EDITOR’S NOTE: Part 2 of a five-part series.

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It was almost as though Bobbie Kolada’s death hadn’t happened.

When the Rogue Valley Times learned that a caregiver had died March 27 after an apparent attack by a developmentally disabled man she cared for in Medford, the paper began searching for records of the incident to help piece together the circumstances.

No records could be found.

A month after Kolada’s death, the Medford Police Department said no police report had been filed because the 911 call that summoned emergency crews had been treated as a medical call for an accident victim. The person who reportedly attacked her still lives in the house.

When the Times contacted the Office of Developmental Disabilities Services (ODDS) — the state agency that oversees residential services for the developmentally disabled — the agency said it had no record of the incident. A spokesman directed the paper to Jackson County, which it said should have received a report of the incident from Partnerships in Community Living, the company that runs the group home where Kolada worked.

Jackson County, through a letter from legal Counsel Joel Benton, said the county had no records of the tragedy.

Rastrelli

“If nothing got put on paper, it would never come up the ladder to us. This is the sort of thing that we would need to be preventing. If they never reported it, we wouldn’t have anything to even look at.”

— Tom Mayhall Rastrelli, ODDS

In the weeks after the attack that killed Kolada, the only evidence of her death was the dried blood that still hadn’t been entirely scrubbed away on the living room floor of the east Medford group home, according to employees who spoke off the record out of fear of being fired.

In late April, when word reached PCL that the Rogue Valley Times was investigating Kolada’s death, PCL employees told the paper they had been warned not to talk to the media.

When ODDS was informed of the incident by the Times, agency spokesman Tom Mayhall Rastrelli said he was surprised such an incident could have occurred and his agency not been informed by county officials.

“The way it works, if there’s a report made, if something happens, it would start at the level of PCL. They would make an incident report. That report gets sent to the county, and the county report goes into our system we have called the Centralized Abuse Management system,” Rastrelli said.

“If nothing got put on paper, it would never come up the ladder to us. This is the sort of thing that we would need to be preventing. If they never reported it, we wouldn’t have anything to even look at.”

Rastrelli confirmed May 4 that his agency has now opened an investigation into Kolada’s death, after learning about it from Elisa A. Williams, spokesperson for the Oregon Department of Human Services, who was informed of the case by the Rogue Valley Times.

Kolada’s daughter, Jessica Bandy, said she contacted Medford police the last week in April to ask for an investigation. Deputy Chief Darrell Graham confirmed May 4 that an investigation had been opened.

PCL responds

Joanne Fuhrman, co-CEO of PCL, declined to discuss specifics of the incident that led to Kolada’s hospitalization and death but said she was saddened by the loss.

Fuhrman

“What I can say is that we meet all the required staffing patterns that are required through our Office of Developmental Disabilities.”

— Joanne Fuhrman, co-CEO, Partnerships in Community Living

“We’re all really sad about Bobbie. She was a really dedicated, long-term team member, and we’re all sad for her and her family and her teammates and the people that she worked with,” Fuhrman said in early May.

“We’re really in the middle of cooperating with all the state entities that manage these things. There’s a lot of good oversight around these things that will come in when there’s injuries and deaths to review the situation, so we’re cooperating with OSHA and ODDS and worker’s comp.”

Asked whether Kolada’s injuries were related to staffing shortages, Fuhrman emphatically said they were not.

“We are required, regardless of what’s happening, to meet staffing guidelines. What I can say is that we meet all the required staffing patterns that are required through our Office of Developmental Disabilities. We follow those guidelines to make sure people are well supported and our staff are well trained,” Fuhrman said.

“We support about (300) people across the state, and each individual person that we support … has individual support plans, individual assessments and individual teams that outline the support needs that they have. And we follow those individual plans for each person that we support, and that includes providing great training for the staff because, of course, the health and well-being of our staff as well as the people we support is essential to us,” Fuhrman said.

“Obviously, I can’t speak to people’s confidential information. I can just assure you that we do go through all the necessary steps to make sure people have the training and the support that they need to provide support to the people that we serve.”

Bobbie Kolada had been injured many times before

After Kolada died, Bandy found paperwork in her mother’s files for at least 10 workers’ compensation claims for injuries ranging from serious bites to facial wounds from being head-butted — including injuries caused by the man who apparently attacked her Feb. 20, as well as by other developmentally disabled residents she cared for. 

Aaron Corvin, spokesperson for Oregon OSHA, said OSHA learned about Kolada’s death April 7 from a confidential report from an unnamed source.

“We opened the inspection on April 14,” Corvin said, noting that results of the completed inspection will be made public once the process is completed.

“What I would say is that, generally speaking, when we do an inspection, we can certainly take a look at, and we do examine, all past incidents. We’ll kind of give an examination of what happened before at the same site,” Corvin said.

“I can say, on the confidentially filed complaint, generally speaking, the allegations in that complaint are related to workplace violence,” Corvin said.

After OSHA opened its investigation, it asked PCL for information about what happened the night Kolada was attacked.

Aldrich

In talking with staff, the house supervisor, and reviewing the photos taken after the incident, I have not been able to find any environmental hazards that could have caused this injury. … It is my opinion that the cause of this fall was something other than environmental. Could have been medical or behavioral on the part of the (resident).”

— Keith Aldrich, safety operations coordinator for PCL

According to a report sent to OSHA by Keith Aldrich, safety operations coordinator for PCL, Kolada told her daughter she had been helping the resident connect his computer to Wi-Fi, but it “was taking a long time” and the client became upset and repeatedly pinched her. Kolada said she told the resident not to hurt her and repeated herself several times, then she told the man she was leaving the room.

The last thing Kolada remembered was the client “behind her, out of the corner of her eye.”

The report, which listed Kolada’s injuries as “head trauma, brain bleeding, broken neck vertebrae,” goes on to state, “In talking with staff, the house supervisor, and reviewing the photos taken after the incident, I have not been able to find any environmental hazards that could have caused this injury. … It is my opinion that the cause of this fall was something other than environmental. Could have been medical or behavioral on the part of the person supported.”

Coming Tuesday: Part 3 — Bobbie Kolada wasn’t the only caregiver injured by those in their care.

Part 1: ‘Did somebody do this to her?’

Part 2: Who is investigating Bobbie Kolada’s death?

Part 3: ‘I remember thinking I was going to die’

Part 4: ‘Culture of disregard for employees’

Part 5: ‘I don’t want her to have died in vain’