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Sedated hours after moving in, newcomer fell and later died
Death points to problem at Illinois nursing homes: Drugged residents falling

Original source:,0,6062883.story
By Sam Roe and Nicole Leonhardt, Tribune reporters
October 27, 2009

Just eight hours after he moved into the nursing home, state inspection records show, Lloyd Berkley was approached by four employees, one of whom had a needle behind her back.

While three of them held down the 74-year-old man, the fourth injected him with a high amount of the antipsychotic drug Haldol, which quickly sedated him, according to state records. Several hours later, Berkley fell in his room, hurt his head and died at a hospital.

The worker with the needle, investigators discovered, was not licensed as a nurse and did not have a doctor's order to give the man the medication.

Berkley's death offers a dramatic example of a common problem in nursing homes: heavily drugged residents falling and suffering injuries -- or worse. Though inspectors have documented hundreds of instances of residents falling while on psychotropic drugs since 2001, authorities have done little to address the issue.

Berkley was admitted to the Pekin Living and Rehab Center in Downstate Pekin in July 2005. He had diabetes and breathed with the aid of an oxygen tank, but state and coroner records do not indicate that he was psychotic.

"This is the first time he'd been in a nursing home, which is hard for us because we had to put him there," his youngest daughter, Pati Jockisch, told investigators. "We didn't have a choice and we'd promised him we never would."

Before she walked out of the facility that day, she said she told staff: "Please don't let anything happen to my dad."

A few hours later, unlicensed nurse Karissa Bent recorded in her notes that Berkley had become "very angry and combative," saying he was "going to blow up the facility with his oxygen tank," according to a state investigative report. A nurse's aide later told investigators that Berkley did not want to be in the home and tried to hit staff members.

The oxygen tank was removed from his room, and Bent, then 23, instructed three nursing aides to hold Berkley down, records show. She then injected him with the Haldol.

"It was scary. I had never seen anybody like that before," Bent said in an interview. "I had just got out of nursing school."

Berkley fell asleep, his pulse plummeting to 48. After he awoke about six hours later, he fell and struck his head on a fan while unsupervised, according to state inspection reports. He died two days later of bleeding in the brain.

A Tazewell County coroner's inquest ruled the death a homicide, and coroner Dennis Conover said he asked State's Attorney Stewart Umholtz to consider criminal charges.

Umholtz said he has no record of such a request and does not recall the case. He reviewed a transcript of the inquest after Tribune inquiries and said there was no evidence that Bent intentionally hurt Berkley.

The Illinois Department of Public Health fined the facility $55,000, and the home fired Bent. But the Illinois Department of Financial and Professional Regulation granted her a nursing license three months later. The department also said that if Bent agreed to a written reprimand -- the lowest penalty -- the agency would not pursue harsher sanctions.

"This will be on her record the rest of her career," said agency spokeswoman Susan Hofer, defending the agreement. "She will have to explain it every time she applies for a job."

Bent, now a nurse at a hospital west of Peoria, said she regrets her actions and was treated fairly by the state. She said she administered the drug without an order after unsuccessfully trying to reach the patient's doctor by phone.

Now, she said, "I won't even give a Tylenol without the doctor order."

The family settled a lawsuit against the nursing home out of court for $380,000. The facility has since been acquired by Petersen Health Care and has changed its name to Timbercreek Rehab and Health Care. Petersen Health Care declined to comment.

Jockisch said she misses her father every day.

"I'm one of those people who believe that when it's your time, it's your time," she said.

"But this wasn't right. This was horrible."