At about 4 p.m. on May 1, Thomas Rohosky, a severely retarded patient at the Forest Haven home in Laurel, was sunning himself as unsual on a grassy curbside near the facility's kitchen.
Ten minutes later, a construction worker saw the 35-year-old Rohosky lying on his left side with a large gash on his head. He was bleeding profusely from his ears, nose and mouth. Rohosky, who had spent the past 25 years of his life at Forest Haven, died at Prince George's General Hospital nine hours later.
The mystery of what happened to Rohosky appeared partly solved when a Maryland state medical examiner found tire marks on his body, indicating he had been the victim of a hit-and-run accident.
A federal grand jury is investigating also are looking into several perplexing questions about the treatment Rohosky received in the aftermath of the accident. According to one source close to the investigation, this treatment "does not seem to arise to the point of criminal negligence, but it's an appalling situation."
Among the questions troubling the investigators:
Why was Rohosky not given treatment at Forest Haven's own hospital before being sent elsewhere?
Why did Forest Haven doctors decide to send Rohosky to D.C. General Hospital 21 miles away, before paramedics decided to take him instead to Prince George's General Hospital?
Although there were three doctors and several nurses on duty at the Forest Haven hospital, the only persons who administered any first aid to Rohosky before an ambulance arrived were two kitchen workers and a driver at the facility, according to reports filed with the D.C. Department of Human Resources by Forest Haven employes. The DHR operates the home for 822 mildly to severely retarded adults.
Although the Forest Haven hospital has some of the same emergency medical equipment a Laurel medic team eventually used to aid Rohosky, doctors at Forest Haven decided against treating the injured man there.
Instead, the doctors looked at Rohosky as he lay in a van outside the hospital and decided to send him to D.C. General Hospital, 21 miles from Forest Haven, according to the reports on the incident.
Forest Haven officials also told rescue workers that Rohosky, who was virtually incapable of oral communication or of performing such basic tasks as washing and shaving himself, had fallen from a window, according to the chief of the rescue squad.
"It wasn't clear whether it was due to an [auto] accident" at that point, said Larry Hoover, a counselor assigned to Rohosky's cottage at the Forest Haven facility. "One doctor thought it might be an internal thing, a hemorrhage."
Despite the instructions to go to D.C. General, the paramedics who arrived with the Laurel rescue unit decided to take Rohosky to Prince George's General Hospital, which is only 12 miles from Forest Haven and which is equipped with a special shock trauma unit for treating critically injured accident victims.
When Rohosky was operated on at Prince George's General, doctors found he was suffering from multiple internal injuries. Rohosky died at about 1 a.m., five hours after the operation.
According to Dr. Margarita Korell, a state medical examiner, there were tire marks on Rohosky's body, and he had suffered several fractures at the base of his skull.
Chester Jones, Forest Haven's administrator, refused to say whether he felt Forest Haven personnel should have done more to help Rohosky. He said the inspection office of the Human Resources Department eventually will decide whether or not any Forest Haven employe was negligent.
Jones said Rohosky was ambulatory and did not need constant supervision. He said at the time of the accident, counselors were in a cottage about 75 feet from where Rohosky was injured.
"The conuselors seem to feel there could have been more prompt help by the medical staff. The medical staff feels what they did was appropriate," Jones said.
One of the three Forest Haven physicians involved in the case could not be reached for comment. A second said he could not remember the incident. The third physician said that by the time she arrived on the scene, another doctor had decided to send Rohosky to D.C. General Hospital.
According to the DHR reports on the incident, Forest Haven authorities were first notified of the accident when they received a call for medical assistance from a food service worker and a counselor at the cottage where Rohosky lived.
"As I got there I found the little dude sitting on the ground, choking on his own blood," said a kitchen worker who was one of the first on the scene and who asked not to be named.
Other kitchen workers gathered around and asked someone to get a towel "to cover up the hole" in Rohosky's temple, the worker said. Eventually, one of the workers used a towel to clear blood from Rohosky's mouht to help him breathe.
In the meantime, the control office had sent a nurse with a walkie-talkie to the scene. She told the kitchen workers that the doctors wanted Rohosky brouhgt to the hospital. So the workers loaded the unconscious Rohosky into a van and drove it the few hundred yards to the hospital.
Willie Paul Sims, Forest Haven's administrative officer, arrived in front of the hospital and asked what was happening. An employe, he wrote in his incident report, "indicated that . . . a resident was bleeding profusely and that the food services employes were in the [van] working on him. I thought this was rather strange since the medical people were standing outside the vehicle."
About the same time, Dr. Margaret Mola was walking out of the hospital on her way to the van carrying Rohosky. At the van, she said, she encountered Dr. Reginald Mitchell, another Forest Haven doctor.
Mitchell, Mola said, told her, "Don't bother seeing him, we'll send him to D.C. General." So she turned and went back inside the hospital, she said.
Mitchell, who has since retired from his post, said he doesn't remember sending Rohosky to D.C. General.Nor could he recall anything else about the Rohosky case. "I'm no longer there, so I'm not responsible," he said.
According to Larry Hoover, Rohosky's counselor, "One of the doctors, Mitchell or Mola, decided he should go to the hospital."
As Rohosky lay in the van, one of the kitchen workers who had some medical training while serving in Vietnam, said he asked a doctor at the scene for a suction device to take some of the blood away from Rohosky's nose "because he was about to smother to death."
When the Laurel rescue squad arrived at about 4:22 p.m., rescue workers and the kitchen worker pumped blood from Rhoshosky. They also gave him oxygen and applied bandages, according to Alan Good, chief of the rescue squad.
At 4:35 p.m., the rescue workers transferred Rohosky to an "advanced life support" ambulance at the Laurel Plaza shopping center. The ambulance was manned by a team of medics.
It was 5:09, about an hour and nine minutes after he was found, that Rohosky arrived at the Prince George's hospital emergency room.
Assistant U.S. Attorney Kurt Schmoke, who is handling the grand jury investigation, refused to comment on the case. The federal government has jurisdiction in the case because the Forest Haven facility is located on federal property.
Forest Haven has been investigated in recent years for suspicious deaths and alleged abuse of patients, according to Detective Fred Cunningham of the U.S Park Police.
Last year, a food service worker went on a shooting rampage at the facility, injuring two residents and five employes. Forest Haven is scheduled to close in about 10 years, according to Jones.
In the final weeks of his life, Rohosky, a sandy-haired, husky man who looked only about 19, was being trained to pick up trash, according to one of his counselors. CAPTION: Picture, Superintendent Chester Jones walks by the building where the fatally injured patient used to live. By James A. Parcell - The Washington Post