--from Samaritan Health System's Mission Statement
The right to be free from misappropriation of funds, and from medical, psychological or physical abuse.
--Number 14, Good Samaritan Care Center Residents' Rights
Jafet Coronado worked as a certified nursing assistant at Good Samaritan Care Center, for $6.49 an hour, the sole support of his wife and child. In May 1995, he was fired from the transitional care facility, charged by the Maricopa County attorney with sexually assaulting a patient and a co-worker while on the job, and jailed. Because he didn't have $15,000 to post as bond for the $150,000 bail, Coronado's aunt and uncle put up their own real estate to get him out of jail. Coronado got a new job as a used-car salesman, where he could be expected to make enough to scrape by.
Then, while Coronado and his family regrouped to face his accusers in court, providence smiled on him. Miraculously, it would appear, Coronado came to be represented by Tom Henze, one of the highest-priced criminal defense attorneys in town. Henze works for one of the most prestigious law firms in town, Gallagher and Kennedy. His client list includes the likes of Hap Tovrea, Jake Plummer and James Robson.
Now a minimum-wage guy who can't even raise his own bail bond has found his way onto Henze's distinguished client list. Is Henze a charitable fellow? Possibly. Is he a smart lawyer who knows how to serve a deep-pocketed client? Absolutely. And by defending Coronado, he is doing just that. Samaritan Health System--the umbrella organization that includes Good Samaritan Care Center, Coronado's former employer--is footing the bill for Coronado's legal defense. Why is Good Sam interested in Coronado's defense? Simple: If Coronado is convicted in the Sian Pitonzo case, Good Sam's liability in a potential million-dollar civil lawsuit filed by one of the alleged abuse victims is established.
On January 3, 1996, Jafet Coronado was indicted by a grand jury in Maricopa County Superior Court, charged with three counts of sexual assault and two counts of sexual abuse.
Angela Fulmer, a fellow nursing assistant at Good Samaritan Care Center, accused Coronado of cornering her in a patient's bathroom and grabbing her breast. She alleged that Coronado then forced her hand down his pants to his penis and forced his own hand down her pants, penetrating her vagina with his fingers.
Sian Pitonzo, a quadriplegic patient, accused Coronado of fondling her breasts and forcing his penis into her mouth.
Last month, on the advice of his attorney, Jafet Coronado pleaded guilty to one count of sexual abuse, a felony under Arizona law: He admitted grabbing Angela Fulmer's breast. Tom Henze had made a deal with the prosecutor, and the other four counts were dismissed. Coronado admitted no wrongdoing with regard to Sian Pitonzo.
Henze was officially representing Coronado's interests, but it's hard to miss the fact that the outcome of Coronado's case benefited Samaritan Health System.
Sian Pitonzo and her family are suing both Coronado and Samaritan Health System, holding Good Sam responsible for putting Sian Pitonzo at risk. An admission of guilt--or even a "no contest" plea--with regard to the alleged crimes against Sian Pitonzo would have been devastating to the defense of the civil case. Henze represents Coronado in the civil suit, too. Again, Samaritan is paying the tab. Samaritan, a co-defendant in the civil suit, has separate counsel--Lonnie Williams, another high-powered attorney from another high-powered firm, Snell and Wilmer. Although Coronado is named in the civil suit, he isn't really the target. Good Sam has assets and therefore stands to lose the most financially.
Critics would argue that if Henze had acted in Coronado's best interest, he would have either let the case go to trial or cut a deal in which Coronado pleaded "no contest" to the charges.
The prosecution had a weak case. One victim was emotionally disturbed; the other has a severe head injury. Henze could have taken the chance of going to trial and clearing his client of all charges. Or he could have agreed to a plea of "no contest," which doesn't admit guilt but does admit that the state has enough evidence to convict.
Instead, Henze made sure all charges that stemmed from Coronado's alleged assaults on Sian Pitonzo were dismissed, while allowing one of Angela Fulmer's charges to stand in criminal court.
Fulmer's charges seemed not to concern Henze. Perhaps because Fulmer is not suing. The two-year statute of limitations in her case ran out in May.
In any event, Angela Fulmer would not have been available to testify. She's dead. Fulmer committed suicide eight months after her encounter with Coronado. Fulmer was emotionally unstable before she met Jafet Coronado, and her diary reveals she was distraught over the abuse incidents and the treatment she encountered by Good Sam personnel in their aftermath.
While Angela Fulmer and Sian Pitonzo were shown little respect--in fact, Fulmer was eventually shown the door--Good Sam has given Jafet Coronado break after break.
Securing Tom Henze's services is just the latest in a series of moves the organization and its employees have taken to protect Jafet Coronado in its campaign to cover its own butt.
Henze, prosecutor Kevin Rapp, Good Sam defense attorney Lonnie Williams and Jafet Coronado refuse to comment on Coronado's case. But hundreds of pages of police interviews, civil and criminal case records, Angela Fulmer's personal diary and Jafet Coronado's personnel record reveal the efforts Good Sam's and Coronado's lawyers have made to insulate their clients from liability in the civil case. The records clearly demonstrate a pattern of poor work habits and allegations of improprieties on the part of Coronado and a series of contradictory actions on the part of Good Sam personnel.
Good Sam employees, even in the face of their own contradictory records, maintained in police interviews and depositions that Coronado was a model employee.
Coronado was hired in 1994, despite that he faced a felony conviction in federal court for gun smuggling. If the nurse who hired Coronado had checked his references, she would have learned he had recently been fired from a nursing assistant job where he'd been accused of taunting patients.
At Good Samaritan Care Center, despite that he earned below-average performance reviews and was written up for tardiness, absences, mistreatment of patients and sexual harassment, Coronado was given two merit pay raises during his 14 months on the job.
After Coronado was eventually fired--accused of assaulting Angela Fulmer and Sian Pitonzo--Good Samaritan employees sang his praises to police and lawyers investigating the case. And last spring, when Joe Pitonzo and Vicki Johnson, Sian Pitonzo's parents, filed their civil suit in Maricopa County Superior Court, Good Sam promptly hired Tom Henze to assist Coronado's own budget-priced lawyer in the criminal case, and to represent him in the civil case.
Henze's going rate is about $250 an hour, but his total bill would be chicken feed compared to what Sian Pitonzo could get from a jury.
Joe Pitonzo blames both Good Sam and Coronado for the abuse his daughter allegedly suffered.
"Their [Good Sam's] conduct is just as outrageous, if not worse. They knew better. They were in a position to stop it."
As for rising to Coronado's defense, even after firing him? "They're very clear," Joe Pitonzo continues. "They're financially driven. It's an amoral approach to business."
Good Samaritan Care Center is a transitional-care facility, designed for patients who aren't sick enough to be in the hospital, but who still need constant care they can't get at home. Typical patients are recovering from surgery, receiving chemotherapy or, like Sian Pitonzo, have been in a devastating accident and need rehabilitative services.
According to its promotional brochure, the center relies on both licensed practical nurses and certified nursing assistants to provide care for patients like Pitonzo, who was unable to walk, feed or bathe herself.
Jeanette Slack, director of nursing at Good Samaritan Care Center, received a call in March 1994 from a colleague in California. When questioned later, she could only remember the woman's first name, Judy, but did recall that she'd met Judy a few times at nursing conferences.
Slack recalled, "She said, 'I have an excellent nursing assistant by the name of Jafet Coronado. He's wonderful. He's good with his patients. He's moving to Phoenix, and I wondered if you'd have a position open for him.'"
As it turned out, Slack did. Judy raved about Coronado's performance--though he'd only worked for her for a few months, and Samaritan's application asks for references who've known the applicant for more than two years. And Judy offered one caveat.
Coronado was being forced to move back to Phoenix from Southern California to face federal charges of gun smuggling, Judy explained. But, she told Slack, "He's just a kid. He knows he did wrong."
So Slack hired Coronado. If she'd called another of his previous employers, Royal Convalescent Hospital in Browley, California, she would have learned that Coronado was fired after less than two months on the job.
Coronado was given a written warning from Royal Convalescent Hospital after being disrespectful to a female resident and cursing at another resident. He was terminated after it was reported that "You poked a resident in the stomach and teased him about his weight. You also unplugged his television and wore his baseball cap against his wishes."
Jafet Coronado began work as a nursing assistant on the third floor of Good Samaritan Care Center March 13, at $6 an hour.
He was not a model employee.
By mid-June, Coronado had already been written up by a supervisor, nurse Jolynn Chew, for tardiness. A week later, a written review stated he needed constant supervision, and "needs to spend more time doing pt [patient] care rather than stand at desk, or visit with staff."
A few days later, Coronado was transferred to the care center's second floor. That's where he encountered Sian Pitonzo, a quadriplegic. Unlike most of the center's patients, Pitonzo was young, in her early 20s. She had been hit by a bus, and has a severe head injury which makes it difficult for her to speak.
Although it would be almost a year before she'd admit it to police, Gloria Colley, another nursing assistant, had chastised Coronado that summer for fondling Pitonzo's breasts.
In a police interview, Colley says Pitonzo was lying on her back when Coronado cupped her breasts.
"I told him not to do that because that's kind of wrong. . . . I ain't never seen him did that before, you know, until that happened. I--I got onto him about it. I told him not to do that no more, because that's not even nice for you to touch her breasts like that."
Colley continues, "He kind of looked at her, and, you know, I know she didn't like it, and I didn't like it because I didn't want nobody do me like that. And she can't do anything, you know."
She says Coronado told her, "She likes me when I do that."
Also that summer, a written "corrective action" was placed in Jafet Coronado's file, by a registered nurse, Patricia Guelf.
Guelf wrote, "Sexual harassment beginning with frequent compliments of a sexual nature, sexual gestures and an effort to kiss me while cornering me in a patient's room. Jafet had signaled to me to come into a patient's room. Once in the room he directed my attention to the lighted patient's bathroom. While I was walking toward the BR, Jafet closed the door to the patient's room and approached me and tried to kiss me. (No patients in the room at that time.) Since this incident there have been additional sexual overtures."
Margaret Butterly, assistant nursing director, signed the slip, and under "describe improvement expected," wrote, "All behavior which falls under the definition of sexual harassment, including comments, gestures and/or overt behavior of a sexual nature will stop immediately. In addition any offensive behavior will stop immediately and will not be tolerated in the future. Further performance/behavior problems will result in the continued corrective action process, up to and including discharge."
Just four days after the corrective action, on August 26, Coronado was reviewed again. The incident with Guelf was not mentioned; to the contrary, Coronado received a satisfactory review and a pay raise, to $6.24 an hour.
In September, he got a warning for absenteeism.
In November, a patient complained that Coronado didn't change his linens and didn't rinse his urinal after emptying it.
That fall, he had pleaded guilty in federal court to felony charges of gun smuggling and lying on an Alcohol, Tobacco and Firearms application. He was sentenced to probation.
At the end of March 1995, Coronado got another raise, to $6.49 an hour.
On Monday, May 8, 1995, Angela Fulmer walked into Sian Pitonzo's room. Fulmer, a nursing assistant, wasn't surprised to see her friend and colleague, Jafet Coronado. They sometimes lunched together at a nearby Jack in the Box.
According to Fulmer's account, Coronado tried to rub her shoulders as she tended to Pitonzo. She told him she was busy. He told her to get on her knees. She just looked at him; he left. Five minutes later, he was back, and asked Fulmer to help him transfer Pitonzo from her wheelchair to bed. That task accomplished, Fulmer walked into the bathroom to wash her hands.
"As I turned to leave the bathroom," she wrote, "Jafet said what are you going to do for me. I didn't know what to say or do. At that time he grabbed my right hand and stuck it inside his pants. I pulled away from him and tried to go around him. He pulled me back against him and put his right hand down my shirt and his left hand down my pants. I don't remember exactly what I said, but he stopped."
According to her diary, Fulmer reported the incident to her supervisor, Jolynn Chew, about 90 minutes later.
The following day, Pitonzo noticed Fulmer was visibly upset.
Fulmer wrote, "I was feeding Sian Pitonzo breakfast when she asked me what was wrong with me. At first I told her I was OK. A few minutes later she asked me again so I told her. I said remember the guy that was in your room with us yesterday. She said she did so I said that he had touched me and it made me feel very uncomfortable. She looked up at me and said he touched me. I asked her what she meant. She said he kissed her on the lips, neck and breast. He also jiggled her breast, she said."
Pitonzo later alleged that Coronado also pushed his penis into her mouth.
Fulmer approached Affirmative Action--Good Sam's employee grievance department--about what had happened to her. She asked Chew if she should tell them about what Sian had told her, too, and wrote that Chew told her, "Sian is a woman of the 90s. If Affirmative Action asks her she can tell them herself."
Jafet Coronado was suspended from his job May 10, and fired May 12.
When Fulmer approached Jeanette Slack, the nursing director who had hired Coronado, she wrote that Slack said, "'Angie you can't say that Jafet did anything to a patient because you don't know.' I just looked at her. She also said, 'Some things are better left unsaid.'"
On May 26, Fulmer called Vicki Johnson, Sian Pitonzo's mother, and told her about her daughter's statement regarding Coronado.
Fulmer missed a great deal of work in the ensuing weeks; eventually, she took disability leave. She returned to the care center July 12, with a doctor's slip giving her permission to work again. But Fulmer wrote in her diary that she was told by two of her supervisors, Jolynn Chew and Margaret Butterly, that she could not return to work.
She wrote, "Margaret told me you can't come back to work until this mess with the police and Jafet and Sian is all settled. I asked her who's idea is this. She said Risk Management."
That line in Angela Fulmer's diary is the first inkling that Good Samaritan was more concerned about liability than the lives of its workers and patients. Although assistant nursing director Butterly told police she never made such a statement to Fulmer, subsequent testimony did reveal that the entire matter was being handled by Good Sam's risk-management department.
Over the next few months, Fulmer met with Good Sam personnel, eventually getting a new job at a rehabilitation facility associated with Samaritan Health System. But it is clear from her diary, which ends October 9, that Angela Fulmer was a very troubled woman.
Additional documents and interviews indicate that she had attempted suicide in the past, drank on the job and claimed to be HIV positive. So it is unclear how much Fulmer's actions were directly related to what happened to her at Good Sam, and what simply had to do with the fact that she was an emotional wreck.
In November 1995--on the day she was forced to resign from Good Sam--Fulmer showed up at her former supervisor Jolynn Chew's Scottsdale home. Chew insisted on driving her home, because Fulmer appeared drunk, but when they reached Fulmer's north Phoenix home, she pushed Chew away and took off in Chew's truck with her two children, ages 2 and 8. She returned them safely that night, but that wasn't the last visit Angela Fulmer would make to Jolynn Chew.
In mid-January 1996, Fulmer stormed Chew's home and took her 2-year-old son hostage in a bathroom for more than eight hours. The boy made it out okay; Fulmer shot herself to death.
In a police interview, Jolynn Chew admitted that she felt remorse for not listening to Fulmer's accusations regarding Coronado, and "self-reported" herself to a nursing board.
Chew's co-workers showed no such sympathy. In fact, their recollection of events given in police interviews and depositions often varies dramatically from personnel records.
Jeanette Slack, director of nursing, told investigators she barely recalled whether it was a female or male employee who complained about Coronado's sexual harassment in the summer of 1995, and thought the complaint was merely regarding an "inappropriate comment."
Slack said, "The employee came to me and said, 'I have this complaint about Jafet. You know, he said such and such to me.' So I talked to Jafet, and he said that it was just a joke. He did not understand that--that many, many comments can be misconstrued as sexual harassment today. . . . What he told me in response was that this is the way he was raised. . . . He said, 'I thought I was doing what women love.'"
When she saw that the complainant was Patricia Guelf, who accused Coronado not just of making inappropriate comments but of closing her in an empty room and trying to kiss her, Slack blamed it on Guelf. "Patty is obsessed with getting into a relationship, and she also overexaggerates things," she said.
Jeanette Slack's impression of Jafet Coronado's on-the-job performance: "The patients loved him. He was kind, considerate, did a good job. He was wonderful. And they told me that every time I talked to them. They just loved him."
And Margaret Butterly, who signed the corrective action against Coronado, regarding Guelf's concerns, said, "I never got a complaint from any staff member about Jafet."
When Tom Henze was hired as Jafet Coronado's lawyer last May, it wasn't because Coronado didn't have a lawyer. Anthony Zuniga represented the defendant; technically, he continues as a member of Coronado's legal team.
Zuniga says he fully supports Good Sam's decision to add Tom Henze to the criminal defense team.
"He [Henze] is one of the most outstanding criminal defense lawyers in the state, apart from me," he says without sarcasm.
And while Zuniga admits that the civil case was probably at least part of Good Sam's motivation for hiring Henze, he says Henze had Coronado's interests in mind, not Good Sam's.
Henze's presence--and the fact that Good Sam is paying his bills--has not gone unnoticed by Sian Pitonzo, her parents and their attorney, Frank Verderame.
Joe Pitonzo, Sian's father, questioned Henze about it at Coronado's plea agreement hearing.
Henze answered that it is a "normal thing in the legal community" for an employer to provide legal representation in a civil suit in which an employee--even a terminated employee--is being sued.
And, Henze continued, "For reasons that I suspect are Samaritan's, they also felt it was prudent for them to have the same lawyers presenting, assisting in and representing Mr. Coronado in the criminal case because the factual interdependence of the two cases, civil and criminal, were the same."
In other words, if the criminal case got screwed up, and Coronado was actually charged with or pleaded guilty to the allegations regarding Sian, or if testimony damaging to Good Sam was admitted for the record, Good Sam stood to lose the civil case--and a lot of money.
Henze took the safe route. A conviction seemed far from certain. County prosecutor Kevin Rapp didn't have such a hot case. He had two victims: One was dead, and had been emotionally unstable. The other was severely head-injured, could barely speak and her version of events varied from one day to the next.
As one might imagine, Coronado's version of events varies dramatically from his accusers'. He claimed Patricia Guelf and Angela Fulmer both came on to him, not vice versa, and that the day he found himself in a patient's bathroom with Fulmer, she grabbed his penis.
As for Sian Pitonzo, Rapp had an eyewitness to the breast-fondling incident, but Coronado tried to explain that away by saying it was necessary to touch patients as part of his job.
He told police: "In my position as a nursing assistant, when I have to clean, bathe patients . . . I'm not going to say I never saw Sian without clothes, because I even gave her a shower and everything. But put my penis in her mouth or touching her with another intentions, never, never."
And there was no eyewitness to the penis incident.
But Henze's client chose to plead guilty to one count of sexual abuse against Angela Fulmer. He faces up to two and a half years in prison, or as little as a year in jail. Because he pleaded guilty to a sex crime, he will have to undergo counseling and may even be registered by the state as a sex offender.
The plea agreement may not have been in Jafet Coronado's best interest, but it certainly must have pleased Good Sam. Coronado will emerge from criminal court with absolutely no record with regard to Sian Pitonzo, who is, after all, the one suing.
Samaritan Health System spokesman Dan Green makes his company's motivation in hiring Henze quite clear: "The outcome of the criminal trial could obviously have an influence on the civil case, so as a matter of a business decision, we felt that it was in our best interest to assure that Mr. Coronado had the best possible defense."
Jafet Coronado will be sentenced in criminal court November 19. The civil case is scheduled for trial in June.
On a recent fall day at her home--she now lives with her mom, Vicki Johnson--Sian Pitonzo gathers with her parents and attorney to discuss Sian's case.
Her parents are asked: What do you think about Henze's appearance on the scene?
A noise from the corner, where Sian is propped in her wheelchair. Her voice is so weak it takes several tries for her to finally be heard: "That stinks."
Sian's parents and lawyer are more loquacious. Their civil suit--which also asks for damages because of a broken leg Sian suffered at the care center when an aide dropped her in February 1995--centers on the notion that Good Sam never should have hired Jafet Coronado in the first place.
Frank Verderame says, "It just goes to show that even now, even today, they haven't learned their lesson. Instead of making Jafet Coronado take his legal lumps and go to jail for as long as the law allows, they're putting this guy back on the street in a year--and maybe expose him to somebody else--in order to protect their legal exposure."
Verderame, a successful plaintiff's attorney, knows that if he wins this case, he'll make himself a little richer. He also knows a cash award would make Sian Pitonzo's life a little easier.
Most important, he says, is the message a win would send.
"I'm going to ask the jury for justice," he says, "and I'm going to ask them to send a message to Good Sam and all the hospitals in this community, that you damn well better protect your patients. You don't take helpless people and put them in the hands of convicted felons. And then, when the convicted felon does something bad, you don't try to cover it up. You own up to it, you fess up to it, but you don't try to cover it up. You try to do the right thing.
"And Good Sam has demonstrated that unless a jury tells them how to do the right thing, it ain't gonna happen."
Vicki Johnson has kept a coffee-stained copy of a Good Samaritan Care Center brochure, produced during the time Sian lived there. Along with a description of its services and a list of "Residents' Rights," the pamphlet features black-and-white photos of smiling residents. One shot is of Sian and Vicki, laughing together. Sian is holding a stuffed animal.
Even today, more than two years after Sian Pitonzo accused an employee of sexually assaulting her, left the care center and eventually filed a lawsuit against Good Sam, those brochures are still sent to prospective clients.
Samaritan will operate cost-effectively and provide the necessary financial resources to accomplish our mission.
--from Samaritan Health System's Mission Statement