DENVER - Facing the possibility that one of their 77-year old patients had been sexually assaulted in one of their private suites, managers at Advanced Health Care of Aurora moved to keep the potentially damaging story away from their patients and staff, according to a state report obtained by 9Wants to Know.
Investigators with the Colorado Department of Public Health and Environment eventually chastised AHC management for failing to “conduct and document interviews with individuals pertinent to the investigation and to follow up on findings.”
Police won’t comment if the lack of a substantive internal investigation impacted their criminal investigation, but 15 months after an elderly and “unresponsive” patient arrived inside an Aurora emergency room with injuries nurses believed to be consistent with a sex assault, police have yet to identify a single suspect in a case that appears to be stalled.
AHC calls the allegations “unfounded” and suggests “surveillance video on the patient area and the Police investigations rule out” the family’s claims.
Aurora Police say that’s not necessarily true. The head of the Aurora Police Sex Crimes Unit calls the police investigation “open and ongoing,” adding the department hasn’t ruled anything in or out as of now.
Family and friends of Susan Mason believe the woman they affectionately called “Sue” deserved better.
“I think this broke her,” her daughter Carolyn Mason said.
Less than two days into Sue Mason’s stay inside Hall 3 of Advanced Health Care’s Aurora facility, something happened. Not long after 6 a.m. on Nov. 9, 2017, a nurse called 911 after finding Sue “unresponsive” in her room, according to a Colorado Department of Public Health and Environment (CDPHE) report.
At 6:55 a.m., paramedics took her to The Medical Center of Aurora. The hospital is three blocks away from AHC of Aurora.
According to a Sexual Assault Nurse Examiner (SANE) report reviewed by 9Wants to Know, staff at the hospital suspected a sexual assault due to the nature of Sue’s injuries around her genital area.
Someone at the hospital phoned Sue’s daughter who was in California at the time in need of verbal consent to do a sex assault examination. Carolyn Mason, stunned, said yes before hanging up her cell phone.
“I held it together until I got to my car, and then I lost it. I really didn’t know what to do,” Carolyn Mason said.
A family friend and attorney, Julie Groves, agreed to go to the hospital to help witness and document the SANE exam.
Intubated at the time, Sue Mason was conscious but unable to speak.
“Obviously, she was terrified,” Groves told 9Wants to Know.
Slowly, nurses started asking Sue Mason questions.
Were you assaulted?
According to the SANE exam, “She nodded yes.”
Was he white?
“She nodded yes.”
Someone with the hospital notified the Aurora Police Department. The Sex Crimes Unit was assigned to the case.
The next day, as doctors removed the ventilator tube, Groves said, “The second they removed the tube the very first thing [Sue] said to me was, ‘I was mugged.’”
According to an affidavit made under penalty of perjury, Groves also recalled, “The SANE team and I noticed bruising on Sue’s neck that had not been noticeable the previous day.”
Later that day, again according to Groves’s affidavit, “Sue described to me in detail that attack that occurred at Advanced Health Care.”
“Sue described that she was in her bed at Advanced Health Care and that a man came to her door and asked to use her bathroom. She agreed. When he exited her bathroom he ‘coldcocked’ her and hit her around the head and neck area,” Groves suggested.
Sue Mason would go on to recover from her physical injuries, but mentally, her daughter said, her mother was never the same.
“I think this finally broke her, I mean, I think probably more about the humiliation,” Carolyn Mason said. “I think she just didn’t know how to come back from it.”
Julie Groves said her friend remained frightened for months. “She was very fearful, and that was not the Sue I knew,” Groves said. “She insisted on having her bed face the door, she insisted on having the [bedroom] door open, and she did not like to be left alone.
Sue Mason passed away on Feb. 8, 2018.
“She was terrified up until the day she died. She didn’t deserve this,” Groves said.
Sue Mason was known for her smile, her determination, her wit and her opinions.
“She skied. She played tennis. She was just willing to try anything,” Carolyn Mason said. “Every hurdle that came in front of her, she leapt over and continued going.”
She loved to travel to places like Turkey. Adventurous through her core, Sue Mason loved life.
In October 2017, however, COPD started to take over Mason’s ailing lungs. She was hospitalized for a few weeks. On Nov. 7, 2017, she went to AHC of Aurora for what was supposed to be a short rehab stay.
Two days later, she came via ambulance to The Medical Center of Aurora in bad shape.
A forensic nurse involved sex assault examination who did not want to be identified due to the sensitive nature of the case told 9Wants to Know, “I absolutely believe this was a sex assault. I don’t know what else the injuries I saw could be from.”
“Whoever did this left her for dead,” the nurse added.
Aurora Police won’t say much on what their officers still consider to be an open investigation, but interviews done by 9Wants to Know indicate that investigation has stalled.
Sgt. Rudy Herrera, head of the department’s Sex Crimes Unit, told 9Wants to Know the case hasn’t concluded anything.
“It is open and ongoing,” he said. “At this point, we don’t have evidence a crime did or did not occur at this facility.”
Part of the problem is that video surveillance provided by AHC has failed to show a suspect. “The door to [Sue Mason’s] room, on security video, that door is not fully visible.”
In addition, no substantive DNA evidence has been collected.
A week before Mason died, she helped file a civil lawsuit against AHC of Aurora. The lawsuit – which alleges Sue Mason was “sexually assaulted at AHC” -- has yet to be resolved. While the suit was initially filed under the name Jane Doe, her family has since elected to use her name in the lawsuit and for the purposes of this story.
The lawsuit alleges, among other things, that “sometime on the night shift on November 8-9 , Plaintiff was brutally assaulted while in her bed at AHC. The assault was both sexual and physical.”
Groves said Mason believed she had been sexually assaulted by an object.
AHC of Aurora has denied the allegations outright -- first in a email sent to Groves in November 2017 -- that asked Groves to “refrain from making any such additional statements” regarding a police investigation that had not “determined that an assault occurred in our facility.”
On February 16, attorney Catherine O’Brien Crum responded to specific questions asked by 9Wants to Know with the following response: “On behalf of Advanced Health Care of Aurora, unfortunately, we cannot comment on pending litigation except to say that we have denied the allegations as unfounded.”
She would not say which of the allegations AHC wished to deny.
Wednesday, Crum provided an additional statement to 9Wants to Know that stated the following:
“AHC of Aurora and the Aurora Police have done thorough investigations and found no support for the allegation. Surveillance video on the patient area and the Police investigations rule out the allegations. The facility doors are locked and alarmed for security. The seasoned and compassionate staff cared for this patient in a competent and compassionate manner. Her medical condition was fragile following her discharge from Swedish Hospital and transfer to AHC of Aurora and she was transferred for a higher level of care appropriately. It is noteworthy that an allegation of assault was made by this patient previously when she was admitted to Swedish Hospital as well. Although we have not been provided the medial records from the Medical Center of Aurora, there are likely sound medical reasons for the alleged findings based on this patient’s prior medical history and delirium at times.”
Crum could not provide specifics as to the previous allegation of assault other than to say, “It was not a report that it happened [in Swedish Medical Center]. Rather, simply a report by the patient she had been assaulted but could not remember when.”
9Wants to Know reached out to a representative of Swedish to try to independently verify the claim, but are still waiting on a response.
As for the claim that police had “found no support for the allegation” made by Mason and her family with regard to Mason’s 2017 stay at AHC of Aurora, Sgt. Herrera would only say his investigation has not come to any conclusions.
In addition, CDPHE cited AHC in 2018 for its handling of the investigation.
In its report, obtained by 9Wants to Know, CDPHE said AHC “failed to thoroughly investigate allegations of possible resident abuse.”
For example, CDPHE found the facility’s management “did not have any direct interview with the staff that took care of the resident.” Instead, AHC management chose to ask multiple staff members these four “general questions”:
- In the last 72 hours have you witnessed anything inappropriate as far as care or anything abnormal for patient in room (redacted)?
- In the last 72 hours has the patient indicated to you any concerns or anything abnormal or out of the ordinary to you?
- In the last 72 hours did you notice anyone who didn’t have reason to be in room (redacted)?
- In the last 72 hours have you seen any visitors on non-staff members go into room (redacted)?
The CDPHE report said, “There was no indication that any follow up had been conducted with the results of these questions.”
CDPHE went on to report “several staff members mentioned seeing a ‘woman/caregiver/nurse/lady in hat/family/friends’ in a resident’s room, but no follow up was made to indicate if this person/persons were identified, if they were the same person and if they were allowed to be in the facility.”
CDPHE investigators also found AHC management sent three generic questions to only four of the 17 residents who lived in Mason’s hallway. The questions were:
- How has your stay at our facility been so far?
- How has the staff treated you?
- Do you have any concerns with the care you are receiving?
The report concluded, “No issues or concerns were identified.”
The lawsuit alleges AHC failed “to investigate the circumstances surrounding [Mason’s] assault” and failed “to monitor or investigate the presence of unfamiliar persons entering the building during the night.”
Groves, for her part, called AHC’s initial investigation “close to non-existent or sloppy at best.”
Crum did not provide a response to the CDPHE report.
CDPHE is the state’s sole regulator of health facilities. When a facility gets into trouble, it’s up to investigators with CDPHE to go into the facility to figure out what might or might not have happened.
Those investigators then put together a report that’s designed to be publicly available.
In the AHC case, CDPHE finished its report in February 2018.
CDPHE is supposed to keep an updated list of its investigations into facility deficiencies online here, but when 9Wants to Know checked for deficiencies related to AHC of Aurora related to an initial complaint lodged by Carolyn Mason in early 2018 the term “no citations were found for this survey” popped up.
“That was a failure of our computer systems,” said Randy Kuykendall, the division director for CDPHE’s Health Facilities and Emergency Medical Services. “It absolutely should have been online.”
When 9Wants to Know asked Kuykendall why a credible allegation of assault went unreported on CDPHE’s inspections for more than a year, Kuykendall responded, “So, Chris, that is something we never would want to see happen again.”
He pledged to have his staff put the report up right away. As of Wednesday morning – a week after the interview – the report was still not linked to the facility on the state’s website.
It can, however, now be found in a separate section on CDPHE’s website.
Peter Myers, complaints and occurrences section manager for CDPHE, told 9Wants to Know, “Due to the nature of the problem with our website we were unable to post it directly to the facility's page. In anticipation of your story, we created an "In the News" section on our website.
You can find it here: https://www.colorado.gov/pacific/cdphe/health-facilities-news
This page contains the Advanced Health Care of Aurora survey results for your story, as well as another survey that we found was missing.”
On the state’s website, CDPHE says, “The search function for finding results of facility inspections isn’t working correctly. We’re working on resolving this problem. Meanwhile, if a facility inspection is either blank or states no citations were found for this survey, you may contact Michael Lastoczy, Records Manager, by email at Michael.email@example.com.”
You can also go to this website to look up Centers for Medicare and Medicaid Services data/inspection reports for various facilities.
For tips on this or any other story, contact firstname.lastname@example.org