MOUNT HOLLY >> Burlington County Jail staff, including nurses, were negligent in their duties resulting in the 2014 death of inmate Jerome Iozzia, according to a signed expert report from a Registered Nurse with more than 20 years of professional experience.
Jail staff and/or nurses then tried to cover up their negligence by altering documents related to Iozzia’s care, according to the report, which outlines a myriad of ways medical staff deviated from the Standards of Practice and protocols of nursing, as well as internal standard operating procedures.
The report, filed in civil court last week, is signed by Helen Strasko, a Licensed Professional Registered Nurse in Manchester. She was asked to review hospital and jail medical records and evaluate the circumstances surrounding Iozzia’s death. Strasko is expected to testify as an expert witness in the case against BCJ and companies that provide its medical care, which is scheduled for trial in January 2017.
Iozzia, 50, died in BCJ on Feb. 25, 2014. His demise, along with the December 2013 death of 75-year-old Robert Taylor, sparked a Trentonian investigation that revealed the poor quality of healthcare and unsanitary conditions inside the facility.
Burlington County prosecutors have said neither death was the result of criminal wrongdoing, and a medical examiner ruled both deaths the result of natural causes.
Doctors and medical specialists said both deaths could have been prevented with proper medical care.
“The prosecutor’s office should reopen the investigations of these two deaths,” Robert Fuggi, the attorney representing Iozzia’s estate said in an interview last week. “Somebody should be held criminally responsible.”
Iozzia’s medical records and the jailhouse letters he sent to his fiancee outline a horrifying three-months of despair. Suffering endured during the final months of Iozzia’s life was communicated to others.
“Animals in a veterinary clinic are treated better than he was,” Fuggi said. “Whether someone is in jail or in a hospital, they deserve to be treated with dignity. They treated him like an animal.”
Iozzia’s family filed a $25 million lawsuit against the state of New Jersey, Pemberton Township Police, the Department of Corrections, now-retired warden Lawrence Artis and medical personnel who were responsible for his care at the time of his death.
Pemberton PD and the State have since been dropped from the lawsuit after a judge ruled the tort claim notice against them was filed outside of the 90-day period required by law.
“Even some well-educated people don’t know about these strict requirements to file a tort claim notice,” Fuggi said. “It’s kinda unfair. Pemberton police got out on a technicality.”
According to his fiancee Jasmine Rodriguez, Iozzia – known affectionately as “Jerry” – had a history of struggles with substance abuse. He was battling those demons when he took Rodriguez’s car without her permission.
On Nov. 15, 2013, Iozzia was arrested after Pemberton Police found him driving that car on Lakehurst Road. During the arrest, Jerry fought with police and was pepper sprayed during the struggle.
The active ingredient in pepper spray is capsaicin, which among other dangers, is hazardous to inhale. In fact, severe overexposure to capsaicin can result in death, according to ScienceLab.com.
Iozzia’s arrest documents say he was pepper sprayed after running “directly into a chain link fence,” and that the spray “had little to no effect” on him. Documents also say he continued to resist attempts to place him in handcuffs after being sprayed.
Court documents allege that Officer Edward White “unnecessarily” sprayed an “excessive” amount of pepper spray during the arrest, even after Iozzia was tackled to the ground. Documents also say Iozzia “suffered heart palpitations, chest pain and shortness of breath” as a result of an “excessive use of pepper spray,” and that he became immobile.
Jerry had a history of paroxysmal atrial fibrillation after having a pulmonary vein isolation in 2006. At times, the top chambers of his heart beat out of sequence with the bottom chambers.
That was the condition of his heart when Jerry was admitted into Lourdes Emergency Department at Deborah Heart and Lung Center. He was later transferred to the hospital’s electrophysiology (EPS) floor, which specializes in treating patients with irregular and life-threatening heart rhythms.
Iozzia was implanted with a pacemaker to treat an irregular heart rate, and on Nov. 19, he was released to prison in stable condition with discharge instructions stating: “In the case of developing fevers, chills, pain, drainage or discharge from the pacemaker site, he is to come back to the hospital.”
Jerry was scheduled for three follow-up visits: one with the wound clinic seven days later, one with the EPS clinic four weeks from discharge, and one with the pacemaker clinic on February 17, 2014.
He never made it to any of those appointments.
“It was imperative to ensure he kept the clinic appointments,” Strasko said in her report.
Jailhouse letters sent from Iozzia to his fiancee show he complained to jail staff about his heart condition, but received little help.
A letter dated Dec. 30 states: “Call my mom and tell her they are gonna let me sit here for ever (sic). And are not takin (sic) care of my heart. Got my meds all messed up. And still no follow up visit to adjust my pacemaker.”
A letter dated Jan. 25 states: “This thing in my chest is really starting to bother me. Need to get out of here to go back to Deborah hospital to get this adjusted, but they won’t send me back.”
Failure to send Jerry back to Deborah was not only a deviation from the accepted standards of nursing care, but it also violated the jail’s internal standard operating procedures, which requires the medical department to ensure inmates have access to healthcare needs around the clock and receive all care ordered by a doctor.
Strasko’s report also says Iozzia should have been placed on a cardiac monitor after being discharged from the hospital, which would have alerted jail medical staff to issues long before Jerry collapsed and passed out on the evening before his death.
The report also questions why no medications were found in Iozzia’s blood or urine after his death, and why no reason for withholding his medication was provided on jail medical documents.
Jerry’s discharge paperwork from Deborah says he was prescribed Sotalol to treat an irregular heartbeat, and Eliquis to reduce blood clots. Yet, the autopsy toxicology report says no medications of any kind were found in his bloodstream or urine.
“Once administered, these medications should have shown up on the laboratory tests,” the expert report states.
On jail medical forms obtained by this newsroom, it appears Iozzia signed Corizon Health forms refusing medical treatment on two dates in November and one in December. The lawsuit alleges someone forged Iozzia’s signature on those documents.
The expert report says jail medical staff failed to frequently and properly document Jerry’s vital signs as required by nursing procedures, and that allegations of Iozzia refusing to have his vital signs checked are “highly self-serving” considering he had requested medical care and treatment throughout his time at BCJ, according to letters he sent to loved ones.
“Why would he be refusing these important vital sign checks?” the report says. “There’s no documentation that shows why he was refusing these particular vital sign checks and is inconsistent with his requests for care and treatment. This gives rise to whether [jail medical documents] were altered or changed along with the nurses notes.”
Corizon’s contract with BCJ began in January 2008 and ended in December 2013, according to a company spokesperson. The contract was then awarded to CFG Health Systems through a proposal process. Because Fuggi does not know when the jail documents were forged, both Corizon and CFG are named in the lawsuit. Corizon and CFG spokespersons said its policies forbid comment on litigation.
According to Iozzia’s autopsy report, his tooth was extracted on Feb. 21, and he never received antibiotics to prevent infection. While recovering from the abscessed tooth extraction, an infection moved from Jerry’s oral cavity to his right lung, according to Strasko’s report.
The autopsy says “tan pus” filled the “subcutaneous pocket” containing Iozzia’s pacemaker, and that “an early fibrinous empyema” surrounded his right lung. It also states that “clumps of fibrinous clot” were attached to three pacemaker leads.
The autopsy report lists pneumonia/empyema/sepsis as Jerry’s cause of death. Strasko’s report alleges those conditions were a result of negligence, particularly the lack of proper medication to treat both the pacemaker implant and the tooth extraction.
Strasko’s report says there were signs suggesting Iozzia had a septic infection, as noted in jailhouse letters sent to his fiancee, as well as notes by nurse Regina Evans stating that he needed help walking around.
“The fact Mr. Iozzia needed assistance to walk around demonstrated a change in his physical status and was not further investigated by jail or nursing staff,” the report states.
Strasko also says Jerry should have been given something other than bologna sandwiches to eat because of its high-sodium content. Jerry would have benefited from a low-sodium diet since he suffered from an irregular heart rate and hypertension, which would predispose him to problems with fluid overload in his lungs or extremities, the report states. The extra salt would contribute to his body not being able to rid itself of fluid.
The report also says Jerry’s later refusal to eat breakfast indicated a change in his physical and mental status, which should have been investigated and documented by jail staff.
“Refusal to eat signals not feeling well and the slowing down of the gastrointestinal tract’s digestion of food,” the report says. “Burlington County Jail staff and Nurse Evans, LPN were negligent in the care and treatment of Mr. Iozzia resulting in his death.”
But even after all that, there still may have been a chance to save Jerry’s life.
According to court documents, on the morning of Feb. 25, 2014, Iozzia collapsed in his cell while brushing his teeth, and a correction officer who found him slumped over the sink requested medical assistance. Nurse Evans’ notes say she responded to the call for help and found Jerry lying face up in a puddle of water. Due to the water on the cell floor, Evans was unable to use an automated external defibrillator (AED) to shock Jerry’s heart and restart its rhythm.
Strasko’s report says Evans and jail staff should have gathered blankets, bed sheets or other dry material, and then moved Jerry to a safer environment where an AED could’ve been used during the 10 minutes it took for paramedics to arrive at the jail.
“Rapid defibrillation is the single most important factor in determining the survival of a person,” Strasko says, citing best practices and procedures for treating cardiac arrest in the report. “The failure to move Mr. Iozzia to a safer area and employ the AED device to restart his heart directly contributed to his death.”
Burlington County officials were unavailable to comment on this report due to the holiday.
