Cathy Perfect
Kern Valley Sun

Gwen Hughes, 55, Kern Valley Healthcare District’s former Director of Nursing, Debbi Gayle Hayes, 51, the facility’s former pharmacist, and Dr. Hoshang M. Pormir, 48, a staff physician at the KVHD, who was medical director of the Skilled Nursing Facility (SNF), entered pleas of not guilty at their felony arraignments in Superior Court in Bakersfield on Feb. 20.

Hughes and Hayes are charged with eight felony counts of causing harm or death to an elder or dependent adult (elder abuse) and two felony counts of assault with a deadly weapon through overmedication. Pormir faces eight felony charges of causing harm or death to an elder or dependent adult.

(Use arrows above to view more photos)

“These people maliciously violated the trust of their patients, by holding them down and forcibly administering psychotropic medications if they dared to question their care,” California State Attorney General Brown said. “This is appalling behavior, which amounts to assault with a deadly weapon.”

The three were arrested on Feb. 18. Hughes and Hayes were held on $450,000 bail. Pormir was held on $400,000 bail. At Friday’s arraignment, Hughes’ bail was substantially reduced to $25,000, while Hayes and Pormir were released on their own recognizance. Pormir was ordered to surrender his passport. All three defendents’ licenses have been suspended pending the outcome of their trials. If convicted, the three face up to 11 years in prison.

The Investigation

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

On April 1, 2008, Donny Fong, Special Agent for the State of California, Department of Justice, Office of the Attorney General’s Bureau of Medi-Cal Fraud and Elder Abuse, launched his investigation of claims that 23 residents were being given, in some cases against their will and without their consent, powerful psychotropic drugs such as Depakote, Zyprexa, Resperidol, and Seroquel, at the KVHD’s Skilled Nursing Facility in Lake Isabella. The complaint alleges Hughes, Hayes, and Pormir prescribed and authorized the administering of psychotropic medications to residents in order to chemically restrain them for “the convenience of the staff.”

The alleged druggings of SNF residents, many suffering from Alzheimer’s or dementia, occurred between August 2006 and January 2007.

The Accused

The 27-page complaint paints a depressing picture of a facility dominated by nursing director Hughes who is accused of drugging residents she deemed “troublesome.” Dr. Samuel Obair II, a pharmaceutical consultant who participated in the investigation, learned from nursing staff that troublesome behaviors included “glaring (at Hughes), responding to her in a disrespectful manner, or refusing to eat in the dining room.” According to the complaint, Obair was told by nursing staff that Hughes believed all residents should have been put on Depakote.

Obair stated that the situation at KVHD is the most severe he has witnessed in his entire professional career as a pharmacist. “It is beyond appalling to me and it is the first time that I have ever run into this severity where it affected so many individuals and was being done so blatantly. I have never gone into a facility and seen psychotropic medications and mood stabilizers such as Depakote, being used on so many patients, and so blatantly, without any regards of any type of legitimate type of diagnosis, without any type of documentation of behaviors. I have never seen anything like this, and I have been doing this for 10 years. I have never seen patients as ‘zonked’ and I have never seen those as affected by drugs as these people were.” He said the nurses were the only individuals who complained and witnessed first hand the residents’ conditions deteriorate while being put on these medications.

Based on his interviews with the nursing staff, Obair asserted that Hughes was able to force compliance by her staff through threats of taking away their nursing licenses and having them terminated if they did not follow her orders.

Holly Lightner, former Licensed Vocational Nurse at KVHD from 1999 through mid 2007, told investigators that Hughes ruled the nurses with an “iron fist” and created an extremely hostile work environment for the nurses.

Following Hughes’ dictates, Director of Pharmacy Hayes wrote prescriptions for psychotropic medications SNF residents. Asserting that Director of Nursing Hughes presented herself as “knowledgable and experienced in the most recent research on how to deal with ‘troublesome’ patients,” pharmacist Hayes complied with her orders to write prescriptions. Investigators noted, “This was done without a psychiatric or medical diagnosis performed by a psychiatrist or physician on the residents. KVHD did not employ a psychiatrist.” Many of the residents who were placed on psychotropic medications suffered weight loss, were lethargic, and dehydrated, according to the report.

Department of Public Health Facility Evaluator Nurse, Linda Goldsmith stated, “A physician or psychiatrist must make a medical/psychological diagnosis on a resident and obtain consent from the resident or his conservator prior to administering psychotropic medication to the resident.” Instead, Goldsmith reported, “Hayes wrote the orders for the psychotropic medications and the nurses administered the medication to the residents. The Medical Director Pormir would sign the orders at a later time. There were instances when Pormir did not sign the orders until three weeks after the medication was ordered.”

Obair stated that both Hayes and the KVHD were fined by the Board of Pharmacy, California Department of Consumer Affairs, for writing orders for medications without proper protocols in place. Hayes and KVHD were issued monetary citations.

he explained that there are much greater risks involved with giving psychotropic medications to geriatrics. All of the residents at KVHD who received these medications were geriatrics. Older patients are more prone to side effects than the general population and some psychotropics should not even be given due to the potential of these side effects. Obair said that geriatric patients who receive Depakote, Zyprexa, Resperidol, and Seroquel, can have negative side effects such as psychosis, tremors, constipation, and lethargy.

Obair said the KVHD residents who were put on these psychotropic medications absolutely suffered harm. Based on the review of the Nurse’s Notes and Communication Logs, some of the residents suffered weight loss, body tremors, slurred speech, sat in geri chairs all day with glazed eyes, and some may have become psychotic. Some suffered from these symptoms for close to a month.

Residents were often administered the powerful drugs without patient consent. At least two residents were forcibly injected; a third had psychotropic drugs sprinkled on her food.

Obair said that in his professional opinion, Pormir, Hughes and Hayes were all responsible for chemically restraining these residents.

Fong interviewed DPH Medical Consultant, Dr. Michael Bennett, a physician for 27 years and a participant in the DPH Survey of KVHD in April 2007. Bennett’s primary role in the survey was to interview Dr. Hoshang Pormir, Medical Director of both the Acute Care Hospital and the Skilled Nursing Facility (SNF) of KVHD. Pormir stated to Dr. Bennett that prior to April 2007 he had little involvement with the SNF, but had recently become more involved.

Based on his interview with Pormir, Bennett said he believed that Pormir, as the facility’s medical director, should have been more involved with medical care of the residents and should have been informed and aware of the medical care given throughout the facility. “It was obvious that Pormir was not aware of the care that was provided to the KVHD residents,” Bennett said. Pormir allegedly rubber-stamped Hughes' orders for medication, failed to examine patients and was "either willfully or naively ignorant" of his proper role, according to the complaint.

Bennett noted that “Pormir was very remote from the patients and was not involved with the day to day care at KVHD. He was also not involved with his staff in how they were providing the medical care to the residents.”

Partial List of Alleged Victims

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. He also had a foul-smelling bedsore on his right heel. Shepter was given Seroquel, Depakote, and Zyprexa. Shepter was severely dehydrated and lost 24 lbs. in one month.

Dr. Kathryn Locatell, a particpant in the investigation, stated in her report that it is her opinion that Shepter “was severely maltreated by facility staff and Dr. Pormir, and the poor care and treatment caused Shepter to develop an infected heel ulcer, lose almost 20 percent of his body weight in three months, become severely dehydrated, and spiral downhill with pneumonia and sepsis while no one noticed how sick he was until he was hours from death. Likely the addition of Seroquel, Depakote, and Zyprexa played a major role in this downhill course and in my opinion was totally unwarranted. This resident died because of over medication and nursing neglect.”

• Eddie Dolenc was given unnecessary psychotropic medication of Seroquel and Duragesic. Investigators strongly believe that these two medications made Dolenc extremely sedated, which caused him not being able to eat and drink, and that he likely died from some complication such as dehydration or pneumonia that was not noted by KVHD medical staff. Dolenc died at KVHD only one month after being admitted to the facility.

• Jack Wallace was given high doses of psychotropic medications of Seroquel, Depakote, and Ativan at KVHD per orders of pharmacist Hayes. These three medications in combination surely caused resident to have severe side effects that led to his severe dehydration and near comatose state on Oct. 3, 2006. Dr. Locatell believed that these medications at such high dosages were totally unwarranted. In Wallace’s care plan review note, Hughes wrote that Wallace was hallucinating.

• Alexander Zaiko was admitted to KVHD on Sept. 12, 2006 and was dead by Sept. 20, 2006. He died at KVHD of pneumonia and severe dehydration. One day after being admitted to KVHD, pharmacist Hayes increased Zaiko’s dosage of Zyprexa by 50 percent. Hayes then ordered Depakote for Zaiko for his dementia. On Sept. 15, 2006, a nurse charted Zaiko as having drunk only about 1 ounce of water and later that day he was moaning with pain, and did not respond verbally.