Download as pdf
COUNTY OF PLACER
CORONER’S RECORD
SUPPLEMENTAL INVESTIGATION
MALFALDA 8013-9412
$-9-13/1000 hrs. Chief Deputy Coroner Dennis Watt assigned me the Death
Investigation related to the death of Decedent (D’) Genine M.
Zizzo. Watt advised Zizzo had died 12-19-12 at approx. 1700 his. in the Kaiser
{Hospital Roseville. The death had not intaly been reported to PCSO by Kaiser
Hospital, as the D’ had died while as an “In Patient” in the hospital, Per policy
{he D’ had been released back to her family for funeral services, The D was
buried and initially believed the incident closed. However, recently the D's
had died as the result of physical abuse and neglect. Conover was now
demanding an investigation into D's death.
Watt provided me Conover's contact information and requested | conduct an
investigation as requested.
{1300 hrs. | contacted Conover via telephone. | advised her | had been assigned
the death investigation and requested to meet with her to obtain her Statement,
Conover advised she was unavailable at that time, as she wanted her
husband to be present when she gave her statement and he wae currently
9-11-13/0945 hrs. | arrived at Conover’s residence, ‘air
aks Califomia, | met with Conover and her husband Dane Conover" Ineket
‘Conover and Dane to explain what they knew about D’ and her death. Conover
and Dane said the following in summary:
Approx. 1980 suffered her first heart attack. Whi treating for the heart
attack medical staff discovered D’ had high cholesterol. The medical staff
fan multiple tests and determined D's high cholesterol was due to
“genital defect”. Medical staff told Conover that D’
overproducing cholesterol. At one point D's cholesterol level was
diagnosed at 650. D’ was placed on medication and a modified diet to treat
this condition. D’ changed her diet to a complete vegetarian diet.
returned to her home where she resided by herself.
Between 1980-1987 D's cholesterol levels fluctuated between 220-240. COUNTY OF PLACER
CORONER’S RECORD
‘SUPPLEMENTAL INVESTIGATION
‘GENINE MALFALDA ZIZZO SO 13-9412
February 1987 D’ once again began experiencing chest pains, D’ was sent
to Mercy General Hospital in Sacramento, where they performed an
Angiogram. Medical staff discovered D’ had 5 blocked arteries and needed
immediate heart surgery. The medical staff performed « Quintuple by-pass
on’. D’ once again returned to her residence.
Over the next several years D's condition appeared stable. However, D's
Triglycerides remained high at approx. 1200 ¥/._
Suffered her second heart attack. D’ was given another
ac@ again medical staff discovered D’ had § blocked arteries
Once again a quintuple by-pass was performed,
ed D's heart valve at that time. D's health
anedication was changed to Zocor and her cholesterol levels
‘were lowered to 140. Once again D’ returned to her residenee,
Qver the next several years D’ lead a fairly active, independent life and
appeared to be doing fine.
on a series of antibiotics to treat
Cardiologist,
12-2-12 at approx. 0630 hrs. got out of bed to go to the bathroom. D’ began
walking back to her bedroom from to the bathroom, when somehow the
c2/gen tubing became entangled around her legs/feet. D' tripped over the
tubing, causing her to fall to the floor. D’ struck the floor with such force COUNTY OF PLACER
CORONER'S RECORD
SUPPLEMENTAL INVESTIGATION
GENINE, MALFALDA ZIZZO 30 13-9412
that her left check began swelling and hor back began hurting. D’ called
Conover via telephone and advised of what had just occurred. Conover
offered to respond to D’s residence and take her to the ER. D’ declined,
stating she merely wanted to take a Vicodin and lay down for a while.
Conover agreed and advised D’ to call if things worsened.
Approx. 1030 hrs. D’ called Conover via telephone, D” said, “Oh my God |
think I broke my back”. D’ her back was in severe pain
and she was having difficulty moving. Conover and Dane immediately
responded to D's residence. Upon their arrival, D’ was lying in bed
meaning and “was obviously in a lot of pain”. Conover sna Dane offered to
call 911 and have an ambulance respond to take D'to the hospital. D’
declined stating she didn’t want her neighbors to ses the situation.
Conover told D’ if her back was truly broken, Conover was not qualified to
move D’. D’ agreed to allow Conover to call 911,
Conover called 911 and a short time later the Fire Dept/Paramedics
arrived. The Fire Dept. gurney would not fit down D'e Narrow hallway, 80
the Fire Dept. personnel grabbed a chair from D's dinning room, placed D’
gute the chair and carried her outside on the chair. Ones in the front yard,
the Fire Dept. personnel placed D’ onto the gurney, then into the
ambulance and transported D’ to the Kaiser Hospital Roseville.
Enroute D’ was in such extreme pain that the Paramedics gave D’ Morphine
forthe pain. =~
Once D’ arrived at Kaiser Hospital Roseville the medical staff ran a series
of tests, including x-rays of D’s back. The medical staff advised the x-rays
did not show any fractures/breaks to D's back or spine. The madical staff
diagnosed D’s pain was due to “A deep bruise of hor back”. The medical
i i -ation (Vicodin), 4-5 times.
al staff also wanted to place D’ into
“Short term Rehabilitation” or a nursing home while she recovered. COUNTY OF PLACER
CORONER'S RECORD
SUPPLEMENTAL INVESTIGATION
GENINE, MALFALDA ‘SO 13-9412
D’ refused to be Placed into a nursing home, ‘stating she wanted to return
home. Conover and Dane discussed with D’ the advantages of being in a
snort torm rehabilitation setting as opposed to returning home. Affe: come
discussion, D’ agreed to be placed in Roseville Point Health & Wellnoce
Conter (RPHWC), located on Sunrise Ave. in the City of Rosevil
Ror to transporting D’ to RPHWWC, Conover and Dane responded to
RPHWC. They met with the facility Admissions staff,
Provided them with a tour of the facility. Con
heard about the “unethical practice of chemi
repeated absolutely no chet
agreed.
Conover and Dane returned to Kaiser Hospital and had D’ transported via
‘medical transport to RPHWC. D’ remained at RPHWC for the next 10 days.
12-3-12 Conover returned to RPHWC and met wi ROCCO,
(Admissions Director). Conover re-iterated to {MMP that “under no
circumstances or for any reason” was D’ to be treated with “anti-psychotic
drugs”. *REREH assured Conover and Dane this would not happen and
Stated she would have this noted in D’s medical charts,
Conover and Dane went to D's room. Conover and Dane were shocked to
See D’ wearing an adult diaper. Conover asked D’ what had happened. D’
replied, “Oh my God they put a diaper on me”. Conover asked or why. D”
stated when she had to go to the bathroom she would push her call button,
At first the staff responded to her room. D’ told them she had to go to the
bathroom and needed help. The staff told D' they were busy and would be
back in a minute to assist. However, they did not return eo > once again
Pushed her call button. Once again the staff responded to D's room. Once
again D’ told them she needed assistance to get to the bathroom: Once COUNTY OF PLACER
CORONER’S RECORD
SUPPLEMENTAL INVESTIGATION
MALFALDA SO 13-9412
Conover became upset and contacted the staff. Conover insisted D’ was
not supposed to be wearing diapers. Conover further insisted that per
doctor's orders D’ was to be assisted to the bathroom.
Conover returned to D’s room. D’ further stated that when the staff moved
her call button she was unable to roach it when her pain increased. D’ was
forced to ask her room mate to push her call button for assistance. D's
room mate refused to push her call button to assist. At this point, D's room
mate overheard the conversation between D’ and Conover. the room mate
said to Conover, “Oh that woman is such a princess and thinks everyone is
here just to wait on her”.
Conover told the room mate the conversation between Conover and D’ was
none of the room mate’s business. Conover becam upset she exited
D's room and went to the nursing station. Conover demanded the staff
{omove D's diaper and move to D’ to another room. The staff complied,
They moved D’ to a different room with a different room mate. Conove
described this room mate as, “a nicer person who wasn't so agitated”,
However, the staff refused to remove the diaper, claiming it was policy to
help prevent pationts/residents from having accidents. Conover demanded
they remove the diaper and place pads under D” instead, The staff finally
agreed to do so but never removed the diaper.
During visits over the next several days D’ would complain of needing to
90 0 the bathroom or of being in pain. Conover would attompt to get D° COUNTY OF PLACER
CORONER'S RECORD
SUPPLEMENTAL INVESTIGATION
MALFALDA ZZZ0 80 13-9412
Also during this time period D’ began physical therapy. D’ began
wan Diaining this caused her a great deal of pain. Conover believed t
pogen taahe staff began “Drugging my mother”. Conover belieces sh
Pegan to see a change in D’s behavior. Conover demanded to review D's
Dracation charts. The staff complied. Conover believed the medications
D’ was receiving were not ith proper treatment. Conover
, oth
then to give D’ more medication. D's Primary Care Physician said no one
had ever given D’ a CAT scan. So before anyone Jumped to any
cor nuusions about over medicating they wanted to dos CAT scan to rule
out head injury. Conover agreed.
Conover and Dane retumed to RPHWWC and ordered the staff to get a
fraclical transport to tako D' to Kalser, The staff declined stating D' was
fine and didn't need to go back to the ER. Conover ine
Primary Care Physici
doctor is not the one in charge while she:
D’ was given a CAT scan. The
D' was still ina
Consistent with a mere bruise as originally diagnosed. Dr.
insisted there were no fractures to D's spine and her condition was not life
threatening. insisted D’ was ok to return to RPHWC. D” was in
‘$0 much pain she could not get up from the hospital gurney herself, Two
6 COUNTY OF PLACER
CORONER’S RECORD
SUPPLEMENTAL INVESTIGATION
erat lifted D’ off the gurney. AT that point D” screamed out in pain. Dr.
Walliams ropliod, “No pain no gain. She can walk”. Dane aaid
medical records from the ER visit and that Dr. Aas
as “Zero”. Conover begged Dr. Wilms to help D’.
there was no further testing necessary and released D’ to return to
RPHWC.,
12-7-12/0100 hrs. D’ returned to RPHWC. D’ was so exhausted and very
wreak. RPHWC staff placed D back into her bed. Conover saw that D's call
button was once again placed out of her reach. Conover moved the call
button back to D’s bed and safety pinned it to D’s sheet se D could reach
it
0145 hrs. Conover and Dane wore themselves exhausted and left for the
night.
0930 hrs. Conover returned to D’s room. RPHWC staff approached
Conover and said, “Oh your mother was very agitated and combative after
you loft’. ‘The staff advised that at approx. 0140 hrs. D’ “suddenly woke up
Aisoriented and psychotic”. The staff stated D’ got out of her bed, exited
her room and began walking up and down the hallway by herself b°
rancered into other patient's rooms, began screaming, yelling, punching,
hitting and scratching staff.
Staff claimed they had tried calling Conover to advise of D's condition.
However, Conover insisted the staff never called. The staff claimed they
had attempted to call but there was no answer so they left voles mail COUNTY OF PLACER
CORONER’S RECORD
SUPPLEMENTAL INVESTIGATION
GENINE MALFALDA 8013-9412
The staff contacted Kaiser's on call Doctor, Dr. eet
approx. 0150 hrs. and advised of D’s violent behavior. Dr.
diagnosed D's behavior as “Psychosis” and ordered two (2) “inter
muscular shots of Haldol” be given to D’. The RPHWC staff ‘complied and
gave D’ the two shots prescribed.
Conover said, “I was outraged and | went into my mother’s room”.
Conover asked D' what had happened after Conover and Dane had left the
raght pefors. D’ began crying and said shortly after Conover and Dan ted
[eR D's pain medication wore off. D’ was in such terrible pain she certs
pressing her call button for help. No one responded, D’ said she began
yelling, “Please someone help me I'm in pain”. D said the next thing she
knew, nurse Sq (not sure of the Spelling), a male staff
wheel chair. The staff wheeled D’
station. D’ asked where they wore lied, “Shut
up” as they continued wheeling her down the hall. D Said, “They wheeled
me into a big room that had Christmas decoration”. Jeremy and the two
fomale staff remained in the room with D’ wi loft.
Approx. 5-10 minutes lator, Siiweeteo returned. D’ said the nurse pulled
and tra aPPeared to be a light green to clear plastic cord then Siwtomeato
and the other staff tied D’s wrists tog One of the other female staff
members pinched D’s upper arm whil jected something into
Dis arm. D’ told the staff she was going to put everyone in jail. D's said
phe was going to call the police, as they couldn't do thie to her. The sicft
{eet,D” in this room for alittle while longer. The next thing D” ine one of
the female staff pinched D’s upper arm again and gave D’a
her ragrnlection. The staff then untied D’s wrists and wheeled her beck to
her room. The staff then put D’ back into her bed.
Daren told Conover, “! don't feel good. What did they give Conover
{01d D itwas Haldol. D’ asked Conover if this was a tranquilizer, Conover
told D’ no this was an anti-psychotic. D' replied, “Oh my Sod they
poisoned me”. COUNTY OF PLACER
CORONER’S RECORD
‘SUPPLEMENTAL INVESTIGATION
GENINE MALFALDA ‘SO 13-9812
Conover left the room and located Sma Conover demanded to know
what they had done to D’. Jllmmmptold Conover the same thing as had the
nurse when Conover first arrived. Juggump further stated the incident was
documented in a written report in D’s medical records. Jealiaefurthor
stated that earlier that night they had attempted to give D’
medication. D’ refused to take it claiming they were trying to poison her.
Conover asked dqgumy if SRaM@NWWRo had told D’ what she was giving her
before or after injecting 0’. Jammmmerepliod, “She didn’t say anything”. The
nurse did not tell D’ what was being administered.
Conover want to fjjme and demanded D’ be transferred to another facility,
a8 D’ fears for her life. SNM said, “Let me work on it. It's a Friday and Ill
see what | can do”. agai then apologized for what had happened. Ragme
offered to buy Conover dinner and Conover declined.
Conover returned to D’s room and attempted to comfort her, as D’ was “so
traumatized”. Approx. one hour later @ayMp returned to D's room and said
there were no beds available in the area. Ragu loft the room. Conover
asked D’ what she wanted to do. D’ replied,
afraid to stay alone. I'm afraid they are going to try and kill m
told D’ she would try to arrange for D’ to be placed on in home care.
Conover then remained with D’ until visiting hours onded. ‘tagmme returned
to D’s room and told Conover she needed to leave. Conover refused
stating D’ didn’t fool safo. le said, “Legally you have to leave, because
you will be violating her room mate's Hippa privacy rights”.
Conover insisted that@ajm put D’ into a private room “Wile advised
there were none avail Conover stated she would not leave. Payne
replied, “Then I'm going to have to call someone”. Conover replied,
cahat’s fine. While you're doing that I'll call the police”. aij then agrood
to allow Conover to stay.
12-8-12/0100 hrs. Conover was so exhausted she could no longer stay.
Conover left and returned to her residence. Conover remained home for
approx, 2 to 2% hours then decided to return to D's room. COUNTY OF PLACER
CORONER’S RECORD
SUPPLEMENTAL INVESTIGATION
GENINE MALFALDA ‘SO 13-9412
Approx. 0400 hrs. Conover arrived at D’s room. Conover remained for
approx. 2-3 hours.
Approx. 0630-0700 hrs. Conover left D’s room. Conover drove to D’s
residence to check on D's mail and messages. Conover discovered the
RPHWC staff had called D’s home when they were trying to contact
Conover and advise of D's alleged violent behavior. The staff left four (4)
messages on D's answering machine. During the first message the staff
advised they needed to talk to Conover as they had “Emergency Medical
information for her”. During the second message the staff advised they
had information for Conover and to please call them. During the third
message was a hang up call and Conover is not certain if it was the staff
calling or some one else. During the fourth message a differont female
staff membor said, “Please call it’s not an emergency but please call”.
Conover returned to RPHWC and asked staff to see the nurse’s notes from
the night before. The staff complied and provided Conover the notes. The
notes stated the nurse had called to leave messages for Conover.
However, based on the time lines listed In the notes the nurses had called
Conover after the Haldol had been administered not prior.
12-912 Conover was visiting D’. Once again D’ asked for assistance so
Conover called out to the staff to assist. The staff did not respond.
Conover began yelling for help until one of the staff finally responded to
the room. Conover became so upset with this she went to Silke and
demanded D’ be moved to another room. Conover demanded D’ be moved
to a room across from the nursing station so they could hear the calls for
assistance and respond quicker greed and moved D’ to a room
directly across from the nursing station.
12-10-12 Conover once again met with Fjiid. Conover confronted
Hagman and advised she believed the nurses were lying about what had
happened. Conover further believed the staff had lied about when they had
called to circumvent Conover's authority and injected D’ with ant
Psychotic medications against Conover's instructions. ily replied,
10 COUNTY OF PLACER
CORONER’S RECORD
SUPPLEMENTAL INVESTIGATION
“Wall if you don’t let us use that protocol, you're tying our hands and what
are we supposed to do”.
Conover further stated the staff had made serious allegations of D’
assaulting staff so Conover demanded to see the injuries the staff had
feceived. Conover further demanded to know the names and correct
Spelling of each staff member allegedly injured. Holland refused stating
thig would violate the staff's privacy rights.
Conover then demanded GuaagUWatiasE (not sure of spelling) the
Director of Nursing take D’s statement for filing a complaint. qumm
agreed. Conover demanded to be present when MM took D's statement.
Conover and Holland stood by while tigqgiiemet with and took D’s
statement. dali interviewed D' and appeared to be taking notes.
Conover asked for a copy of those notes and asked they also be placed
into D's medical records. Imag agreed to provide the notes. However,
‘once she completed her interview of D’ (ijl stated she didn't believe
what D’ sald, nor did Sq believe the staff had tied D’s hands/wrists.
Conover became angry and toldiqgge she was not there to intimidate D’
only to take statements and document what D’ claimed. {NB ended the
interview and left D’s room.
Later that evening Conover and Dane noticed D’ was now appearing
‘somewhat catatonic. Conover and Dane had made repeated attompts to
talk to D’, but “she was rapidly losing her ability to communicate”.
Conover and Dane would say something to D’. D’ would not reply so.
Conover and Dane would repeat what they had said. 0’ appeared to
become upset as she thought she had been talking/replying when she had
not.
12-11-12 Conover and Dane realized D’s physical and mental conditions
wore getting worse, “She was almost seemingly liko in a vegetative stato
and in tremendous pain”. : COUNTY OF PLACER
CORONER’S RECORD
SUPPLEMENTAL INVESTIGATION
GENINE MALFALDA “zz 3013-9412,
12-12-12 Early morning Conover and Dane were visiting D’. D’ was “very
catatonic. Not in a coma but not able to say more then one or two words.
Not full sentences”.
Later that day 3M (family friend and D’s care giver at home)
arrived.
0250 Attempted to contact Marissa Conover, left a msg stating that! needed to share some urgent medical information c her, will cont to attompt——SMIRaNER/RN 0330 Haldol 2mg was effective, pt. is calm, verbally responsive, 0 Screaming, sitting in wic by the nursing station, stands up from wie to ‘stretch her back occasionally, 0 s/s ofdistress, 0808, Personal alarm attached and activated every time pt. stands up, still awaiting call back from daughter-——SaammmB/RN* Afier this point the Nurse's Notes reference Q’ refused to take prescribed pain ‘wemedications, . . fasted Summ ifthe staff would have given D’ a second dose of Haldol without listing iin the Nurse's Notes/Medical Records. Gibson stated absolutely not. Haldo is 80 powerful if first dose was not effective they would not have i & second dose. The staff would have tried another medication that the attending doctor would have recommended before giving a second dose of Haldol. {2sked@limmefor copies of D's medical records. Wn advised she needed to get a supervisor's approval. — began by stating one time use of Haldol is not dangerous. The side effects listed on the information page refer to long term/repeated use, Mam acknowledged staft had mot with Conover regarding D’s care, ‘Shim and staff attempted to advise Conover that D’ was refusing her Gerapy treatment and pain medication. However, each time they mot with Gonover she became very authoritative and would constantly intorrupt and demand things. Staff told Conover due to D's current status and refteal 12 16 COUNTY OF PLACER CORONER’S RECORD SUPPLEMENTAL INVESTIGATION Participate Conover might want to pursue alternative programs, including a discharge plan. Conover acknowledged she knew D’ was “in bad shape and had thought about Hospice”.You might also like
