The 2015 death of a Nassau jail inmate “may have been prevented,” according to a new state report that found not only did the facility’s embattled medical vendor fail to provide crucial care, but one of its nurses abandoned the inmate after he stopped breathing.
The state Commission of Correction’s report on the death of Antonio Marinaccio Jr., 53, of Levittown, also suggests investigators found signs that vendor Armor Correctional Health Services may have tampered with or partially falsified the inmate’s medical records after his collapse — allegations Newsday reported in January.
Marinaccio’s sister, Gloria Gazzola, broke down in tears Thursday when she heard the commission’s findings.
She said her brother had a health checkup right before going to jail, and he shared medical information with Armor to try and ensure he got good care.
“It’s hurtful to hear. I know he suffered. What a place to die in,” she said.
The state commission’s recent findings have come to light in the wake of New York’s attorney general filing a lawsuit Monday against Armor, a civil action that follows a series of inmate deaths since the Florida-based company first won an $11-million-a-year Nassau contract in mid-2011.
That lawsuit claims Armor has routinely denied inmates adequate care and defrauded taxpayers by collecting public money for its services, while county officials have failed to take any action against Armor to enforce the contract’s terms.
Armor, however, has repeatedly defended its standard of care and has also said it will mount a vigorous defense against the attorney general’s claims.
In January, Armor first denied allegations regarding any tampering with Marinaccio’s medical chart, and Thursday released a statement saying the company “strongly disagrees” with the commission’s findings — calling them “clearly contradicted by the facts presented in this case.”
“Armor adamantly disagrees with all allegations made, and is again disappointed by false statements that appear to be perpetuated to harm the reputation of Armor caregivers who work diligently each and every day to deliver quality patient care to many individuals otherwise underserved in our communities,” spokeswoman Yeleny Suarez added.
The state commission’s findings in Marinaccio’s May 2015 death — now part of the state attorney general’s case — mark the third time the jail oversight agency found a Nassau inmate’s death “may have been prevented” and its fifth finding that Armor provided inadequate care in connection with a Nassau inmate fatality.
“It’s shocking to the conscience that not only did they create a situation that resulted in an acute incident, but when the acute incident occurred, they failed to take any appropriate response that could have saved his life,” said attorney Harry Demiris Jr., who in February filed a lawsuit against Armor and the county on behalf of Marinaccio’s family.
In a statement Thursday, Nassau County Attorney Carnell Foskey said: “The Commission of Correction allegations are extremely disturbing and concerning.”
Marinaccio died while hospitalized on May 2, 2015, after his family made the decision to disconnect life support when tests showed he became brain dead after suffering an April 26 heart attack in jail custody.
His collapse came two days after he started a 1-year sentence for a conviction on charges including felony DWI from a 2014 case and resisting arrest from a 2013 domestic case in which his relatives later alleged police had assaulted him — a claim a police union official refuted.
In their lawsuit, Marinaccio’s relatives also claimed he suffered injuries at the hands of correction officers before his jail collapse, which they have suggested could have been payback for his 2013 encounter with police at their home.
The state commission report, however, shows correction officers reported that they stepped in to give CPR to Marinaccio after an Armor registered nurse who was called to render emergency aid instead left to get a different Armor nurse after the inmate stopped breathing.
The morning of Marinaccio’s collapse, the inmate told a correction officer at 2:45 a.m. that he felt like he was having a heart attack, and the officer notified Armor the man was in distress, the commission report said.
An Armor registered nurse went to Marinaccio’s cell at 2:50 a.m. to evaluate the inmate, according to what correction officials told the commission.
But at 3:34 a.m., an officer on a security round saw Marinaccio lying facedown in his cell.
Correction officials found Marinaccio was unresponsive and had white foam coming from his mouth, before a registered nurse told the officers to take him out of his cell, the state report said.
But when a correction officer saw Marinaccio wasn’t breathing, and asked the male nurse to start CPR, the nurse instead left the area to get an Armor licensed practical nurse, the report said.
Two officers told the commission that they then started CPR on Marinaccio, the report said. Officials told the commission an ambulance arrived at the jail at 3:50 a.m.
The commission found that the male nurse’s action of “leaving the scene of a patient requiring resuscitation meets the definition of abandonment,” and asked the state Education Department to investigate him for professional misconduct.
But even before Marinaccio’s ultimate collapse, the state commission found that problems with the inmate’s medical care began soon after his arrival at the East Meadow jail.
The state commission found that if a physician had ordered an EKG and performed a thorough intake exam, signs of an impending heart attack could have been detected and Marinaccio could have gone to a hospital for intervention that may have saved his life.
Marinaccio’s family and attorney have said he brought records with him to the jail showing he had heart abnormalities and herniated discs and needed substance abuse detox.
But Marinaccio’s medical chart didn’t show that he got medications as prescribed, the attorney general’s office said in its lawsuit.
The state commission report, which authorities heavily redacted, further found that Marinaccio’s routine asthma treatment was interrupted, and that crucially, he never got a chest X-ray.
Newsday reported earlier this year that state authorities had gotten information alleging Marinaccio’s record was tampered with by Armor in an attempted cover-up of negligent health care decisions before his death — allegations later repeated in his family’s federal lawsuit.
Investigators were told a note disappeared from the inmate’s file that had documented that a doctor didn’t want an EKG done, or the inmate sent to the jail’s infirmary, after hearing about Marinaccio’s substance abuse history and that he’d had gone on a drug binge right before going to jail.
State authorities also got information alleging that after Marinaccio’s collapse and hospitalization, his chart was falsified to say that a chest X-ray had been ordered for him, Newsday previously reported.
Thursday, Armor said they had hired an outside law firm to look into the records tampering claim, and found “all claims to be wholly without merit.”
But the state commission noted in its report that the order for a chest X-ray on Marinaccio’s chart “may have been added at a later time.”
The state investigation also showed Armor had never added Marinaccio’s name to a separate “X-ray log” where inmate names are written when an Armor official orders such a test.
The state report also showed a female Armor registered nurse reported to the commission during its probe that she found a note missing from Marinaccio’s chart after looking at his file following his collapse.
But the nurse didn’t fill out an incident report for Armor management, “nor were there any witnesses to this,” the state report added.
New York’s Commission of Correction’s findings in inmate Antonio Marinaccio Jr.’s 2015 death:
-Levittown man’s death “may have been prevented” with proper medical care
-Jail medical vendor Armor Correctional Health Services didn’t provide critical medications and diagnostic tests
-Armor nurse abandoned inmate after he stopped breathing, leaving correction officers to start CPR
-Report suggests state found signs Armor may have tampered with inmate’s records -- which Armor has denied, while strongly contesting the commission’s findings