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"Reports detail fatal druggings at nursing facility"

Original source:

The Bakersfield Californian

BY STACEY SHEPARD AND JAMES BURGER, Californian staff writers
Wednesday, Feb 18 2009 8:23 PM

Last Updated: Thursday, Feb 19 2009 7:41 AM

In one allegation, nursing home resident Opal Towery was injected with anti-psychotic drugs after an argument with the nursing director and spent the next week in a zombielike state.

In another, Louise Zimmerman was pinned down by four staffers and injected with the same drugs because she was biting, hitting and kicking others. She never regained full consciousness.

Those were among the disturbing stories in a criminal complaint filed by the California Attorney General’s office that led to the arrests Wednesday of three current and former employees of the Kern Valley Healthcare District’s skilled nursing facility.

The complaint alleges a nursing director, pharmacist and physician drugged at least 22 elderly residents with mood-altering medications to quiet and control them, leading to the deaths of three.

The alleged druggings occurred between August 2006 and January 2007.

“These are powerful medications that were given, in some cases against people’s will, primarily for management, not health reasons,” Attorney General Edmund G. Brown Jr. said. “It's unconscionable behavior and it’s certainly not what people expect when they entrust their parents or grandparents to a skilled nursing home.”

District officials declined to comment but released a statement saying they fully cooperated with the investigation and have taken corrective action. Subsequent inspections have found no significant problems, the statement said.

Arrested were:

  • Gwen Hughes, 55, the former director of nursing.
  • Debbi Gayle Hayes, 51, the facility’s former pharmacist.
  • Dr. Hoshang M. Pormir, 48, a staff physician at Kern Valley Healthcare District, who was medical director of the skilled nursing facility.

Hughes and Hayes face eight felony charges of causing harm or death to an elder or dependent adult and two felony charges of assault with a deadly weapon through overmedication.

Pormir faces eight felony charges of causing harm or death to an elder or dependent adult.

They were being held at the Kern County Jail in Bakersfield. Hughes and Hayes were held on $450,000 bail. Pormir was held on $400,000 bail.

If convicted, the three face up to 11 years in prison.

Hughes declined to be interviewed. Hayes and Pormir did not respond to interview requests.


The 27-page complaint describes interviews with facility nurses and medical experts who say Hughes ordered certain patients to receive high and unnecessary doses of anti-psychotic drugs.

Pharmacist Hayes followed her orders, telling investigators she thought Hughes was knowledgeable in the treatment of psychiatric conditions. Pormir, the physician, signed off on the orders after the drugs were administered, according to the interviews.

They say Hughes’ orders often came after residents acted out or complained, and were often administered without patient consent. At least two residents were forcibly injected; a third had psychotropic drugs sprinkled on her food.

The investigation found none of the residents received a medical exam or diagnosis prior to receiving the powerful doses.

Samuel Obair II, a pharmacist who assisted with the investigation, called the situation “beyond appalling,” saying it was “the first time that I have ever run into this severity where it affected so many individuals and was being done so blatantly,” according to the documents.

The situation came to the attention of authorities in January 2007, when an unnamed healthcare ombudsman filed a complaint after seeing Zimmerman held down and forcibly injected with drugs.


The attorney general’s investigation identified three residents believed to have died as a result of being drugged and neglected:

  • Fannie May Brinkley died Dec. 23, 2006, after receiving Depakote, a drug to treat mood disorders. After not eating for six days, she was rushed to the emergency room, where she died.
  • Eddie Dolenc was given unnecessary anti-psychotic medication that caused him to become extremely sedated, and unable to eat or drink. He died one month after being admitted to the facility, likely from dehydration or pneumonia.
  • Joseph Shepter went to the emergency room on Jan. 14, 2007, for dehydration and died five hours later. He had been given three anti-psychotic drugs.

Phyllis Peters, Brinkley’s daughter, has filed a personal injury suit against the facility. Her attorney, Daniel Rodriguez, said Peters noticed her mother was dehydrated and losing weight but was never told by facility staff that her mother was receiving the drugs.

“The family entrusted their mother and grandmother to this hospital — to this nursing facility,” Rodriguez said.


In addition to the three deaths, the drugged residents suffered serious side effects ranging from severe lethargy that inhibited eating and drinking for long periods to weight loss, drooling and incoherence, the complaint said.

People interviewed by investigators pinned most of the blame on nursing director Hughes, who was fired in 1999 from a Fresno nursing home after the state cited the facility for over-medicating patients.

Hughes was dismissed from Kern Valley Healthcare District in January 2007, when the attorney general’s investigation began.

Nurses at the Kern Valley facility said the drugging of patients began when Hughes was hired. She held “interdisciplinary team meetings” in which she and the staff discussed residents' behavior and Hughes told the pharmacist what drugs to prescribe, the nurses told investigators.

When the nurses objected or raised concerns, Hughes threatened to fire them and have their nursing license revoked, they said.

Several nurses left the facility during Hughes’ tenure. One nurse told investigators she was so distraught by the situation that she was on the verge of “a nervous breakdown.”

Steve Muni, a deputy attorney general on the case, said a Kern Valley Healthcare District hospital administrator lost her job over the case.

“We did not press charges against her, feeling that there may be civil or administrative” action, he said.

After her dismissal from the Kern Valley facility, Hughes was hired by Mercy Hospitals as a nurse. Mercy spokeswoman Sandy Doucette said Hughes was employed from February 2007 to April 23, 2007.

She has a clear nursing record and no actions against her, according to the state consumer affairs Web site for registered nurses.

— Californian columnist Lois Henry contributed to this report.