OR: In replacing fentanyl with tap water, Asante nurse may have caused deaths

A Medford nurse’s diversion of drugs is believed to have led to numerous deaths over the course of 12 months; questions are swirling as police investigate and a lawyer prepares to sue.

Reports that a nurse at Asante Rogue Regional Medical Center may have sparked fatal infections of patients by replacing fentanyl with tap water in their IV bags have sparked national attention.

For patients, the victims’ relatives, and others in Oregon health care, the reports are sparking questions as well. It now appears that the deaths linked to the Medford hospital occurred over a span of at least 12 months, The Lund Report has learned. Given the reports that as many as ten patients may have died in this manner, how did this happen? And where does it end?

Diane Rogers, a 71-year-old resident of Klamath Falls, said in an interview that Asante officials reached out to her in November to tell her that the death of her husband, Barry Samsten, was caused by a bacterial infection after his fentanyl was replaced with non-sterile tap water. But she said she hasn’t heard back since.

“The whole time he couldn’t talk,” she said. “And if he wasn’t on pain medicine what was he on? It was awful. I kept asking, ‘Is he in pain? Is he cold? Could you give him a blanket?’”

Officials are not saying much about the incident. But interviews by The Lund Report suggest how hospital drug diversion — a common occurrence — may have sparked an uncommon and tragic result. They also point to where this could end up: in court.

David deVilleneuve, a trial lawyer based in Medford, told The Lund Report that he has been investigating the issue on behalf of victims of the Asante situation. He’s interviewed several of them, including family members of people who died from infections, as well as victims injured by a non-fatal infection of pseudomonas, the bacteria that’s also been linked to the deaths.

His impression from talking to them and other informed people is that the first known death of an Asante hospital patient due to the drug diversion may have occurred as early as December 2022 —a full year before the situation became public.

As the presumed beginning of the alleged pattern of deaths keeps getting pushed back, it makes him think “there may be more people that we don’t know of at this time that were affected by this,” deVilleneuve said.

What’s known so far

On Dec. 29, NBC5 News broke the news that police were investigating at least one patient death at Asante with unnamed sources saying up to 10 patients possibly died as a result of a nurse replacing medication with tap water.

Family members of two alleged victims told the Rogue Valley Times the hospital notified them that their loved ones died from infections after their medications were tampered with by a hospital employee. The news outlet cited multiple unnamed hospital sources who said dozens of patients had been injured by having their medications diverted.

Hospital administrators and local law enforcement have not named the suspected employee and released few other details.

An Asante spokesperson sent The Lund Report a short statement saying management was “distressed to learn of this issue” and has referred it to law enforcement.

According to a statement issued Wednesday by Medford police spokesman Lt. Geoff Kirkpatrick. officials from Asante contacted the Medford Police Department in early December 2023 regarding an employee suspected of stealing “controlled substances” that harmed patients.

Police don’t know how many patients have been harmed, according to the statement, but have received  “numerous calls from individuals asking if they or a family member have been impacted by the suspected actions of the former Asante employee.”

According to the statement, Asante has been notifying involved patients or their families:  “We would like to acknowledge the community’s concern with this case and ask for patience and understanding as this investigation is complex and ongoing.”

Drug diversion common, but fatalities not 

Theft of drugs from health care facilities, known as “diversion,” is common.

Health care analytics company Protenus estimated in a 2023 study that at least 1% of medical workers have diverted drugs. HealthcareDiversion.org puts it at roughly 10%. A 2019 study in the Journal of Hospital Medicine concluded that “drug losses and theft from the healthcare system are accelerating.”

“It happens more than you’d like to believe,” Lisa McElhaney, who spent 25 years as a south Florida sheriff’s deputy specializing in drug diversion and now works as chief operating officer for the National Association of Drug Diversion Investigators, told The Lund Report.

Studies from the Centers for Disease Control and Prevention and the Mayo Clinic both found that patients are put at risk of infections from medical equipment left contaminated by health care workers stealing drugs

While diversion of drugs including fentanyl is common, this number of reported fatalities in a single cluster is not.

One possible explanation cited by observers? The tap water at Rogue Medical Center.

Tap water contributed?

In April, Asante addressed “water quality rumors” in a post on its website. The post states that the hospital saw infections in its intensive care unit the previous year that “prompted extra measures,” but management regularly monitors the hospital’s water supply and there was no known water contamination.

“Bacteria can be common in any water supply and may be harmful when used for patient care of our vulnerable patients,” reads the post. “That’s one reason why we check our water source regularly and have precautions in place to prevent waterborne infections.”

According to deVilleneuve, his research indicates that “Pretty much any tap water poses a severe threat if it’s put directly into your veins because it’s full of bacteria, even tap water that’s considered clean and … water that you and I drink out of the faucet at home.”

Among the many questions deVilleneuve is exploring is how did it take so long to notice what was happening.

Health care-acquired infections are not uncommon, and they got worse in Oregon during the pandemic, as some nurses expected would result from staffing shortages.

At Asante, they were a particular problem.

In a March 2023 post on its website, Asante reported a “winter spike” in central line infections at the hospital the previous year. The post stated that there were 10 infections and the hospital was reviewing its processes, stressing that keeping tap water away from patients was the best way to protect against waterborne organisms.

Meanwhile, federal data from 2022 puts Asante at “worse than the national benchmark” for central line associated bloodstream infections. They occur when bacteria or viruses enter the bloodstream from a tube doctors place into a patient’s neck, chest or groin to administer medication or fluids.

It’s unclear how or when the hospital linked its employee’s suspected drug diversion to the deaths.

Potential for prosecution

Josh Marquis, former Clatsop County District Attorney, told The Lund Report that Oregon laws include a felony charge for tampering with drug records that is often also used for drug diversion cases.

He said it can be applied to situations where someone alters a doctor’s prescription, adding a zero to increase the number of doses. But he said that in Oregon, it’s unusual for anybody convicted of it to do hard time.

Bringing more serious charges, such as manslaughter, against a nurse who replaced a patient’s medication with tap water would require showing there is a high-level of recklessness and extreme indifference to the value of human life.

“And that’s harder than it sounds to prosecute,” he said.

He also said that a prosecutor could face difficulty proving that the tap water caused a patient’s death. A defense attorney could argue that a patient has a complex medical history and other factors could have contributed to their death.

According to deVilleneuve, the nurses he’s spoken with told him that “Pretty much any nurse would know that putting tap water is going to pose a substantial threat to someone’s health.”

No indictments have been filed publicly in the case.

Jackson County District Attorney Beth Heckert told The Lund Report in an email that the “case is still under investigation by the police and has not been submitted to my office yet.”

“I don’t have any information to release at this time,” she wrote.

Similar cases elsewhere

Studies from the Centers for Disease Control and Prevention and the Mayo Clinic both found that patients are put at risk of infections from medical equipment left contaminated by health care workers stealing drugs

David Kwiatkowski, a traveling health care technician carrying Hepatitis C, in 2013 admitted to diverting fentanyl from patients to feed his narcotics addiction. Pleading guilty to federal drug charges, Kwiatkowski told a court that he would inject himself with syringes of fentanyl prepared for patients, refilling them with syringes with saline, causing them to be infected with Hepatitis C. Kwiatkowski was linked to outbreaks in eight states.

Two nurses in Colorado were sentenced to prison for stealing painkiller medications and replacing them with tap water, according to HealthcareDiversion.org.

McElhaney said she couldn’t speak to the circumstances at Asante but said hospitals, home health care agencies and hospice providers should be reviewing their safeguards.

“The facilities with more stringent protocols will have less occurrences,” she said.

Health care facilities in recent years have turned to data and analytics to prevent the theft of medications, she said. This approach involves tracking how much medication is given to a patient and how much is left over and needs to be disposed of, she explained. If an employee is disposing of a large amount of medication, it could be a sign of diversion, she said.

Hospitals should closely monitor sought-after drugs, like fentanyl, restricting staff access to it and keeping it on special carts, she said. They should also watch to make sure a seal on a drug hasn’t been tampered with and it hasn’t been diluted, she said.

Some facilities, she said, won’t take action until they face a large fine from the  U.S. Drug Enforcement Administration.

“If you’re not going to look for it, you’re not going to see it,” she said.

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Tags: Drug Trafficking

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