On December 20, 2013, Andre Harvey died at the Milwaukee County Mental Health Complex (“the Complex”), after he was injected with sedatives and placed in physical restraints. Following Mr. Harvey’s death, the United States Centers for Medicare and Medicaid Services conducted an inspection of the Complex and issued a report detailing the results of the inspection. The report found that Complex staff failed to document Mr. Harvey’s care, such as noting the times that certain actions were taken and when Mr. Harvey’s behavior changed. The report also determined that staff was not familiar with the rules regarding chemical and physical restraints. In addition, the report criticized Complex staff for failing to take a blood test to determine whether Mr. Harvey was suffering from delirium due to his diabetes. Also according to the report, there may have been a delay in providing medical attention to Mr. Harvey after he found to be pulseless and not breathing.