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AG Coffman Announces the Prosecution of Two Homicide Cases Involving the Deaths of Vulnerable Coloradans

Prosecutions the result of investigations conducted by Medicaid Fraud Control Unit

 

DENVER, CO- Today Attorney General Cynthia H. Coffman announced the prosecution of two alleged homicide cases involving the deaths of vulnerable Coloradans in long-term care facilities. These cases were the result of extensive investigative efforts by the Medicaid Fraud Control Unit (MFCU) in the Attorney General’s Office.

“What happened to these two victims is heartbreaking and the tragedy of their loss is made worse by the fact that their deaths were preventable,” said Attorney General Coffman. “My office is dedicated to protecting Colorado’s most vulnerable citizens and I am thankful that we will now be able to pursue justice for Ms. Gatewood and Mr. Rai, and hopefully be able to provide some solace to their loved ones.”

In the case of Buddhi Rai:

Victoria Pletting (60) and Joanita Serwadda (52) have both been arrested in the death of Mr. Buddhi Rai, an at-risk adult with multiple diagnoses, including a seizure disorder.  

Buddhi Rai was a resident at the Wheat Ridge Regional Center (WRRC) in a community group home called Secrest House. As a result of frequent seizures and his proclivity to displace his gastronomy tube, which delivered medication, liquids and nutrition, Buddhi Rai had a behavior program which required that staff maintain line-of-sight supervision while he was awake and conduct fifteen minute checks on him while he was sleeping. This line of-sight protocol was documented numerous times on many directives for Buddhi, including his Behavior Plan, his Individual Program, and his “Cues and Clues”. “Cues and Clues” were a condensed version of Buddhi Rai's behavior plan, which allowed staff to more quickly familiarize themselves with Buddhi Rai's behaviors, procedures, and medical issues.

 In addition to the line-of-sight protocol, Buddhi Rai's “Cues and Clues” specifically noted, "He (Buddhi Rai) should have close visual supervision during bathing for prevention of injury should he have a seizure." Lastly, there was a posted sign on bathroom doors in the home that warned that Buddhi Rai was not to be left unattended in the restroom for any reason. Staff at WRRC were required by policy to be familiar with the clients' Behavior Plan, and Individual Programs, and were trained and expected to review the “Cues and Clues” at the beginning of every shift.

In the early morning hours of November 20, 2014, Buddhi Rai indicated that he wanted to take a bath and got into the bathtub. Statements from both Ms. Pletting and Ms. Serwadda showed that both women were aware that Buddhi Rai was in the bathtub with the door closed, and that he was unattended. When staff did go in to check on Mr. Rai, approximately 10 minutes later, they found him lying in the bathtub on his side with his nose and mouth under water. CPR was attempted but was unsuccessful. Mr. Rai died, and the coroner’s office listed the cause of death as drowning, which may have been precipitated by a seizure.  

As a result of his death, Ms. Pletting has been charged with Manslaughter and Criminally Negligent Homicide of an At-Risk Adult.

Ms. Serwadda has been charged with Criminally Negligent Homicide of an At-Risk Adult.

In the case of Mary Gatewood:

Arrest warrants have been issued for Deidre Lopez (32), Roxanne Ousley (36), and Jasmine Salgado (22), in connection with the death of 94 year-old Mary Gatewood. Ms. Gatewood had advanced dementia and was a resident at the Ashley Manor Assisted Living Facility where Ms. Lopez, Ms. Ousley and Ms. Salgado were employed. Ashley Manor specialized in "memory care,” and had a policy for staff to conduct headcounts every fifteen minutes to ensure the safety and wellbeing of the residents that lived there. On June 15, 2016, Ms. Gatewood went into the backyard of the residence, fell and landed in a landscaping rock bed where she lay for almost an hour and a half before being found by staff. The temperatures outside on that day were between 86-92 degrees Fahrenheit. Ms. Gatewood died, and the autopsy findings cited "Probable Heat Stress" as the primary cause of death. Video surveillance revealed that she had not been checked on by staff for at least 3 hours. Ms. Lopez, Ms. Ousley and Ms. Salgado were the staff members responsible for conducting the headcounts while Ms. Gatewood was outside.

Ms. Ousley has been charged with Criminally Negligent Homicide of an At-Risk Adult and Tampering with Physical Evidence. Ms. Salgado has been charged with Criminally Negligent Homicide of an At-Risk Adult. Ms. Lopez has been charged with Criminally Negligent Homicide of an At-Risk Adult and Attempting to Influence a Public Servant.

Ms. Lopez has been arrested. Ms. Ousley and Ms. Salgado have not yet been located for arrest. If anyone has information about their location, they can contact their local law enforcement agency.

More than 30 years ago, then Governor Romer signed an executive order which granted the Attorney General’s Office the authority to investigate abuse and neglect of patients in federally-funded long-term care facilities and to investigate and prosecute fraud committed against the State by providers of Medicaid products and services. The MFCU is a state and federally-funded unit that conducts these investigations, and MFCU investigators, are highly trained, sworn peace officers who specialize in this area.

The Attorney General’s Office is committed to protecting vulnerable Coloradans, and encourages anyone who may have information about fraud committed against the State by providers of Medicaid products and services, or the abuse and neglect of patients in federally-funded long-term care facilities to contact the office directly.

Reports can be filed online at https://www.stopfraudcolorado.gov/about-consumer-protection/complaint-forms/report-medicaid-fraud-or-abuse#overlay-context=about-consumer-protection/complaint-forms/report-medicaid-fraud-or-abuse.

Reports may also be sent by email to mfcu.investigations@coag.gov or made by phone by calling (720) 508-6696.

It is important to note that the filing of criminal charges is merely a formal accusation that an individual committed a crime.  Every defendant is presumed innocent until and unless proven guilty.

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CONTACT
Annie Skinner
Colorado Attorney General’s Office
720-508-6553 or Annie.skinner@coag.gov