Prisons NYM Page 2 of 3 EFTA00073959 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg /t: 76318-054 Date of Birth: 01/20/1953 Sex: M Facilit : NYM Unit Team: A&O Date: 07/09/2019 08:41 Provider: PhD/Chief Psychologist RECOMMENDATIONS Inmate Epstein is currently on psychological observation pending suitable housing placement. In light of his current sex offense charges and extensive media coverage on the television, he will need to be confined in a suitable housing unit. Inmate Epstein will be seen daily while on psychological observation and will be seen for a psychological observation follow-up session once he is released from observation. Inmate Epstein denied the need for psychological intervention, self-help materials, or follow-up. He has been classified as a CC1-MH inmate at this time. CARE1-MH is indicative of an inmate who shows no significant level of functional impairment associated with a mental illness and demonstrates no need for regular mental health intervention. Suicide Watch: A suicide watch is not warranted at this time Completed by PhD/Chief Psychologist on 07/09/2019 10:36 e 129 of 148 Withheld tip° (b)(6): (b) ) exemption ,( )(C) of the Freedom of Information Generated 07/09,2019 10:36 by PhD/Chief Bureau of Prisons NYM Page 3 of 3 EFTA00073960 Bureau of Prisons "SENSITIVE BUT UNCLASSIFIED'. Psychology Services Suicide Risk Assessment Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Facilit : NYM Unit Team: A&O Date: 07/09/2019 08:41 Provider: PhD/Chief Psychologist Type of Housing: Other Psychological Observation Cell Accommodation: Single Cell FINDINGS This assessment and the resulting recommendations are based on the following sources of information: Clinical Interview, Medical Record Inmate Epstein was placed on chological observation when he returned from court yesterday evening 7/8/19 for precautionary reasons. He i a suicide watch at this time. Reason for Referral Inmate Epstein is being seen e risk assessment today for precautionary reasons. Inmate Epstein has various risk factors for suicidality at thi ing a high profile case with media attention, sex offense/trafficking charges. pre-trial status, and he had a court o ing yesterday which could have given him bad news regarding his legal situation. As such, this writer instruc &D staff s well as the Lieutenant's Office, to immediately notify the psychology department when he returned fro Inmate Epstein returned from court after duty hours and denied suicidality. The aforementioned staff notifi -call psychologist and inmate Epstein was placed on a precautionary psychological observation status until psycholo terview him this morning to conduct a suicide risk assessment. Developmental History Inmate Epstein denied any history of being the victim n arifilfcatg physical or sexual abuse. Educational History/Cognitive Impairment Withheld exemption Inmate Epstein reported he obtained his high scholbrikie a me graduate classes in the area of mathematics. Arrest History and Experience of Incanteisatilanpdom of Information Inmate Epstein reported he has served time in Palm Beach County jail apse charges (soliciting prostitution) in the past. He is now being charged with sex trafficking, on a federal level. Mental Health History Inmate Epstein denied any history of mental health treatment, either on an inpat 45 ) tient basis. Inmate Epstein denied any treatment in the past or present with psychotropic medication. He also d acute mental health symptoms at this time. Self-Harm History Inmate Epstein denied any past or present suicidal ideation, intention or plan. He denied ever ging in any suicide attempts or self-injurious behavior in the past. Substance Abuse History Inmate Epstein denied any alcohol or substance abuse. He said it is well-known that he does not even drink alcohol. Medical Concerns Inmate Epstein denied any significant medical problems, other than a history of high triglycerides. He reported feeling constipated at this time. Current Problem Inmate Epstein is currently on psychological observation due to his having multiple risk factors associated with suicidality. He denies any suicidality at this time and has no mental health or suicide history. He is being seen for a suicide risk assessment in an abundance of caution. Current Mental Status Level of Consciousness: Alert and Oriented Generated 07/09/2019 10:36 by PhD/Chief Bureau of Prisons NYM Page 1 of 3 EFTA00073961 Inmate Name EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Facilit : NYM Unit Team: A&O Date: 07/09/2019 08:41 Provider: PhD/Chief Psychologist Psychomotor Activity: Normal General Appearance: Normal Behavior: Cooperative Mood: Appropriate to Content Thought Process: Goal Directed Thought Content: Normal Inmate Epstein did not exhibit any acute psychopathology and exhibited a clear mental status. Current Mental Status: Mr. EP IN was alert and oriented. He was polite, calm, and cooperative in demeanor. He exhibited a neutral affect with appropri e. Eye contact and hygiene were appropriate. The inmate spoke with normal rate, tone, and volume. His thoughts nized and coherent, with no loosening of associations or tangential. circumstantial, or irrelevant content. There ce of perceptual disturbance, delusional ideation, or a formal thought disorder. He did not engage in any bizarre or ina e behavior. He noted having normal sleeping and eating habits. Mr. EPSTEIN explicitly denied recent and curre eation, planning, and intent. He was future-oriented and expressed a commitment to life and safety, agree' act staff immediately should he experience suicidal ideation. RISK AND PROTECTIVE FACTORS SSED• This writer screened the inmate for a variety of validated factors commonly associated with risk for self-harm and suicide. The following STATIC risk factors were assessed t e t and increase the inmate's risk for engaging in suicide related behaviors: High Profile Crime. Lack of family connect' s, ender status Of the DYNAMIC risk factors assessed, none were foun it. 148 The following PROTECTIVE factors were assessedWil :Gse the inmate's risk of suicide:Able to identify reasons to live. Adequate problem solving skills. Denial of suici tention/plans. Future orientation, View of death as negative. Willingness to engage in treatment (b)(6) (b) (C) As noted above. Inmate Epstein is a 66-yesflitidIrceaddrAidifilftlattn factors for suicidality at this time including a high profile case with extensive media attention. sex offense/tr rges. pre-trial status. and he had a court proceeding yesterday which may have given him bad news regarding his leg Inmate Epstein also informed this writer that his only family at this time is his brother, with whom he does not hav Cl tionship with. Despite these risk factors, inmate Epstein possesses a number of protective factors atRfi Inmate Epstein adamantly denied any suicidal ideation, intention or plan. He was very future oriented and requeste call, to meet with his attorney. to take a shower. and to brush his teeth. He was eating his cereal when this writ r d said "I have my paper spoon here." He reported he is going to have a bail hearing on Monday and believes he is go g t sed from jail. Inmate Epstein reported he is a Banker and has a "big business" in the community and that "bei fun." He also revealed he enjoys learning and teaching. He has confidence in his attorney and described him as mpetent." Inmate Epstein denied any mental health history or history of suicidality. He also reported none of his family members have mental health histories. Inmate Epstein stated he is a mathematician and took post graduate classes in this area of study. Inmate Epstein stated he has a support system in the community, including friends and other associates. Finally. inmate Epstein demonstrated a good sense of humor and did not appear dysphoric, agitated or anxious. No acute psychopathology was noted. Overall. inmate Epstein has numerous protective factors at this time that outweigh his risk factors for suicidality. He has a positive outlook regarding his legal case, demonstrates no psychiatric symptoms, has no psychiatric or suicide history, and verbalized a desire to be alive at this time and future orientation. DIAGNOSIS- No Diagnosis. No Dx - Current CONCLUSIONS The Overall Acute Suicide Risk for this Inmate is: Low Overall Chronic Suicide Risk for this Inmate is: Absent Generated 07/09,2019 10:36 by PhaChiel Bureau of Prisons NYM Page 2 of 3 EFTA00073962 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg Et: 76318-054 Date of Birth: 01/20/1953 Sex: M Facilit : NYM Unit Team: A&O Date: 07/09/2019 08:41 Provider: PhD/Chief Psychologist RECOMMENDATIONS Inmate Epstein is currently on psychological observation pending suitable housing placement. In light of his current sex offense charges and extensive media coverage on the television, he will need to be confined in a suitable housing unit. Inmate Epstein will be seen daily while on psychological observation and will be seen for a psychological observation follow-up session once he is released from observation. Inmate Epstein denied the need for psychological intervention. self-help materials, or follow-up. He has been classified as a CC1-MH inmate at this time. CARE1-MH is indicative of an inmate who shows no significant level of functional impairment associated with a mental illness and demonstrates no need for regular mental health intervention. Suicide Watch: A suicide watch is not warranted at this time Completed by PhD/Chief Psychologist on 07/09/2019 10:36 e 132 of 148 Withheld • exemption (b)(6) ; (b) )(C) of the Freedom of Information Generated 07/09/2019 10:36 by PhD/Chief Bureau of Prisons - NYM Page 3 of 3 EFTA00073963 Bureau of Prisons Health Services See Amendment Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Encounter Date: 07/09/2019 08:41 Facility: NYM Amendment made to this note by PhD/Chief Psychologist on 07/10/2019 09:20. Page 133 of 148 Withheld pursuant to exemption (b)(6) ; (b)(7)(A) ; (b)(7)(C) of the Freedom of Information and Privacy Act Bureau of Prisons - NYM EFTA00073964 Bureau of Prisons "SENSITIVE BUT UNCLASSIFIED" Psychology Services General Administrative Note Inmate Name: EPSTEIN, JEFFREY EDWARD Reg St: 76318-054 Date of Birth: 01120(1953 Sex: M Facility: NYM Unit Team: MO Date: 07/08/2019 10:41 Provider: PhD/Chief Comments This writer consulted with Dr. , Central Office, regarding inmate Epstein. Inmate Epstein has various risk factors for suicidality including a high profile case with media attention. sex offense charges, pre-trial status, and a court proceeding today which could otentially be giving him bad news regarding his legal situation. As such, when inmate Epstein returns from court. staff as well as Lieutenant's have been informed to immediately notify the psychology department. If he returns after duty hours, the aforementioned staff were instructed to notify the on-call psychologist and to place inmate Epstein on a watch status until psychology can conduct a thorough suicide risk assessment. Completed by PhD/Chief Psychologist on 07/08/2019 10:49 Page 134 of 148 Withheld pursuant to exemption (b)(6) (b)(7)(A) (b)(7)(C) of the Freedom of Information and Privacy Act Generated 07/08/2019 10:49 by PhD/Chiel Bureau of Prisons NYM Page 1 ol 1 EFTA00073965 Bureau of Prisons "SENSITIVE BUT UNCLASSIFIED— Psychology Services Risk of Sexual Abusiveness Inmate Name: EPSTEIN. JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01!20'1953 Sex: M Facility: NYM Unit Team: MO Date: 07108:2019 09:35 Provider: PsyD/PhD Comments Risk of Sexual Abusiveness During the intake screening process. for Inmate Epstein. based on the documentation available at the time of the screening. and Inmate Epstein's self-report. he was identified as being at risk for sexual abusiveness due to previous perpetration of sexual abuse in the community or in an institutional setting, as evidenced by the following objective criteria: ( ) Having a history of prior institutional violence or sexual abuse perpetration (X ) Having a history of prior sexual abuse perpetration in the community (X ) Having prior convictions of violent offenses As required by P5324.11. Sexually Abusive Behavior Prevention and Intervention. Inmate Epstein was seen by Psychology on today's date to assess his risk factors for sexual abusiveness. At the onset of this clinical contact, the inmate was informed about the BOP requirements regarding PREA. Inmate Epstein indicated he understands the institution's policy against engaging in sexual behavior. His risk factors for sexual abusiveness were assessed and include: ( ) History of prior sexual victimization in prison Page 135 of 148 ( X ) History of prior prison sexual predation withheld pursuant to exemption ( ) History of head injury with loss of consciousness ( ) History of childhood psychological, physical. sexi yM(7)(A) (b)(7)(C) ( ) Witnessed family violence ( ) Antisocial Personality Disorder traitspfltielfebildrogilnieivnatiorsarrctiRrietttgsittoess ( ) Hypersexuality (defined by eight or more orgasms a week prior to prison) ( ) Hypermasculinity ( ) Other: Based on this clinical assessment. the inmate is considered to be at: (X ) Low Risk of Abusiveness at this facility (Note: Even though this inmate is judged to be at low risk of sexual abusiveness, an unforeseen change in risk factors may significantly alter his risk level.). Programming recommendations included sex offender treatment. Inmate Epstein declined programming recommendations.The inmate understands the procedure for contacting Psychology for routine or emergent services. ( ) Moderate Risk of Abusiveness. The Unit Team and Correctional Staff have been notified regarding Psychology staffs recommendation that he not be housed in a cell with any inmates identified as at increased risk for sexual victimization. Psychology also recommends a greater level of supervision regarding his work and education assignments. Programming recommendations include XXXXX. Inmate =inmateLastName is agreeable to/ declined programming recommendations. ( ) High Risk of Abusiveness. It is recommended this inmate be housed in the Special Housing Unit in accordance with P5324.11 to "keep separate those inmates at high risk of being sexually victimized from those at high risk of being sexually abusive" until Correctional Services and Correctional Programs staff can assess his appropriateness for general population at this facility. This inmate should not be housed with any inmates judged to be at an increased risk for sexual victimization. Programming recommendations include XXXXX. Inmate =inmateLastName is agreeable tol declined programming recommendations. Generated 07/08/2019 09:41 by PsyD.'PhD Bureau of Prisons NYM Page 1 ol 2 EFTA00073966 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Facility: NYM Unit Team: A&O Date: 07/08/2019 09:35 Provider: PsyD/PhD Completed by PsyD/PhD on 07/08/2019 09:41 Page 136 of 148 Withheld pursuant to exemption (b)(6) ; (b)(7)(A) ; (b)(7)(C) of the Freedom of Information and Privacy Act Generated 07108/2019 09:41 by PsyD/PhD Bureau of Prisons - NYM Page 2 of 2 EFTA00073967 Bureau of Prisons "SENSITIVE BUT UNCLASSIFIED•• Psychology Services Intake Screening Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Facilit : NYM Unit Team: A&O Date: 07/08/2019 09:24 Provider: . PsyD/PhD Limits of Confidentiality Limits of confidentiality were reviewed with inmate EPSTEIN. He expressed an understanding of the limits of confidentiality and consented to be interviewed accordingly. Data Source(s) The following data sources were reviewed in conjunction with this Initial Intake Evaluation: Self-Report. SENTRY, Staff Observation. Inmate Epstein is a 66-year-old. Black male who was seen by Psychology Services due to newly arriving at MCC-NY. He denied a history of mental health treatment on his Psychology Services Intake Questionnaire. Mental Health History and Current Symptoms No history of mental health issues was noted. No history of prior mental health treatment was noted. No current mental health symptoms were noted. No suicidal ideation, attempts, or self-harm were noted. Substance Abuse No history of substance abuse was noted. No history of substance abuse treatment was noted. Sex Offenses No sexual offense convictions were noted. Page 137 of 148 No history of sexual predation in a correctional sltigigawied rsuant to exemption Relevant Psychosocial History Noteworthy psychosocial issues: Other. (b)(6) ; (b)(7)(A); (b)(7)(C) Inmate Epstein is currently incarcerAtchd U oex Toff4king. Ft spoi led he wap previously incarcerated three months for prostitution. Inmate Epstein statedWI! 0;1p &918 d8bITSARAIViy%Rfreft. He revealed he was living in New York. He stated he completed high school. He stated he was employed in banking work prior to his incarceration. Adjustment to Incarceration Adjustment to incarceration concerns were identified: Other. SEXUAL ABUSE HISTORY Inmate Epstein denied being the victim of physical or sexual abuse. He is currently charged with sex trafficking and has previously been charged with prostitution. He was informed of the programs offered by MCC-NY as well as the Bureau of Prisons. Additionally, he was informed of this institutions self-help program. Inmate Epstein reported he was not currently interested in any treatment programs. MENTAL STATUS: Inmate Epstein appeared calm, controlled, without signs of psychomotor agitation or retardation. He was fully cooperative, maintained good eye-contact. and related in an interpersonally appropriate manner with interviewer. Speech and thought processes were organized. coherent, logical, and goal-directed. Based on informal assessment during this interview, this inmate's cognitive functioning appeared within normal limits, as reflected by adequate long and short-term memory, good attention, and appropriate concentration during interview, as well as adequate receptive and expressive language skills. Inmate denied any current sleep disturbances and described his appetite as adequate. This inmate denied recent or present morbid thoughts, passive or active suicidal ideation, intent or plan and contracted for safety. This inmate's verbalizations were optimistic, future oriented, and without indications of helpless or hopeless thinking. Inmate Brown denied any familial history of suicide behaviors or attempts. This inmate was provided with supportive psychotherapy. and psycho-education to strengthen coping skills and facilitate adjustment to incarceration. Findings Care Level: CARE1-MH Generated 07/09,2019 09:30 by PsyDiPhD Bureau of Prisons NYM Page 1 of 2 EFTA00073968 Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Facilit : NYM Unit Team: A8O Date: 07/08/2019 09:24 Provider: . PsyD/PhD Inmate EPSTEIN denied any history of mental health symptoms or treatment. He denied any current mental health symptoms. He does not meet criteria for any current psychological diagnosis. He meets criteria for Mental Health Care Code 1. CARE1-MH is indicative of an inmate who shows no significant level of functional impairment associated with a mental illness and demonstrates no need for regular mental health intervention. Recommendations The following psychological services are recommended: Other. Inmate EPSTEIN was educated about both routine and emergency procedures for contacting Psychology staff. He does not appear to be in distress at this time. He agreed to contact psychology if he feels he needs psychology services in the future. He meets criteria for CC1 and does not require scheduled follow up at this time. Completed by . PsyD/PhD on 07/08/2019 09:30 Page 138 of 148 Withheld pursuant to exemption (b)(6) (b)(7)(A); (b)(7)(C) of the Freedom of Information and Privacy Act Generated 07108:2019 09:30 by PsyDiPhD Bureau of Prisons NYM Page 2 of 2 EFTA00073969 Federal U.S. Medical Center for Federal Prisons Bureau of 1900 W. Sunshine Street Prisons Springfield, MO 65807 417-874-1621 ••• Sensitive But Unclassified Name EPSTEIN, JEFFREY Facility MCC New York Collected 07/09/2019 13:34 Reg # 76318-054 Order Unit E06-547U Received 07/10/2019 10:44 DOB 01/20/1953 Provider MD Reported 07/10/2019 14:46 Sex M LIS ID 188191004 CHEMISTRY Sodium 137 137-148 mmol/L Potassium 4.7 3.5.5.0 mmol/L Chloride 99 99.114 mmol/L CO2 27 22-30 mmol/L BUN 17 7.22 mg/dL Creatinine 1.05 0.66.1.25 mg/dL eGFR (IDMS) >60 GFR units measured as mUmini1.73 m^2. If African American multiply by 1.210. A calculated GFR <60 suggests chronic kidney disease if found over a 3 month period. Calcium 9.8 8.5-10.9 mg/dL Glucose 102 70.110 mg/dL AST H 57 11.55 U/L ALT 62 Page 139 of 148 11-66 U/L Alkaline Phosphatase 64 41.133 U/L Bilirubin, Total Withheld pursuant to exemption 0.2.1.3 mg/dL Total Protein 77 6.0-8.2 g/dL (b)(6?; (b)(7)(A) ; (b)(7)(C) Albumin 4.4 3.6.5.1 g/dL Globulin of the Freedom otlaformation and Privacy Act 2.0.3.7 g/dL Alb/Glob Ratio 1.50 1.00-2.30 Anion Gap 10.2 9.0.19.0 BUN/Creat Ratio 16.1 5.0.30.0 Cholesterol H 216 <200 mg/dL Triglycerides H 413 10-150 mg/dL Calculation of LDL is not appropriate for samples with a triglyceride greater than 400 mg/dL. Therefore the LDL is not calculated. HDL Cholesterol L 31 40.60 mg/dL Chol/HDL Ratio H 6.9 0.0.4.0 HEMATOLOGY WBC 7.6 4.3-11.1 K/uL NRBC% 0.0 RBC 5.42 4.46-5.78 M/uL Hemoglobin 15.6 13.6-17.6 g/dL Hematocrit 47.8 40.2-51.4 MCV 88.2 82.5-96.5 fL MCH 28.8 27.1-34.9 Pg MCHC L 32.6 33.0-37.0 g/dL RDW-CV 12.8 12.0-14.0 Platelet 338 130-374 K/uL FLAG LEGEND L=Low LI=Low Critical H=High H!=High Critical A=Abnormal A! =Abnormal Critical Page 1 of 3 EFTA00073970 Federal U.S. Medical Center for Federal Prisons Bureau of 1900 W. Sunshine Street Prisons Springfield, MO 65807 417-874-1621 •" Sensitive But Unclassified ••• Name EPSTEIN. JEFFREY Facility MCC New York Collected 07/09/2019 13:34 Reg # 76318-054 Order Unit E06-547U Received 07/10/2019 10:44 DOB 01/20/1953 Provider MD Reported 07/10/2019 14:46 Sex M LIS ID 188191004 HEMATOLOGY MPV 10.4 6.9-10.5 fL Neutrophils 58.7 % Therapeutic decision mak ng should be based on absolute values, rather than percentages Lymphocytes % 25.0 Monocytes % 11.1 Eosinophils % 4.1 Basophils % 0.8 Immature Granulocytes % 0.3 0.0-5.0 Neutrophils # 4.4 1.9-6.7 K/uL Lymphocytes # 1.9 1.3-3.7 K/uL Monocytes # 0.8 0.3-1.1 K/uL Eosinophils # 0.3 0.0-0.5 K/uL Basophils # 0.1 Page 140 of 148 0.0-0.1 KJuL Immature Granulocytes # 0.02 0.00-0.50 10^3/uL Withheld pursuant to exemption HEMNI-Pf#4081A(7)(c) Hemoglobin A1C H 6.3 <5.7 5.7 6.4 Increased Risk of the Freedom of Information and Privacy Act > 6.4 Diabetes SEROLOGY IPR Non-Reactive Non-Reactive Results may be affected in patients with severely advanced immunosuppression. FLAG LEGEND L=Low LI=Low Critical H=High H!=High Critical A=Abnormal A! =Abnormal Critical Page 2 of 3 EFTA00073971 Federal U.S. Medical Center for Federal Prisons Bureau of 1900 W. Sunshine Street Prisons Springfield. MO 65807 417-874-1621 "' Sensitive But Unclassified "' Name EPSTEIN. JEFFREY Facility MCC New York Collected 07/09/2019 13:34 Reg # 76318-054 Order Unit E06-547U Received 07/10/2019 10:44 DOB 01/20/1953 Provider MD Reported 07/10/2019 14:46 Sex M LIS ID 188191004 HIV HIV 1/2 Negative Negative Screening test - See confirmatory testing for Reactive results Page 141 of 148 Withheld pursuant to exemption (b)(6) (b)(7)(A); (b)(7)(C) of the Freedom of Information and Privacy Act FLAG LEGEND L=Low L!=Low Critical H=High H!=High Critical A=Abnormal A! =Abnormal Critical Page 3 of 3 EFTA00073972 Bureau of Prisons Health Services Cosign/Review Inmate Name: EPSTEIN, JEFFREY EDWARD Reg #: 76318-054 Date of Birth: 01/20/1953 Sex: M Race: WHITE Encounter Date: 07/10/2019 16:58 Provider: Lab Result Receive Facility: NYM Cosigned by on 07/14/2019 18:12. Page 142 of 148 Withheld pursuant to exemption (b)(6) ; (b)(7)(A); (b)(7)(C) of the Freedom of Information and Privacy Act Bureau of Prisons NYM EFTA00073973 8P-A.0469 JUN 10 U.S. DEPARTMENT OF JUSTICE I-UV COUNSELING DOCUMENTATION FEDERAL BUREAU OF PRISONS Directions: Use the following criteria to counsel the patient who is tested for the HIV anibody. Check off each item as they are discussed. Write NA beside any item that is inappropriate to the situation. Thereverse side of this form will be utilized to document seronegative and inconclusive test result. Then file in the patient's reco rd, documenting in progreis notes that counseling was completed. PRETEST: Y e 1. Explain purpose of session. T 2. Explain..confidentiality. . 3. Explain HIV antibody test. a. What HIV is b. What the test is c. Test Procedure _de.. Meaning of test results Inability of detecting early infection (false negatives) A f. Potential need for additional testing q. Significance of a positive test. _, , 4. Ust risk factors/clinical signs: (check all that apply) Injecting drug use, sharing drug or tattoo equipment q. — b.. Unprotected or multiple sex partners Page 143 of 148 Treated for sexually transmitted infections, hepatitis, or TB • d. Clinical sts: fever or illness oMilikhOISIINUOMIltitjirftlIfitenklf AIDS opportunistic. infections. e. Exposure: recent occupational or non-occupational exposure/incldent, i f. Pregnant female (b)(6); (b)(7)(A); (b)(7)(C) . , Other. of the rreedom ofintormaticirrand KiVaty Mr - ----6. • Obtain informed consent (when applicable). . ___ -.6. Risk Reduction Behaviors. Educational material given. /7. Patient ReactionslComments. Explain how the patient will be notified of the result. The above information has been explained to m,e in a language I can understand. SignatUre of Inmate ^ .. Signature of Staff uunseloci ,N,Q0,Se S Date: 4 Institution: File in tty$Medical Record: Section 6. Prescribed by P6190 Replaces OPS489.061 &APR EFTA00073974 BP-S359.060 SEP 05 MEDICAL TREATMENT IEFUSAL CDFRM U.S. DEPARTMENT OF JUSTICE FEDERAL BUREAU OF PRISONS 7-9-2019 Date I JEFFREY EPSTEIN 76318-054 , refuse treatment recommended by the Federal Bureau of Prisons Medical staff for the following condition(s): DESCRIBE CONDITION IN LAYMAN'S TERMINOLOGY: Rectal and genital examination The following treatment(s) was/were recommended: Rectal and genital examination Page 144 of 148 Withheld pursuant to exemption (b)(6): (b)(7)(A) : (+7)(C) Federal Bureau of Prisons Medical sta ffinembers,ha.ve carefully.explaiged to me that the following possible consequences and/or cor9iOnEifin V9gCliffecrtFeaWiyibfusal to accept treatment: Undetected and untreated medical condition. I understand the possible consequences and/or complications, listed above, and still refuse recommended treatment. I hereby assume all responsibility for my physical and/or mental condition, and release the Bureau of Prisons and its employees from any and all liability for respecting and following my expressed wishes and directions. kmi -2019 n 14 )5 Counseled by Date Patient's Signal Date W.1d:cal Omcc MCC NY 7/1/(5 NYM-NEW YORK MCC Signature of Witness Date EFTA00073975 BP-S358 06C MEDICAL TREATMENT REFUSAL CDFRM SEP CS U.S DEPARTMENT OF JUSTICE FEDERAL BUREAU OF PRISONS 7-24-2019 Date I, JUT:REY EPSTEIN 76318.054 refuse treatment recommended by the Federal Bureau of Prisons Medical staff for the following condition(s): DESCRIBE CONDITION IN LAYMAN'S TERMINOLOGY: EYE DOCTOR EVALUATION The following treatments) was/were recommended: EYE DOCTOR EVALUATION. Page 145 of 148 Withheld pursuant to exemption (b)(6) (b)(7)(A) : (b)(7)(C) Federal Bureau of Prisons Medical nrpaspagsolmf8rFaofAmpixakytiibto me that the following possible consequences andlor complications may result because of my refusal to accept treatment: INABILITY TO DIAGNOSE CURRENT OPTHALMOLOGIC DISEASES. I understand the possible consequences and/or complications, listed above, and still refuse recommended treatment. I hereby assume all responsibility for my physical andfor mental condition, and release the Bureau of Prisons and Its employees from any and all liability for respecting and following my expressed wishes and directions. ID 7-24-2019 Date NYM--NEW YORK MCC 7re-cie- EFTA00073976 BP-A0618 A&O DENTAL EXAMINATION JUN 16 (Initial Clinical Dental Findings) U.S. DEPARTMENT OF JUSTICE FEDERAL. BUREAU OF PRISONS Occlusion: Oral Hygiene: Gocd Far Poor • N X1 2 3 4 5 9 7 8 0 1011 1213 14 15 18; CPITN: Head & Neck / Soft Tissue: 3 2- 3 3 32 31 30 29 28 21 28 25 24 23 22 21 20 19 18 17 Classification: D: M: I CLr F: Pain Scaie: PIO 1! Pa9p 146 of 148 J E nt to exempt-w as.' Tan Dental Prostheses at Intake: Yes (b)(6): 09 )(AR/ /1 15 /1.1"-r2 Type: Age: R SS ‘,G2 21 /2 SUU-2- • 0.10 set _f e d of the Freedom of Int rr itoye And c2r z.„ Aic y t ay. cayoLiA Condition: Intra-oral Photos Taken: Radiographs Taken: (DocJrnent findings on A&O encounter) Yes Yes C Instructed how to obtain argent and non-urgent dents: care: Yes: I No: Treatment Polities: None: Non-urgent: Urgent: Referred to Sick Call: non-urgent Radiographs authorized: Prophylaxis authorized: Yes No ✓ PAs: (Approve: yak 18 months from examination date) IN/s: Panorex-. nt Name: Dentist nanl £ 1>Ds Number: Institution: Date: ignaturc Block/Stamp: 76 3 IT- os-M MCC NEW YORK 7-26 Chret Dental Officer MCC New York PDF Prescribed by P6400 Replaces BP-A0618 cf N 10 EFTA00073977 BP-S358 06O MEDICAL TREATMENT REFUSAL CDFRM SEP 05 U.S DEPARTMENT OF JUSTICE FEDERAL BUREAU OF PRISONS 7-24-2019 Date I JEFF REY EPSTEIN 76318-054 , refuse treatment recommended by the Federal Bureau of Prisons Medical staff for the following condition(s): DESCRIBE CONDITION IN LAYMAN'S TERMINOLOGY: EYE DOCTOR EVALUATION. The following treatment(s) was/were recommended: EYE DOCTOR EVALUA HON Page 147 of 148 Withheld pursuant to exemption (b)(6) (b)(7)(A) (b)(7)(C) Federal Bureau of Prisons Medical INteWia possible consequences and/or complications tfisdPR&M IMUNcrispia,AgiVtto me that the following may resu t cause of my refusal to accept treatment: INABILITY TO DIAGNOSE CURRLNT OP1HALMOLOGIC DISEASES. I understand the possible consequences and/or complications, listed above, and still refuse recommended treatment. I hereby assume all responsibility for my physical and/or mental condition, and release the Bureau of Prisons and its employees from any and all liability for respecting and following my expressed wishes and directions. 7-24 2310 Cou Date Patient's Sign Dale NYM--NEW YORK MCC EFTA00073978 BP-S358.060 MEDICAL TREATMENT REFUSAL CDFUM SEP C5 U.S. DEPARTMENT OF JUSTICE FEDERAL BUREAU OF PRISONS 7-10-2019 Date I, JEFFREY EPSTEIN 76318-054 , refuse treatment recommended by the Federal Bureau of Prisons Medical staff for the following condition(s): DESCRIBE CONDITION IN LAYMAN'S TERMINOLOGY: 66 YR OLD MALE WITH NO PMHX , REFERRED FOR ROUITNE CXR. The following treatment(s) wasfwere recommended: CHEST X-RAY Page 148 of 148 Withheld pursuant to exemption (b)(6) (b)(7)(A). (b)(7)(C) Federal Bureau of Prisons Medica4 ta7rmyrbgirsntfoirryinr aenfAxvemlained to me that the following possible consequences and/or cSm TicaiTas may resuff because refusal to accept treatment: WORSENING THE CONDITION IF THERE IS ANY FINDINGS I understand the possible consequences and/or complications, listed above, and still refuse recommended treatment. I hereby assume all responsibility for my physical and/or mental condition, and release the Bureau of Prisons and its employees from any and all liability for respecting and following my expressed wishes and directions. . X-RAY 7-10-2019 Counseled by Date Patien Signature Date NYM-NEW YORK MCC Signature of Witness EFTA00073979