116 3rd St SE
Cedar Rapids, Iowa 52401
Claims detail repeated assaults at Iowa mental hospital
Former Independence Mental Health Institute nurse: ‘I don’t understand why you don’t want your staff to be safe’
Apr. 28, 2025 5:30 am, Updated: Apr. 28, 2025 9:29 am
The Gazette offers audio versions of articles using Instaread. Some words may be mispronounced.
Olivia Berger, as a nurse at the Independence Mental Health Institute, helped some of the most vulnerable Iowans. But the experience there became her darkest nightmare and forever changed her life.
Berger, 34, who resigned in August 2023, last week told The Gazette she repeatedly was physically assaulted and — in one incident — sexually assaulted over the course of a month in 2023 by some of the most violent patients, both adolescents and adults. She had worked in the state hospital since March 2022.
She suffered multiple injuries from the assaults, including a traumatic brain injury and concussion. She continues to have nightmares, panic attacks and has been diagnosed with post-traumatic stress disorder, anxiety and depression, she said.
Berger said many of the psychiatric patients in MHI have killed people or committed other violent offenses but are there because their mental health condition prevents them from being tried in court. The Iowa Department of Health and Human Services runs MHI, as well as the Cherokee Mental Health Institute in northwest Iowa.
“It’s very scary and baffling to know there are murderers there and nobody to help you except other co-workers like me,” Berger said. “No security cameras or guards. The radios didn’t work most of the time. Nobody to save you.”
Berger is one of seven former nurses, so far, who in March filed similar claims of gross negligence against the state and its Health and Human Services department. Filing a tort claim with the State Board of Appeals is the initial step state workers must take before filing a lawsuit. The state has six months to investigate the claims and take action to resolve them. If no action is taken, the claimant has the right to file a lawsuit.
“Will somebody finally be killed?”
Darin Luneckas, Berger’s Cedar Rapids lawyer, said state officials have known this claim was coming because there already has been a steady stream of workers filing workers’ comp claims, and he continues to reach out to the same insurance adjuster each time.
“New person with same safety issues which resulted in injuries,” Luneckas told The Gazette. “It’s not a matter whether someone is going to get hurt in the next day or week, it’s who’s going to get hurt, how badly and will somebody finally be killed?”
Berger reached out to Luneckas to file a workers’ compensation claim and told him other people there also had endured assaults and had serious injuries from patients.
“They want to see better safety protocols in place, more staffing to prevent another brain injury or cervically fused neck after getting stomped by a patient without someone to help them,” he said.
Two former nurses who filed claims agreed to share incidents with the media, giving these accounts of what led to their claims:
• Lora Smith lost her unborn child in June 2024 after being kicked in her abdomen by a patient, which caused her to miscarry. It was especially heartbreaking because she was able to become pregnant after receiving six months of in vitro treatments.
• Angela Timmermann was attacked in August 2024 by an adolescent patient who ripped out a large clump of her hair before repeatedly foot-stomping her head. She had to undergo spinal surgery for her injuries and it has limited her mobility. She still suffers from post-traumatic stress disorder and nightmares.
State: Safety is ‘top priority’
Alex Murphy, director of communications for the Health and Human Services department, in a statement said, “While we cannot comment on pending litigation, the safety of the patients we serve and the employees at our facilities is our top priority. These facilities serve the most vulnerable clients when other options are not available or when a significant level of expertise is warranted.”
Murphy said, as of Friday, 55 patients were at the Independence hospital.
This isn’t the first time safety issues have been alleged by MHI workers.
The nurses’ claim affidavit, provided by Luneckas and Bobby Rehkemper, a West Des Moines lawyer who is working with Luneckas on these claims, listed a pattern of several incidents going back to 2018.
The list includes multiple assaults on residential treatment workers for head injuries; an attack on a nurse made public in 2018 after an employee union said she was fired for taking too long to recover from a brain injury; and 10 Occupational and Safety Health Administration violations in 2019 for systematic safety issues where the state was fined $73,000. Those violations included inadequate emergency response plans and communication protocols.
“They were trying to harm us”
In March 2022 when she took a job at the Independence mental hospital, Berger started out working in the pediatrics unit. Then, a “riot” broke out.
“The children were so violent and they had no repercussions for their behavior,” Berger said. The “horrifying” incident traumatized her and she asked to be moved out of the unit and to care only for adults.
“They would partner together and attack us (nurses and staff),” Berger said as her facial expression become solemn as she recalled the event with the children. “Three kids started being aggressive and started throwing books and other objects at me. I called for help and some staff came, but the kids charged us. They were trying to harm us.”
One of the kids got a staff radio and tried to strike her with it. Ultimately, the staff got control. She said she had to put three of the children in bed restraints and gave them injections to calm them down. Berger, tearing up, said that was the most difficult thing for her to do since she is a mother of a young child herself.
“They worked together to hurt us,” Berger said. “They need help and can’t get it because they are short staffed.”
Berger was moved to the adult women and men units, but her days were not safer, she said. The month of serious assaults against her happened in the adult units.
On July 15, 2023, a “400-pound” patient became upset. When Berger, a smaller framed woman, tried to de-escalate the situation, the patient charged her, grabbed her sweater and started “swinging me around, saying she was going to kill me.”
The hospital was short-staffed, which she said happened regularly. One staff member came to “rescue” her, but when Berger hit the emergency button on the radio, either nobody else responded or the emergency button didn’t work.
“I got away when my co-worker foot stomped her (patient) toes,” Berger said.
Berger said the nurses and staff weren’t allowed to fight back or “put hands” on patients, only rely on de-escalation techniques. The nurses were trained only on basic de-escalation techniques and self-defense skills, she said.
In another incident on Aug. 12, 2023, she was inappropriately touched by a patient with a history of such behavior toward female staff and nurses. He faced no real discipline, she said, because he already was known for that behavior.
A week later, Aug. 19, 2023, she was working on the floor and approached by a patient she always had a good rapport with in the past. But this time, he “sucker punched” her in the face. He ripped off her glasses. As she stepped back, he sucker punched her again, she said.
She turned in her keys on Aug. 19, 2023, saying she couldn’t take it anymore.
Complaints to supervisors
Berger said she sent multiple emails to inform the director of nursing about the radios not working properly — “that was our lifeline for help” — the assaults and how staffing shortages resulted in injuries. But nothing changed.
Radios not working also was cited in lawsuits and as a safety issue in the two murders of a correctional officer, Robert McFarland, 46, of Ely, and a nurse, Lorena Schulte, 50, of Cedar Rapids, in 2021 when two inmates bludgeoned them with hammers during a failed escape at the Anamosa State Penitentiary.
During an hourlong interview with her supervisor, Berger said she was told there “weren’t as many injuries as some claimed,” but she said there were detailed notes of incidents and injuries in the records.
Berger said management was disconnected from staff. The patients, residential treatment staff and nurses were in a separate building from the director of nursing and other supervisors.
The doctors also didn’t spend much time with patients, she said. They “literally made a beeline to the office because they were afraid of them,” Berger said.
Giving up profession
This experience had upended her life. Berger has struggled in her marriage and being a mother. She isn’t comfortable going to family functions or going out with friends. She can’t relax. She has become irritable and is on medication.
Berger started out her career in 2016 as an emergency room nurse, which she loved. “Helping save somebody was liberating,” she said.
She started working at correctional facilities in 2020 and worked at Anamosa State Penitentiary for several months, after McFarland and Schulte were murdered. When asked if she still was working as a nurse, she teared up and shook her head.
“I miss it, but it’s very difficult to be around people when they’re so unpredictable,” Berger said. “This is the only profession where you consistently get verbally and physically assaulted.”
Berger said her personality and mood has “drastically” changed and she didn’t know how she might respond to a patient.
“Honestly, I’m afraid I will hurt someone because my mind is constantly running with thoughts,” she said. “I wouldn’t want to make a medication error and hurt somebody. I just don’t have that security anymore. ”
Berger said by filing her claim, she hopes the hospital will provide more security, get new radios and put better safety procedures in place.
“I don’t understand why you don’t want your staff to be safe,” Berger said. “Mental health is so important and these patients need help, but there’s so much violence going on there that they aren’t getting that treatment.”
Comments: (319) 398-8318; trish.mehaffey@thegazette.com
Daily Newsletters