OFFENSE REPORT Pensacola Police Department

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DATE TIME TYPE OFFICER REPORTING CALL # EDIT DATE EDIT TIME
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Status: APPROVED; 1tl18/2015 14:01

CAD INCIDENT DISPOSITION CODE: [343] [ E) [ A]

On 11-2-2015 I received information about a suspicious circumstance that occurred at Bay

Side Manor. The incident involves a patient and an unknown person. The incident is
currently under investigation by this agency.

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Status: APPROVED 3/15/2016 09:27

On 11-2-2015 I received a phone call from (850-1 2). _was

concerned about a friend, Robert I)who is currently staying at Bay Side Manor, 4343
Langley Ave. Robert is under the care of Hospice but has been placed at Bay Side Manor
because he requires additional care. Robert is terminally ill with a lung disease and is on
oxygen 24 hours a day. _ stated that on 10-25-2015, a mutual friend named Bruce
, (850- reported that Robert's oxygen tubing had been tied into a knot. This
possibly happened again on Sunday, 11-1-2015. I stated that he is concerned that
Robert's step-son, Brian Spencer, could be responsible. 2 & stated that he did not want to
be accusatory but he knows that Robert and Brian have had an on again off again
relationship.

Det. b and I then made contact with Robert at Bay Side Manor, room 117. Robert had
a visitor named "Brandon" who he asked to leave at our arrival. Robert is on constant oxygen
and needs it to sustain life. Robert's oxygen machine is portable and is not connected to a
main system for monitoring. Robert stated that he knew why we were visiting him and he
appeared to be lucid. Robert stated that on Sunday 10-25-2015, his friend Bruce was visiting.
Robert had mentioned that he was having trouble breathing, more so than normal. Bruce was
adjusting the tubing when he noticed a knot tied in the tubing. Bruce then notified the nurse,
later identified as Lucresia j Robert recalled the knot being so tight that it took both
Bruce and Lucresia to get it undone. Once loosened, Bruce took a photo of the tube and
Lucresia replaced the tubing and notified her supervisor. Robert could not recall when he
started having trouble breathing nor could he recall any visitors he had prior to Bruce.
Robert does have a group of approximately 5-6 friends that visit daily. Robert stated that he
believes this knot to have been intentionally tied. However, Brian's wife, Crystal Spencer, met
with hospital administration reference the incident. The details of the discussion are unknown
but Robert stated that everyone in the meeting believed that Robert's movements and his
fidgeting with tubing caused the knot. Robert explained that he disagrees and believes that
someone intentionally tied the knot, trying to restrict his air flow and kill him. After
examining the machine and tubing, it is impossible for a knot to have been caused by Robert's
movements. A slip knot type or a tangled mess would be plausible. The tubing connects to the
oxygen machine. The tubing has a connected end where additional tubing can be connected
for a broader movement area. The other end is then connected to Robert's nose. The tubing
would have to have been disconnected from either the machine or one of the connection pieces
for a knot, like the one photographed to have occurred.

Robert also talked about a second incident where the tubing was tied. Robert stated that on

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11-1-2015, he was having a more difficult than normal time breathing. Robert stated it was
around 8am when he awoke to difficulty breathing. Robert stated that he called the nurse,
later identified as Melissa.- (850r }.Robert stated that he never looked at the
tubing but heard Melissa "nonchalantly" state that she had to untie the knot in the tubing.
Robert stated that another nurse, Roy" (317 ) was also present. Robert stated
that he had several visitors that day. He recalled Brian visiting around 1330 hours. Robert
stated that Brian had told him that he had come by earlier that morning but that he (Robert)
was sleeping. Robert stated that it would have been before 8am. Robert had three other
visitors that day, including "Brandon", "Bob .-' and his best friend, "Bob

Robert then spoke about the family dynamics. Robert is married to Brian Spencer's mother
and has been for approximately 30 years. Robert stated that he and Brian have had some
differences in the past and most recent since arrival at Bay Side Manor 11 weekst~o. Robert
stated that they have had several disagreements, mainly because Robert believes that they are
just "warehousing" him at Bay Side Manor. Robert stated that Brian wants him "out of the
way". They have had other "heated" arguments about Robert's wife. Robert is upset because
she has only been to visit approximately three times since his admission to Bay Side Manor.
Robert stated that during one argument, Brian told him what an "ass hole" he was and that
he was not treating his (Brian's) mother very well. Robert stated that he and Brian have had
approximately 3-4 arguments in the last month. Robert went on to say that he thinks that,
Brian's position and pull that he has, is the reason he is being kept at Bay Side Manor.
However, Robert stated that he was placed into Bay Manor after a,"hallucination", episode
that stems from the morphine that he was administered. It was apparent that Robert could
not take care of himself or his wife at that time. However, Robert strongly disagrees.

Robert requires oxygen 24 hours a day to survive. He can only be off the oxygen for a couple
minutes at a time. He has had a longer extension to the tubing so that he is able to go to the
bathroom and keep the oxygen attached. His tubing line has recently been shortened so that
he has to call a nurse for assistance to use the bathroom. Robert stated that he is aware and
accepts the fact that he needs the oxygen to survive and he wants to continue to live as long as
possible. Robert stated that he believes that anyone who would tie a knot in his tubing to
restrict his oxygen supply is trying to "kill him". Robert has a hard time believing that Brian
would do something like this and does not believe he tied the knot. However, he firmly
believes someone intentionally tied the knot. Robert agreed to allow the police to place a
camera inside his hospital room.

Det. _ and I then made contact with Bay Side Manor Administration. Present was
Martha "Maryann" 1 I, Administrator, Latasha 7 g, Risk Manager, and Kristin
7, Nursing Supervisor. All were in agreement that Robert's tubing was tied
accidentally. When asked to explain, Latasha stated that he moves around and "fidgets" with
the tubing. I explained that knot that I observed in the tubing was clearly tied as result of one
end or piece being disconnected. It would be impossible for a knot to occur from moving or
fidgeting. No one could explain any other plausible way. Maryann stated that they met with
Crystal Spencer after the incident was brought to their attention and all agreed that it was an
accident. Latasha went on to explain that the oxygen tubing is designed to loosen if it is tied
too tight and there is no way that the knot could have been tight enough to cut off his air
supply. Even though the nurse, later identified as Lucresia, was told by Bruce that he believed
this knot to be an intentional act, neither the Agency for Health Care Adminstration

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(ACHA) nor The Department of Children and Families( DCF) were notified on the incident.
Anyone could have been a,suspect, including Bay Side Manor staff. At this time, I did not
know who the nurse was that untied the tubing on the first incident. I described the nurse,
based on Robert's memory, and no one could say who she was. Maryann stated that she
would follow up and provide the nurses information.

On 11-3-2015 Det. __ and I met with Roy _ Roy was Robert's nurse on 11-1-2015.
Robert stated that he was alerted by the aid, Melissa, that Robert was having trouble
breathing. He stated that the two went into Robert's room together. Roy stated that Robert
was in distress but that is not uncommon for him. Robert's oxygen tubing was attached to his
nose. According to Roy, Melissa believed the oxygen was unplugged from the machine end.
However, it was not. It was the extra tubing used for his extension that had recently been
removed. Roy said that they keep the extension piece close by so that when Robert needs to
use the restroom, the can attach it and he go by himself. Roy stated that he checked Robert's
saturation levels and they were fine. Robert was in distress, so it took a while to get his
breathing back to normal. Roy stated that he only cares for Robert maybe once a week. When
asked, Roy stated that Robert was a super nice man and he had no complaints. Roy stated
that it is routine for the oxygen tubing to be changed once a week on Sunday. However, it is
not documented. When asked, Roy did say that it would be very difficult to tie the oxygen
tubing into a knot. Roy also agreed that a "loop style" knot would be easy for Robert to
accidentally do himself but not a knot like the knot found in Robert's tubing. Roy also agreed
that it would have to be disconnected from the machine, the nasal area or one of the extension
pieces. Roy did say that the tubing is coiled when it is removed from the plastic wrapping.
Roy stated that it would be possible that if grabbed wrong, it could have a knot but the knot
would be loose. Roy did say that if a knot was tied and his oxygen decreased that the machine
would alarm. Roy disagreed with Latasha and stated that it is possible to tie a knot into the
tnbing. He went on to say that it would not take much to restrict the oxygen because the
tubing is "rigid". Roy did say that he overheard a heated argument between Robert and
Brian a few weeks ago. He could not provide specifics but it was about Robert not going
home.

Roy was verbally sworn to his statement. Our conversation was recorded.

I then met with Melissa ~ the CNA for Robert on 11-1-2015. Melissa provided the same
statement as Roy about the oxygen tube. Melissa could not provide any additional
information. She has not had much contact with Robert as she just became his CNA on
11-1-2015. Melissa did recall that the light on the oxygen machine was on but did not know
what that meant. She restarted that oxygen machine and reconnected Robert's longer
extension tube. Melissa did recall some of Robert's visitors. She stated that a couple that sees
Robert makes her feel "uncomfortable" but she could not state why.
Melissa was also verbally sworn to her statement. Our conversation was recorded.

Det. 7 S and I performed an experiment on Robert's oxygen machine. Robert was

disconnected from his main oxygen machine and connected to a portable one during this
experiment. Also present was Latasha _. Latasha provided unused tubing for the
experiment. Robert's oxygen levels were set at 4 liters. I tied a loose knot and a tight knot
into the tubing. The loose knot had no effect on the oxygen levels. The tight knot decreased his
oxygen levels to 2 liters. The tubing does not loosen when tied tight as Latasha had stated. The

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machine did not alarm with either knot. The only time the machine alarmed was when the
power supply was cut off and then turned back on. We also placed the nasal portion into a
cup of water. When tied tightly, you can see the bubbles decrease in the water. The oxygen
machine does belong to Bay Side Manor.

We then touched based with the administrative staff. We were told by Latasha that she had
notified AHCA, APS and Brian Spencer. In a sworn written statement, Latasha stated that
she called Brian Spencer to inform him of the police investigation. Brian was already aware of
the incident and Latasha had no lawful reason to divulge to anyone that a police investigation
was underway. And this also alerted a possible suspect of an investigation. I then asked for
the nurse's information from 10-25-2015. I was told they still did not have the information but
would locate her name. I told Maryann that I would call her on 11-3-2015 for the information.

On the same date, I met with Bruce Bruce is Robert's most frequent visitor. Bruce
has witnessed encounters between Robert and Brian. However, Bruce stated Robert can be
the meaner one. He has witnessed Robert saying mean things to Brian. Bruce said that Robert
is frustrated because he wants to die at home, not at Bay Side Manor. Bruce recalled finding
the knot in Robert's tubing. Bruce stated that it was only him and Robert in the room. Bruce
stated that the knot was extremely tight and he would not have taken a picture or had any
concern if had not been. Bruce stated that it took both him and the nurse to loosen the knot.
Bruce expressed his concerns of the knot being intentionally tied; even commenting that
Robert does not have the strength to tighten the tubing. Bruce stated that the nurse told him
she would notify her supervisor on the incident.

A camera was installed in Robert's room. Robert signed a consent form allowing the police to
place the camera in his room

On 11-4-2015 I called Bay Side Manor. Maryann was not available so I spoke with Latasha.
Latasha stated that the nurse's name was Lucresia, unknown last name. Latasha stated that
they called her yesterday and scheduled a meeting for me for 11-4-2015 at 1000 hours. I
informed Latasha that her time was not acceptable and I asked for Lucresia's last name and
contact number. Latasha stated that she would call back with that information. I then located
Lucresia __ on the Florida Nursing License website. I also located a phone number.
Latasha called later and confirmed my information.

I then attempted to make contact with Lucresia at her residence. I spoke with her husband
and left my business card.

On 11-5-2015 and I met with Lucresia at her residence. Lucresia stated that
Kristin was the employee who called to set up the meeting with the police. Lucresia stated that
Kristin had tried to call her Monday evening but they never got the opportunity to speak.
This contradicts what hospital administration had told us. They claimed to not know which
nurse cared for Robert on 10-26-2015. I was told that they discovered Robert's nurse to be
Lucresia on Thursday morning. However, they spoke with Lucresia on Tuesday.

Lucresia is the RN supervisor and was in that position on 10-26-2015. Lucresia stated that the
knot was not loose but not super tight either. She did not express any difficulty in loosening
the knot. Lucresia also claimed that she placed the tubing in a clear bag, in the condition that

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she found it. I showed Lucresia the photo of the knot and she stated that it was accurate.
There are several flat areas on the tubing that represent where the knot was tied and it was
clearly not in the condition that she found it. Lucresia also describes the bag as clear with a
white top. She stated that she wrote" Amber's" (unit management) name on the bag. The bag
that we received the tubing in was not the same bag. Lucresia explained that she wrote a
"note" to Amber and told her about the incident. She stated that she told Amber in the note
that Robert's friend stated to ber that be believes someone purposely tied tbe knot. Lucresia
stated that she told Robert's friend that it probably got tangled up when he took it off to go to
the bathroom. According to Lucresia, this answer did not satisfy Robert's friend so he told
her tbat be was going to take a picture. I explained to Lucresia that the allegations were
concerning to me and that anyone could be a suspect, including the staff. I tben asked if she
recorded this incident on some type of "incident report". Lucresia stated that she did not and
that she just wrote the note to Amber. Lucresia was not sure if Amber completed an incident
report because no one contacted her for follow up. I asked Lucresia the protocol for
documenting an incident on an official report versus a note. Lucresia explained that if a
patient had any bruises or fell, then an incident report would be done. I asked Lucresia why
she did not feel that an incident report and notification to Risk Management was not
warranted in this case. Lucresia explained that she believed it to be an accident, even though
accusations were made, and she is not required to report an accident. I then asked Lucresia
why falls are reported if they are accidents. Lucresia stated "that is not something I can
answer." Lucresia believed that the knot occurred as a result of Robert getting up and taking
it off. However, Robert had a longer extension tubing that allowed him to get up and move
around without disconnecting the tubing from his nose.

Lucresia was sworn to statements. Her interview was recorded.

On 11-6-2015 I removed the camera from Robert's room. Tbe camera was not functional
appropriate for what we needed. This camera required an officer/detective to change out the
SIM card everyday and this optiou was not feasible. Removing and changing the SIM card
everyday could possibly raise suspicious from staff and patients. The camera was also large
and bulky, making it hard to place inconspicuously. Robert was told to contact me should any
further incidents occur.

Based on the above documentation, I have no further investigative leads to follow in reference
to Robert's tubing.

However, based on the actions by the staff at Bay Side Manor, several Florida State Statutes
were violated.

On 11-2-2015 wben we met with the administration, we were both told that AHCA and APS
would be notified. Both those agencies having knowledge are required by law and could have
possibly assisted our investigation. Latasha never mentioned notifying Brian Spencer and in
doing so possibly jeopardized that investigation. By Latasha notifying a potential suspect, she
interfered with an active police investigation and is in violation of Florida State Statute
843.02, a first degree misdemeanor.

On this same date, we asked for the nurse's (Lucresia) contact information. At this time, we
did not even have a name. We were told by Kristin, Latasha, and Mary Ann that they were

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not sure who was Robert's nurse and/or who assisted with the knotted tubing. I asked again
on Tuesday, 11-3-2015, if they had determined who Robert's nurse was and they stated they
would have to go "to the second floor" to locate the information. It was later determined in
my interview with Lucresia, that she was called on Monday evening and on Tuesday by
Kirstin, in reference to this incident. They also investigated this incident and met with the
family in regards to this incident. Lucresia was the nurse who left the tubing and a note for
Amber. I can only assume that Amber would have told the administration how and by who
she received it. This leads me to believe that the administration purposely withheld this
employee's information, in an attempt to speak with her first and possibly corroborate their
statements. Withholding this information obstructed my investigation, also violating Florida
State Statute 843.02, a first degree misdemeanor.

On 11-5-2015 it was discovered during Lueresia's statement that some accidents, involving
patients, are reported immediately. She went to on say that the knot was tied loosely so she
did not believe this to be intentional, even though Bruce was adamant that it was
intentional. Bruce F was so convinced, that he told Lucresia he was taking a
photograph and then repeated that he thought it was intentional. The photos of the knot
clearly depict flat areas on the tubing where, clearly, the tubing was obstructed, to the point
that the tubing had to be replaced. Two other witnesses also claimed that the photo was a
loosened version of the knot. Lucresia's statement about the knot were positively untrue.
Knowingly providing false information to a law enforcement officer during an investigation in
a violation of Florida State Statute 817.49, a first degree misdemeanor. Furthermore,
Lucresia is classified as a mandated reporter of abuse or suspected abuse as stated in Florida
State Statute 39.205 and is required by the state statute to notify the Florida Abuse Line.
Failure to report is considered a third degree felony.

At this time, I do not have probable cause to make an arrest for elder abuse, in regards to
Robert. &. However,several violations of Florida Law were committed by employees of
Bay Side Manor. In lieu of criminal charges, I am requesting the Agency for Health Care
Administration (AHCA) investigate this matter. I feel that the issues would be better handled
by this agency.

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Status: APPROVED t 3/15/2016 09:28

On 1-12-2016 I spoke with Chrystal with ACHA. She is an operator for the 888 line. This
report was faxed to the Complaint Administration Unit with ACHA at phone number
850-488-6094.

I recommend this case closed.

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