What began as a routine early morning diaper change for 73-year-old Catherine Gotcher-Girolamo by a nursing assistant at the Avocado Post Acute nursing home in El Cajon, turned into one of the most horrifying experiences of her life.
“I asked him to stop and he kept telling me that he had to clean me,” Gotcher-Girolamo said of the encounter on June 19, 2019. “And I kept saying, 'no, you're hurting me here.' He kept hurting me. I just went limp. It was really horrible.”
Gotcher-Girolamo told other caregivers at Avocado that morning about what had happened and she said she made it clear she was sexually assaulted, even telling them she felt "sodomized," according to a California Department of Public Health (CDPH) investigation.
Responses from the staff to Gotcher-Girolamo were mixed, she said in an interview with KPBS. Some expressed immediate concern, but others “were acting like they weren't sure they believed me,” she said.
Still, she was convinced her allegations would be taken seriously by Avocado’s management and they would take swift action against the caregiver, who has been identified as Matthew Fluckiger.
“I expected them to fire him immediately,” Gotcher-Girolamo said.
California law requires more than that. The law mandates that staff report all allegations of “abuse, neglect, exploitation or mistreatment” to management immediately. The facility is then required to report allegations of sexual abuse or abuse of serious bodily injury to both the local police and CDPH immediately, but no later than two hours.
None of that happened, according to the state investigation. Avocado made no report of sexual abuse, only that Gotcher-Girolamo was subject to “rough handling.”
Abuse suffered by residents of nursing homes has been a nationwide issue for decades, with advocates continuously pushing for stronger oversight and enforcement to halt the abuse. But Gotcher-Girolamo’s case exposes wide gaps between what is supposed to happen when abuse occurs in nursing homes and what sometimes actually happens.
In this case, Fluckiger was allowed back to work after a two-day suspension.
When a shocked Gotcher-Girolamo asked why she was told that he’d been cleared of wrongdoing and wouldn’t be caring for her anymore, said Scott Fikes, a lawyer representing Gotcher-Girolamo in a lawsuit against Avocado.
“She'd been through the trauma of a sexual assault. And then now you have this almost, you know, disorienting and terrifying event of seeing this person back where you live,” Fikes said.
State investigators also had a harsh assessment of the decisions made by Avocado’s management. “The inaccurate reporting had the potential to put other [Avocado] residents at risk of sexual abuse,” the CDPH investigators said in their report.
And the impact went beyond Avocado, according to interviews and other documents reviewed by KPBS.
The facility did eventually file a report with the El Cajon Police Department, but not until eight days after the alleged assault. Because of the delay, police were not able to gather vital evidence that could have led to a quick arrest, say Fikes and others with knowledge of the case.
This meant Fluckiger was free to find work elsewhere. Less than two months after Gotcher-Girolamo made her allegation, he allegedly jumped on an elderly resident of San Diego Post-Acute Center, another El Cajon nursing home, and fondled her breasts, according to documents obtained by KPBS.
State investigators also revealed that Fluckiger had been accused of sexual misconduct at another nursing home before Avocado hired him.
“It was alleged that he propositioned a patient there, that he would provide them a carton of cigarettes in exchange for oral sex,” Fikes said.
It wasn’t until this August, more than a year after the CDPH initiated its investigation into Gotcher-Girolamo’s allegations against Fluckiger, that the department revoked his license to work as a nursing assistant.
Jon Cohn, a lawyer for Avocado, refused comment on Gotcher-Girolamo's allegations, citing her lawsuit. A CDPH spokesperson would not comment on the investigation.
A KPBS reporter confronted Fluckiger at the front door of his home in El Cajon regarding the allegations. He immediately said "no statement" and shut the door when the reporter identified herself.
Many complaints
Avocado has, in recent years, a large number of complaints to state and federal agencies alleging that the facility routinely falls short in its responsibility to care for residents.
From 2017 through Oct. 5 of this year, 462 complaints were filed against the nursing home, according to the department of public health. Fifty-six of those complaints were filed this year alone, more than four times the statewide average.
Over the years, inspectors have cited Avocado for lax infection control, abuse of residents by other residents and staff, poor supervision and falsifying records.
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In response to questions about its complaint history, Cohn, Avocado's lawyer, said many of the complaints are self-reported and that Avocado should be expected to have a relatively high number of complaints because it is much larger than most nursing homes.
However, advocates for nursing home residents say the facility has a high number of complaints even when factoring in its size.
And so far this year, among nursing homes in San Diego County, Avocado has had the second-highest number of residents who tested positive for COVID-19 among nursing homes in San Diego County, according to CDPH.
Mike Dark of California Advocates for Nursing Home Reform said Avocado’s record is particularly bad. However, he said while shocking, the series of events relating to Gotcher-Girolamo’s alleged assault are not surprising. Repeat abuse often happens in long-term care facilities because caregivers are poorly trained and paid so little which leads to high staff turnover, Dark said.
“They rarely stay beyond a few months and then they go on somewhere else,” he said. “There isn't often much due diligence given to these people when they begin because they need someone who will do very difficult work for almost no money. And then the guy goes on to re-offend again.”
That’s why lawmakers and regulators have been unsuccessful at reducing abuse in nursing homes nationwide.
“Seniors in nursing homes are among the people most vulnerable to the life-threatening consequences of abuse and neglect,” said Sen. Ron Wyden (D-Ore.), during a senate hearing in 2019. “Across this country, that vulnerability is being exploited in unimaginably cruel ways.”
Failures on multiple levels
Gotcher-Girolamo’s case is an example of how a system set up to protect vulnerable seniors still fails.
Like in all nursing homes, every member of Avocado’s staff is a “mandatory reporter,” meaning they are required by state and federal law to report allegations of abuse to the proper authorities.
The CDPH investigators confirmed Gotcher-Girolamo's assertion that she told at least two staff members about the incident on the morning of June 19, and Avocado’s administrator, Dina Mookini, that day.
Still, Avocado’s management largely blamed the failure to make a timely report on two low-level staffers, according to the state investigators’ report.
The first people to see Gotcher-Girolamo on the morning of the alleged attack were another certified nursing assistant and a licensed vocational nurse, according to the CDPH report.
Both acknowledged that Gotcher-Girolamo told them she’d been “sodomized” by Fluckiger, saying he put his fingers inside her, the report said. However, neither the nursing assistant nor the nurse honored Gotcher-Girolamo’s request to report to management that the allegations were sexual in nature because they assumed someone else did, the report said.
That might be irrelevant because Gotcher-Girolamo asserts in her lawsuit that she told Mookini that she had been sexually violated hours after the alleged attack happened.
Yet, Mookini still told CDPH inspectors that she investigated an “allegation of rough handling” on June 19. She said Gotcher-Girolamo “did not allude to the incident being sexual, but that [her] story seemed to ‘evolve,’” according to the state report.
Avocado’s director of nursing said something else, according to the CDPH report. “The director of nursing stated [Gotcher-Girolamo’s] sodomy allegation was present right away and the resident’s story did not evolve,” the report stated.
In her lawsuit and in an interview with KPBS, Gotcher-Girolamo said she remained consistent from the beginning in describing what happened to her. She states in her lawsuit that Mookini entered her room and accused her of “never telling” [Mookini] or any other staff member that [Fluckiger] sexually assaulted her.”
The lawsuit goes on to say: “[Mookini] was trying to intimidate her and make her feel stupid and question her own understanding and recollection of events.”
Gotcher-Girolamo’s doctor told CDPH investigators her story was believable and she “was not known for making things up and he would consider the resident to be a reliable historian.”
Avocado’s director of nursing admitted to CDPH investigators that "I think we could have done a more thorough investigation." And Mookini told investigators “we could have done better,” according to the CDPH report.
In the end, Avocado was cited by CDPH for three violations relating to its improper reporting of what allegedly happened to Gotcher-Girolamo.
The El Cajon Police Department’s investigations of Fluckiger relating to Gotcher-Girolamo’s allegations, as well as those from the other two nursing homes, are still ongoing, according to Fikes. The department did not return repeated calls from a KPBS reporter.
Feeling 'insignificant'
Dark of California Advocates for Nursing Home Reform said “atrocities” like this will continue to happen until authorities get serious about boosting caregiver pay and requiring more training.
“We have to start taking health care for older people seriously,” he said.
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Gotcher-Girolamo, who left Avocado last fall, said she wishes she had been taken seriously. Additional records show the nursing home has in the course of her lawsuit tried to get her to sign paperwork stating she could have refused to allow Fluckiger to “rub on” her during the assault.
Those records show the facility also wanted her to agree with its contention that she herself could have reported the alleged incident to police.
She said the whole experience has left her feeling “very insignificant.”
“I was sexually molested in what should have been a safe environment,” Gotcher-Girolamo said. “I was not protected. And when I went for help, I did not get it immediately. And of course, the person who did this to me is still out there. That’s very disturbing.”
