Pool Party Turns Tragic for Navy Man

EDWIN & PAULA RODAS AS PERSONAL REPRESENTATIVES OF THE ESTATE OF JAVIER RODAS GARRIDO V. DOC INVESTORS, LLC. ET. AL.

On Sunday, June 17, 2001, Javier A. Rodas Garrido had been a guest at a party at the Villages at Deerwood at 9780 Creekfront Road in Jacksonville, Fl. The party was held in the West Village clubhouse (building #1200) and the adjacent swimming pool. The Villages at Deerwood complex is comprised of 380 residential units, as well as four swimming pools and adjacent clubhouse buildings.

Mr. Garrido was a 23-year-old Hispanic male, 4′ 10″ tall, and weighed 124 lbs. Mr. Garrido was in the U.S. Navy and was scheduled to be discharged in the very near future. He was stationed on the John F. Kennedy aircraft carrier docked at Mayport, FL.

Michelle Kraft and Russell Ellefson, the hosts of the party, were given a key and unlimited access to the clubhouse, the swimming pool, and the surrounding area. The party started at approximately 1:30 p.m. – 2:00 p.m. and there were approximately 20 – 25 guests at the party. The weather was clear and the outside temperature on that evening was approximately 80 degrees F. During the party, snacks, beer and alcohol were present and Mr. Garrido was observed drinking beer.

After dark, the remaining guests at the party decided to go swimming in the nude. Mr. Garrido warned others at the party that he could not swim and that he did not want to be thrown into the pool. Because Mr. Garrido was a weak swimmer, he entered the water, on his own, in the shallow end (3.5′ – 4′) of the pool and never ventured into the deep end (5′ – 6′) of the pool.

Joshua Gulbrandson, another guest at the party, noticed the victim lying at the bottom of the pool in approximately 4′ of water. Mr. Gulbrandson removed Mr. Garrido from the pool and yelled for help. Some of the other party guests initiated CPR and called 911. It is not known from where or how the call to 911 was made, or how long it took to place the call, since there was no telephone in the pool area or in the club house.

Upon arrival of EMS personnel, Mr. Garrido was supine on side of pool with CPR in progress. According to the EMS report, Mr. Garrido had been found in the middle of the swimming pool, and upon their arrival, Mr. Garrido’s pupils were fixed and dilated; his skin was cold and cyanotic, and he was in asystole. While CPR was maintained, Advanced Life Support protocols were administered including intubation, oxygen administration, drug administration, cardiac pacing, etc. EMS had been dispatched to the scene for a possible drowning call at 22:59 hrs. They were en-route to the scene at 23:01 hrs. and arrived on the scene at 23:07 hrs. When ALS protocols proved unsuccessful at resuscitating Mr. Garrido, he was pronounced dead at the scene.

The Jacksonville Sheriff’s Department was dispatched to the scene at 23:20 hrs. and arrived on the scene at 23:40 hrs. Upon arrival of Sheriff’s Department Officers, Mr. Garrido was lying supine on the deck of the pool and covered with a sheet.

BREACHES IN THE STANDARD OF CARE

Based on my review of the materials provided to me in this case, as well as my independent research, and my inspection during the site visit, the following Breaches in the Standard of Care have been identified which directly contributed to the drowning death of Javier A. Rodas Garrido on the evening of June 17, 2001.

Failure to conduct a threat analysis of the facility in order to determine the physical hazards that exist and the failure to correct, remove or warn tenants and guests of these physical hazards.

Unless the swimming pool deck, pool water surface, and pool bottom can be sufficiently illuminated, the swimming pool should be closed after dark and all after dark activities should be prohibited in the swimming pool and the swimming pool area. Due to the inability to sufficiently illuminate the pool and surrounding deck, the pool should have been closed after dark.

Failure to conduct a threat analysis of the facility in order to determine those activities that place tenants and guests as risk, and the failure to prohibit or safeguard those activities.

Although the swimming pool is supposed to be closed after 10:00 p.m., because of the poor illumination of the deck and the swimming pool, it should actually be closed around 8:30 p.m. In addition, alcohol should not be allowed to be used by anyone engaged in recreational swimming activities. A noise complaint was also made to the answering service on the evening of the party. It is unknown whether or not this complaint was acted upon my either the answering service, management or maintenance personnel, but it should have been investigated and any activities that placed guests at risk should either have been prohibited or safeguarded.

Failure to prohibit the use of alcohol by tenants and guests engaged in activities in the swimming pool and the surrounding area.

The use of alcohol by persons engaged in recreational swimming activities places them at increased risk for drowning and other injuries. Although a sign appeared on the day of my inspection that the Villages at Deerwood prohibit alcohol use within the swimming pool area, it is unknown whether that rule was in effect on the day of the incident and, obviously, they did not enforce this rule on the evening of June 17, 2001. Also, due to the lighting in the area, this sign would not have been seen on the evening of the incident.

Failure to provide security and to monitor the activities of tenants and guests in the swimming pool and the surrounding area.

The swimming pool is supposed to be closed at 10:00 p.m., and because of the insufficient illumination provided by the lights in and around the swimming pool, it should actually be closed around 8:30 p.m. According to management, the gates to the swimming pool are supposed to be locked at 10:00 p.m. However, on the evening of June 17, 2001, a maintenance person arrived at the pool area to lock up and because the party was in progress, he allowed the party to continue and failed to secure the doors and gates to the swimming pool.

Failure to provide adequate lighting in and around the swimming pool for illumination of the swimming pool deck, the swimming pool bottom, and the surrounding area for night time activities in the swimming pool and the surrounding area.

According to the National Spa and Pool Institute (NSPI), the American National Standards Institute (ANSI), the American Public Health Association, the Florida Administrative Code, and other organizations, all portions of the swimming pool, including the bottom, as well as the pool deck, must be sufficiently illuminated at all times. If not, the swimming pool and the surrounding area should be closed.

Failure to close and secure the swimming pool after dark.

The policy at the Villages at Deerwood was to lock the gates to the swimming pool at 10:00 p.m. However, on the evening of June 17, 2001, the management and staff at the Villages failed to enforce their own rules and regulations, and failed to prohibit swimming activities after dark and after 10:00 p.m.

Failure to develop Standard Operating Procedures (SOPs) or Guidelines (SOGs) for security, inspections, maintenance, and operations of the swimming pool and the surrounding area.

According to the ConAm web site, they claim to be “a leading full-service real estate organization for over two decades and one of the largest multifamily property management firms in America.” In addition, “to better serve its diverse client base, the company also maintains a nationwide network of more than a dozen regional offices located in key metropolitan area.” Also, “the firm is deeply committed to supervior service in property and investment management and maintains a watchful eye for any opportunity which can improve the position or enhance the assets of our clients.”

The Villages at Deerwood is a large complex consisting of three separate and distinctive communities, with 390 units with 4 swimming pools and clubhouses. This particular facility was built in 1985 and was operational for 16 years prior to this incident on June 17, 2001.

In Florida, in addition to the Villages at Deerwood, ConAm owns and/or operates at least 9 other apartment complexes located in Ponte Vedra Beach (Lakeview Village and Ponte Vedra), Jacksonville (Evergreen Club), Caselberry (Sunshadow), Winter Springs (Willa Springs), Winter Park (Parkview Village and Summer Chase), Orlando (Oakwood), and North Lauderdale (Parrots Landing). In addition to these facilities, there are other properties located throughout the U.S. with regional offices located in San Diego, CA; Roseville, CA; Seattle, WA; Phoenix, AZ; Las Vegas, NV; Albuquerque, NM; Aurora, CO; Plano, TX; Houston, TX; and Winter Park, FL.

Yet, with this massive organizational structure, and years of experience in the management and operation of apartment complexes, ConAm was unable to develop and/or implement on June 17, 2001 Standard Operating Procedures (SOPs) or Standard Operating Guidelines (SOGs) pertaining to the safe management and operation of the swimming pools located within their apartment complexes.

Failure to develop security checklists for the swimming pool and the surrounding area.

In addition to their failure to develop and/or implement SOPs/SOGs on June 17, 2001 for the operation and management of their swimming pools, they failed to develop security and safety checklists to guarantee the safe operation of their swimming pools. Note: Samples of a Facility Security Checklist and a Pool & Spa Safety Checklist are included as an appendix to this report.

Failure to enforce their own rules and regulations pertaining to the use of the swimming pool and the surrounding area.

The Villages at Deerwood prohibits the use of the swimming pool after 10:00 p.m. and prohibits the use of alcohol in the swimming pool and the surrounding area. However, they failed to enforce their own rules and regulations in this regard.

Failure to develop, implement, and administer facility-use guidelines for groups using the clubhouse, the swimming pool and the surrounding area.

If residents are allowed to host a party or any type of activity for guests in and around the swimming pool, then it is the obligation of management to provide facility-use guidelines which specify the rules and regulations that need to be adhered to in order to guarantee the safety of all tenants and guests. In this situation, the Villages at Deerwood simply provided a key to the clubhouse and provided absolutely no guidelines, rules and/or regulations pertaining to the use of the clubhouse and the swimming pool.

Failure to develop, implement, and administer layers of protection for the swimming pool and the surrounding area to include lighting, depth markers, lifelines, etc.

The concept of Layers of Protection within the swimming pool and spa industry is used in that the development, implementation, and administration of a combination of protective layers is what is necessary to safeguard the public when engaged in recreational swimming activities. These layers would include appropriate barriers and gates; sufficient illumination; rules and regulations; depth markers and lifelines; etc.

In this instance, the Layers of Protection afforded Javier A. Rodas Garrido were insufficient to prevent his drowning on June 17, 2001 at the Villages of Deerwood West Village swimming pool.

Failure to develop and post Emergency Action Plans (EAPs) for emergency incidents in the swimming pool and the surrounding area.

The fact there was no telephone in the swimming pool area or in the clubhouse; the lack of emergency resuscitation equipment in those areas; along with the fact there were no signs indicating the actions required during an emergency situation, indicates the failure to pre-plan and consider the possibility of an emergency incident, as well as the failure to develop an Emergency Action Plan to be implemented during any type of medical emergency or submersion incident in the swimming pool, the surrounding area, or in the clubhouse.

Failure to develop, implement, and administer Emergency Response Plans (ERPs) or Emergency Operations Plans (EOPs) for the response to medical emergencies occurring in the swimming pool or the surrounding area.

The failure to provide emergency resuscitation equipment along with an emergency communication system within the swimming pool area and clubhouse indicates that no Emergency Response Plans were considered or developed to effectively respond to medical or submersion incidents in the swimming pool, the surrounding area, or in the clubhouse.

Failure to provide the availability of emergency resuscitation equipment for the appropriate response to a respiratory arrest emergency within the swimming pool or the surrounding area.

Oxygenation, ventilation, and perfusion must be restored as rapidly as possible when a person experiences hypoxia as a result of a respiratory distress or arrest incident. Immediate resuscitation at the scene is essential for survival and neurological recovery after submersion. In order to effectively respond to a victim in respiratory arrest resulting from a submersion incident, positive-pressure-ventilation, oxygen administration, CPR, and defibrillation must be quickly and effectively administered, and Advanced Life Support services must be called to respond in a timely fashion without delay.

Basic life support (BLS) resuscitation equipment would include items such as a Personal Resuscitation Mask (PRM), a Bag-Valve-Mask Resuscitator, oxygen administration equipment, and a manual suction device. In addition, a telephone must be readily available in order to call 911 to obtain ALS response to the incident.

Failure to provide the availability of an Automated External Defibrillator (AED) for the appropriate response to a cardiac arrest emergency within the swimming pool or the surrounding area.

The highest potential survival rate from cardiac arrest can be achieved only when the chain of survival is intact and includes early access; early CPR; early defibrillation; and early Advanced Life Support (ALS). Regardless of whether or not the links in the chain are present, if there is any delay in any one of the links, the chance for survival from a cardiac arrest is drastically reduced.

Failure to have a telephone at the pool and/or clubhouse more likely than not reduced the early access link and more likely than not delayed the phone call to 911 for the dispatch of Basic Life Support (BLS) and Advanced Life Support (ALS) providers.

Although CPR was administered by other guests while waiting for the arrival of EMS personnel, an Automated External Defibrillator (AED) was not accessible. Every major newspaper and television network has aired stories about the effectiveness and availability of AEDs. The best response after the rescue of Mr. Garrido from the water would have been immediate CPR and the use of an AED while waiting for EMS personnel to respond. The fact that only CPR was administered without defibrillation during the 8 minutes it took the Jacksonville Fire and Rescue Department personnel to respond, tremendously lessened the chance for a successful resuscitation of Mr. Garrido. As stated previously, “survival rates after cardiac arrest decrease approximately 7% to 10% with every minute that defibrillation is delayed.”

Failure to have a telephone for emergency communication purposes within the clubhouse or swimming pool area for the purpose of contacting the 911 dispatcher in the event of a medical emergency.

The first link in the chain of survival is early access. Once the emergency is recognized, an immediate call to 911 must be placed to initiate a response of BLS and ALS providers. The fact that a telephone was not available within the swimming pool area and/or the clubhouse more likely than not delayed the call to 911, which ultimately delayed the response of BLS and ALS providers to the scene of Mr. Garrido’s respiratory and cardiac emergency.

Failure to train and certify maintenance and/or management staff as Certified Pool Operators

The Certified Pool Operator curriculum, as designed and administered by the National Swimming Pool Foundation and the National Spa and Pool Institute includes a comprehensive course guidebook and instructional program that provides the knowledge and skills necessary for someone to safely and effectively operate a swimming pool. This curriculum includes information about safe operational practices as well as information about lighting requirements needed to safely operate a swimming pool after dark.

SUMMARY

The management and staff of the Villages at Deerwood, as well as the ConAm Group, failed to meet the Standard of Care in the operation and management of the West Village swimming pool on the evening of June 17, 2001, which resulted in the drowning death of Javier A. Rodas Garrido.

This incident could have and should have been prevented through the implementation and administration of basic aquatic facility management principles.

Standard Operating Procedures (SOPs) or Standard Operating Guidelines (SOGs) should have been established and/or implemented on June 17, 2001 to dictate or guide staff and management personnel in appropriate operational protocols dealing with the swimming pool and the surrounding area and clubhouse.

A comprehensive Risk Management Program, including a Threat Analysis of the West Village swimming pool and clubhouse, should have been implemented which would have identified hazards and risks associated with this facility.

Rules and regulations should have been established and enforced regarding the use of the swimming pool, swimming pool area, and clubhouse for private parties.

The swimming pool, if it could not be sufficiently illuminated, should have been closed after dark, and most certainly by the 10:00 p.m. curfew established by the apartment complex.

After dark, and most certainly after the 10:00 p.m. self-imposed curfew established by the apartment complex, the swimming pool area should have been cleared of all guests, and all gates and doors leading to the swimming pool should have been locked.

The use of alcoholic beverages should have been prohibited by anyone using the swimming pool.

The potential for this type of incident should have been recognized, and Mr. Garrido’s distress should have been immediately recognized before he deteriorated into respiratory and cardiac arrest.

A Threat Analysis, as part of a typical Risk Management Program, should have been administered to determine the physical hazards associated with the West Village swimming pool, as well as those activities that can place a guest at increased risk. Once those physical hazards were identified (i.e. insufficient lighting for after-dark swimming), those hazards should have been corrected. Once the risks were identified, it was the responsibility of the staff and management to either safeguard those guests engaged in those activities, or to prohibit those activities altogether.

Sufficient lighting should have been provided to allow for after-dark activities in and around the swimming pool. If the surface and bottom of the swimming pool, as well as the surrounding deck, could not be sufficiently illuminated, then the swimming pool and area should have been closed to all guests after dark.

Regardless of the distress signs exhibited by Mr. Garrido, once he submerged below the water’s surface, if the swimming pool was sufficiently illuminated, Mr. Garrido would have been seen lying motionless at the bottom of the pool. During a respiratory and/or cardiac emergency, every second is critical. The fact that Mr. Garrido was in cardiac arrest at the time he was removed from the water indicates that he was under the water for an extended time (at least 4 – 6 minutes). The failure of the other guests to recognize Mr. Garrido’s submersion was due to the inadequate lighting of the swimming pool and the surrounding area.

Once the incident was recognized, it was improperly managed due to the lack of pre-planning on the part of the staff and management of the Villages at Deerwood as well as the ConAm Group.

A telephone was not provided in the swimming pool area or the clubhouse which more likely than not resulted in a delay to call 911 to obtain a rapid response of Advanced Life Support EMS personnel and equipment.

Emergency Action Plans had not been established and appropriately posted giving directions to guests how to obtain immediate assistance while waiting for EMS personnel and equipment to arrive on the scene.

Emergency Response Plans (ERPs) or Emergency Operations Plans (EOPs) had not been pre-planned and established to provide emergency medical care to guests while waiting for EMS personnel and equipment to arrive on the scene.

A first aid kid, with appropriate emergency resuscitation equipment, was not provided and available for use by guests to effectively administer CPR while waiting for EMS personnel and equipment to arrive on the scene.

An Automated External Defibrillator (AED) was not provided and available for use by guests to appropriately respond to a cardiac arrest victim while waiting for EMS personnel and equipment to arrive on the scene.

It was also reported that a loud noise complaint had been received by the answering service on the evening of June 17, 2001, prior to the submersion incident of Mr. Garrido. However, due to the failure to establish and/or implement SOPs/SOGs for the answering service, as well as the maintenance and management staff, this incident was not appropriately investigated and nothing was done to monitor the activities of the party guests in and around the water.

The management of the Villages at Deerwood, as well as ConAm failed to develop and implement appropriate security measures to monitor the activities of guests and tenants in the swimming pool and the surrounding area and they failed to develop appropriate checklists to be sure the facility was operated in a safe manner.

Therefore, it is my opinion that the staff and management at the Villages at Deerwood, as well as ConAm, were negligent in their actions that resulted in the submersion and drowning death of Javier A. Rodas Garrido on the evening of June 17, 2001.