DOUGLAS COUNTY SHERIFF'S OFFICE INVESTIGATION DIVISION INTERVIEW CR #2013-000069531 DATE: 01-07-2014 START TIME: 1300 LOCATION: EDGEWATER POLICE DEPARTMENT INTERVIEWER/OSN: DETECTIVE ANGELA SPEZZANO, OSN 9830 ATTORNEY GENERAL INVESTIGATOR THERESA BRADBURY INTERVIEWEE/DOB: TACY LOERA VIDEOTAPE: YES: X NO: s DVD: YES: X NO: AUDIOTAPE: YES: X NO: DETECTIVE ANGELA SPEZZANO B INVESTIGATOR THERESA BRADBURY L TACY LOERA Following is the transcript an interview with the following individuals present: L: When it gets cold I have to warm up my hand because it doesn't have any circulation in it. S Oh no. What happened? B Did you have any frostbite? L No. But ... a little over three years ago, it was a horse and rope accident. S Oh, no. L And it . . . when they figured out it was fractured so bad that they . . . S Bless your heart. decided it would be best to just amputate it. L S Wow and that was just three years ago. L Yeah. S Wow. (Inaudible) L I've adjusted. exhibit a 3 1 of \ 04 8 2013-00069531 DET. ANGELA SPEZZANO 02-1 1-14 rw B: Okay. Did they train you on tilings like medication administration or how to do observation runs, anything like that? Do you remember receiving any specific training on that? L: On observations runs and ... B: Okay. L: I think I just was with the male nurse for a day. B: Okay. And do you know who that male nurse was? It's okay if you don't recall. Okay. Um . . . how long have you been an R-N? L: Nineteen ninety six. B: A long time. And prior to that you were an L-P-N, right? L: Dm hum. Since nineteen ninety one. B: Okay. L: I moved to Colorado in nineteen ninety two. B: Okay. So a long time you've been a nurse . . . for a very long time. Um . . . L: And that didn't that, whatever happened to me or . . . I don't know. B: Right. Never had anybody who ... well let me ask you this. So you, your shift was from eleven o'clock at night until seven thirty in the morning, is that right? L: (Nodding head yes) B: Okay. So let's talk about that night. So ... we would be actually talking about um ... July twenty sixth into July twenty seventh, so you start the day before. Oh ... I'll tell you for sure, Carson died on the twenty seventh so we don't have to worry about that date. L: (Inaudible) B: So ... you started work that night at eleven o'clock on the twenty sixth and to seven thirty in the morning the next day? L: Um hum. B: Did you leave right after your shift? 15 of 104 2013-00069531 DET. ANGELA SPEZZANO 02-1 1-14 rw L: Yeah. And I said absolutely not. B Okay. And do you remember who the Med Nurse was? L: It was someone that 1 never worked with before. B Okay. L She had floated from a different unit because... they floated ...unit nurses from Unit Two. B: Okay. L: And then the guy who ... did the rounds ... did most of the rounds the tech ... he was floated from the Adolescent Unit. B Okay. L There it was two people I had never worked with. B Would it be normal for a Med Nurse to come and ask ... the Charge Nurse whether or not they should give him medication? Would that be normal? L Well, I guess if you're new or you just kind of wondered about it. B Okay. L She'd come up and would say ... well he didn't get it earlier. They circled it and they held it so he really could have it. And I said no. B Okay. Wiry, why did you say that? L Because he just seemed kind of . . . drowsy . . . out of it. B What does that look like? Tell me, explain . . . L Well he just didn't think he could fall asleep in his room ... sitting there talking to him. B Okay. L And so 1 didn't think he needed anything to make him more tired. B What would cause somebody to appear that way? I mean what in your experience and training, training and experience, what kinds of things would cause .., like if I was sitting here I probably shouldn't appear ... 1 8 Of 1 04 2013-00069531 DET. ANGELA SPEZZANO 02-1 1-14 nv B So knowing that and the fact that lie was drowsy L (Nodding head yes) B would ... do you have any other thoughts about that now? L Well yeah, now that I know that. B Okay. What, tell me what ... L I mean normally I would be like urn ... that you know, that they have just one Fentanyl patch on him instead of they did some (inaudible). B: Right. L: I would have checked those out a little better. B: Okay. Knowing that, what, what I, what you know now ... do you think that he was overmedicated based on the signs that you saw saying he was drowsy or a little bit more was . . . L: Well ... (Pause) B I mean was it a change from how you had seem him Like before? L B Yes. L Yes. B Okay. So is that enough to be considered that a change of condition . . . L (Nodding head yes) B Was it a change in his condition? L I guess it was. B Okay. So when you guys, again, was there a policy and procedure what . . . what would you normally do if there was a change of condition in a patient? Is there ... is there (inaudible) 40 of\ 04 2013-00069531 DET. ANGELA SPEZZANO 02-1 1-14 rw L: Call the doctor, you could alert somebody, you could send him to the hospital and . . . you know and ... we have a doctor on call so . . . B Okay. And do you know why that wasn't done for Carson? L: No. B Who should call the doctor, do you know? L; My call. B Do you know who? L: It would have been my call. B As the Charge Nurse it would have been your call? Okay. Okay. Have you thought about that since ... since it all happened? I mean have you thought of in your head about what you recall seeing L (Nodding head yes) B and whether or not you would do anything differently? L (Nodding head yes) B And what caused you to do that? L I mean ... it's like could have, should have, would have. You know there's not ... a lot that I could do, urn . . . now. B: No. I know I understand. L: But if it was all done differently then 1 guess it would be like ... you know 1 don't remember like getting his vital signs and doing some more and ... you know, checking him out a little closer. Plus I had . . . plus I had all those other people and all this other stuff going on and ... B: If I were to tell you that his pulse ox from the time of admission until the time of his death had progressively had gotten lower. Would you be concerned about that? L: Yes. 41 of 104 2013-00069531 DHT. ANGELA SPEZZANO 02-11-14 rw B: Right. L: They're like oh ... what in the world. We'd better give them some more (inaudible). B: Okay. So if in fact ... Carson was overmedicated ... and that's what was going on ... if somebody had caught it ... it could have been treated possibly? Is that what I'm hearing you say? L If somebody is B If somebody could have recognized that and ... L At least sent him to the hospital. B Send him to the hospital, call the doctor L B do something like that. (Nodding head yes) Okay. Okay. Um ... so how about this, if you, and again keep in mind I don't have any medical background, so 1 ask questions that you think are ridiculous, it's because I don't know, okay? So .... how about somebody in cardiac arrest., what kind of tilings would a healthy person, so they're in cardiac arrest so are there signs that you would look for? L: Um, then you want, um ... where I worked at then you would look at telemetries or ... we have a cardiac monitor (gesturing to chest), B: Okay. L: And then the (inaudible) monitor calls you or the person monitoring go check on that person now! B: Oh, okay. L: Right now. And if you go in the room and they're like not . . . responding and breathing, you know, we call the (inaudible). B: So let's, okay so let's, (inaudible) sorry I said that wrong. L: But they have, but they have a Core Cart. B: Right. What if somebody's a healthy person are there signs that you could, are there any signs that you could look for that situation? L: I mean not, unless you're, you know some people (inaudible) so ... 51 Of] 04 20 1 3-0006953 1 DET. ANGELA SPEZZANO 02-11 -14 rw B: Okay. So how about overdose, so it sounds like you have some experience with working with methadone as well and (inaudible) and that sort of thing. some of the signs in your training and What are experience of somebody who is experiencing overdose of either legal or illegal drugs? L: (inaudible) B: Okay. I mean . . . are there I mean, are there (inaudible) signs, are there . . . what, what would you look for. So you say not aroused, but let's say somebody is ... walking, I mean . . . does their speech change, does their gate change, what kind of ...I mean in your experience, what kinds of things would you look for as a nurse? Like I know what I look for as a cop, L: Um hum. B: As a nurse, because I'm not going to treat them, I'm going to put them in jail, right, so I'd get them treatment first. L: Yeah but I'd be the nurse at the jail . . . (Inaudible - all speaking at once) B: So as a nurse what would you look for, what would you do? L: Well with the opioids they uh ... think they're going to die but they're not. I mean they're, they, they get goose bumps, their pupils get constricted or small, they feel nauseous, they're like, they just feel, you know it's kind of like they have the flu, they withdraw, a lot of it's more of withdrawal than . . . overdose that I've seen ... B: Um hum. L: So like ... with opioids there's really not a lot. We give them (inaudible) we give them some fluids if they can keep them down. B: Okay. L: We can try to keep them comfortable but in the jail or any place else, there's not a lot we do for them. B: Okay. 52 Of 104 2013-00069531 DET. ANGELA SPEZZANO 02-1 1-14 rw L (Nodding head yes) B but there is a written document . . . L There, there's at least that sheet of all the residents or cases ... the name ... plus there's a board up on the wall (inaudible) ... everybody's name and their (inaudible) status, hold ... B: Okay. L And . . . their doctor and . . . B So ... um ... I think I heard you say earlier, Tacy, that ... he was going to be released soon? L Yeah. B And can you tell me what you know about that? L Because uh ... you know we also had like ... potential discharge on there so ... so that we could pass on like ... if this was a whole day. And this was (inaudible) ready for discharge and he had all his stuff packed up. And we had a suitcase in the break room ... or in our room . . . B: Um hum.. L: And he wanted to add more stuff to it 'cause he was determined that he was going home. B: Okay. So ... you said you were suqrrised when you got the call from Jodi Jenny that he had passed. And why was she calling to tell you, do you know? L: Yeah, 'cause I was the nurse that night. B: Okay. And did she ask you questions at that time that she called you? How long would you say that conversation was? L: Five minutes maybe. B: Okay. And during that conversation did she ... I mean did you go to work L: (Nodding head yes) B- that same night on your regular shift? 54 Of \ 04 20 13 -00069531 DET. ANGELA SPEZZANO 02-1 1-14 rw L: I did. B: Okay. And when you got to work did anybody talk to you about what had happened? L Yeah. B Okay. Tell me about that. L They actually talked to everybody. B And when you say they, who are we talking about? L Uh, Ray, Raymond . . .was the Director of Nursing, at least the . . . B (inaudible) L He was filling in or (inaudible). B Was that Raymond Martinez? L: Um hum. B Okay. L And then the administrator (inaudible). B Lana Cruise(sp) L: Thank you. B Okay. Now did so that's who we talked, now was there Ray and L And Lana. B Lana? Anybody else? L: And Jodi. B Okay. L. And everybody who came to shift was asked to come in a few minutes, like a little early. B: Okay. 55 of 1 04 2013-00069531 DEO". ANGELA SPEZZANO 02-1 1-14 rw L: And then they just talked to us about . . . that this resident he passed away and they had us each sign ... um ... how rounds are to be done and had to sign like (inaudible) and that I agree to . . . B: L: Conduct the rounds . .. Conduct rounds in this particular manner, to do it like this and this and this. And then we turned those in. B Okay. Did anybody meet with you individually? L I talked to Lana like ... a little bit afterward. B Okay. You talked to her (inaudible). L Because I hadn't talked to her yet or Okay B like some of the people had already given a statement and everything. 1 L was away so they waited for me to come to work. B So you met with Lana after that? L (Nodding head yes) B: And about how long did you meet with Lana? L Oh, not very long 'cause I ... I think probably ten minutes. B What kind of things did she ask you about? L I don't remember. B Okay. L I mean ever since then I've talked to like an attorney. B Hold on ... did you do a written statement and everything for Lana? L Yeah. Um hum. I did. I'm sure 1 did. I remember. And then um... B Okay and so ... and did you talk to any other employees about what happened then? L: No. 56 of 104 2013-00069531 DET. ANGELA SPEZZANO 02-11-14 rw B Okay. So afterwards then at some point you talked to some attorneys? L I talked to an attorney and I don't remember his name. B An attorney that worked for the facility? L Um hum. B Okay. L They came in. B Do you remember when that was? After you left? L Yeah. B Okay. L It must have been August . , . seems like. B Okay. 1. Or (inaudible). B Okay. And so they L And then he showed me. He had his chart and everything? You know and showed me, you know I wanted to see his chart so I couldn't review it and look at it. B: So what kind of chart are we talking about? what, what was it? Like the scheduling chart? What, What kinds of things did he ask and . . . L No, it was Carson's chart. B Oh, Carson's chart. L He wanted to go through and look at it. B Sure. L And you know like ... 'cause I had passed the tneds the night before when we were giving him medication the night before. B: Um hum. 57 of 104 2013-00069531 DET. ANGELA SPEZZANO 02-1 1-14 nv L He wanted to look at ... everything, all the documentations and stuff. B You don't recall the attorney's name? L (Shaking head no) B Do you recall what he looked like? (Pause) B Would you recognize him if you saw him again? L Probably. B Younger, older, long hair, no hair, mustache, no mustache? L 1 can't remember. 1 didn't see him, looked like (inaudible) coming in. He looked a little older but not old. B Did he give you a business card? L 1 think he might have but I don't blow. B How do you know that he represented the facility, is that something that he told you? L Well when he got there 'cause I met him at Highlands . . . there. B Okay. L He waited and waited for him to finish talking to Mike. B Mike Cole? L (Nodding head yes) B Okay. The man that was working with you that night? L And then when he was done with him, then he talked to me. B Okay. L Well ... I guess I assumed that. 58 Of 104 2013-00069531 DET. ANGELA SPEZZANO 02-1 1-14 nv B: What does that mean? L: That just means that 1 went back twenty four hours and made sure all the orders were taken off correctly. B Okay. L So . . . the order list for Zofran, which is for nausea. B Okay. L And that they have it by mouth, P-O. B Okay. L But if he throws up then give him a (inaudible) fifty. B Okay. L Which is a big dose of (inaudible). B Okay. L In the hospital I'd probably give him twelve point five ... so twenty five. that's kind of a big dose actually. So Well I mean fifty would make you really sleepy. B Okay. L Fifty milligrams of (inaudible) Phenergan ... that he would be out for the night. B Would or wouldn't? L Out, out, out cold. B Okay. And do you know whether or not he got those medications? L (Shaking head no) B Okay. So you're note just says what the doctor ordered from the . . . L That I looked at the chart B Okay 78 Of 104 2013-00069531 DET. ANGELA SPEZZANO 02-1 1-14 rw L: But ... B: And this is, this is overwhelming. Like I said, it's overwhelming for everybody. It's overwhelming for the family. It's overwhelming for the people who worked there and that is regardless of whether or not they did anything right or wrong. It's, it's difficult. And ... (inaudible) S: Just one actually. (Gesturing to paper) This one when you look at the chart? L: Um hum. S: What is included in the chart that you look at? Is it medications that he's on or is it what, what did you look at? L So I look at the ... I took the MAR . . . S Um hum. L And the chart. And 1 look at the new orders and then, um, 1 make sure that they were transcribed properly. S: Okay. And how does, what does (inaudible) medication, so it's every single medication that he's on? L: Yeah. S Okay. L It's the Medication Administration Record. But I'm ... my concern is this ... in the last twenty four hours so during (inaudible) and if so were they transcribed properly . . . and then in the MAR. B So what the doctor would call in that's what was on ... L Right. B Right, okay. L So if (inaudible - B speaking over L) B ... (inaudible) L The nurses take off this order correctly. S Okay. 95 of 1 04 2013-00069531 DET. ANGELA SPEZZANO 02-1 1-14 rw L: That's my. And then they (inaudible) the and then put everything to the chart. But ... it took hours to do the chart stats because we also get the charts ready and got tilings ready and we did forms all the time. Which took me like so many hours on my shift. B: Okay. L; We spend a lot of time doing paperwork. B: Probably. Very much like us. We do a lot of paperwork. We're not like on T-V where, you know, multiple homicides and in an hour including the paperwork and all. L: No. B: That ... that's the. S: So . . . two questions and then I'm done, I promise, okay? Um, first question is, is that obviously we pulled footage not just for that day that Carson passed away. But we've got numerous hours and all that kind of stuff in footage. It didn't seem like ... any of the checks were done properly. And so it wasn't just that day. What, what do you have to say about that? L: I, I usually go into the room and took the flashlight and checked people, I ... you know people are either breathing you know? You can tell. I mean it's like the only way you can get checks done so you shine your light and uh . . . you can hear them ... or see them. S: Um hum. L: And you're like okay. S: So you, you, you would say (inaudible) is that all the other checks were you feel like you did properly except for (inaudible). The other checks were done properly? L: It ...yeah, yeah, S: Okay. That's fine, that's good. L: And maybe it was because it was he was snoring so loudly that you could hear him in the, you know, in the nurse's station we could hear him, down the hallway you could still hear him. So maybe that was why . . . B: And it sounds like (inaudible) 96 Of 104 2013-00069531 DEI". ANGELA SPEZZANO 02-11-14 rw (Shaking head no) I don't think it ever did. L: B: S: Okay. So my last question is, is that as a nurse . . . while you're checking those charts and you're checking for everything that is going on. It's a hard pill for me to swallow thinking that you were not aware of . . . what Carson was on ... what Carson should have been on ... and whether or not you gave him his Valium without knowing about him. Without knowing his history, without blowing what else he was on . . . you were just kind of . . . gave it to him. L Well he was very anxious. S Okay. L And that's what he had for anxiety. S Okay. And so . . . when you're putting these charts together, you don't remember anything else about that chart? L: Well ... maybe ... S: When you're looking and you're making sure the MAR is correct and you're making sure that everything's okay and all that all the medicine is off, and you're putting charts on or the new papers in for the new checks and all that kind of stuff L I don't remember what every person takes. S Um hum. L Well ... like you might remember some things like oh this person is on Celexa or something, you know you might remember certain things. S: L: Um hum. But now, like now where I'm at ... I don't pass medications. But because I might get a couple that's brand new ... and just because the charts on this and that, I might remember oh , . . this person (inaudible) patches on their knees. S: Uh huh. L: I remember certain things about some residents I would know. There's so many people on so medications and what people take. 97 of 1 04 2013-00069531 DET ANGELA SPEZZANO 02-1 1-14 rw