What Happened
Lauren Perrin, a licensed practical nurse at Maplewood Care and Rehabilitation Center in Amesbury, Massachusetts, was sentenced to 54 months in federal prison for stealing morphine from a dying hospice patient and replacing it with cough syrup.
Perrin took morphine sulfate from three bottles prescribed to a hospice patient for her own personal use. To avoid detection, she replaced the extracted morphine with cough syrup, diluting the bottles to as little as 4 to 29 percent of their intended potency. The patient received the diluted medication and was deprived of adequate pain relief in the weeks before her death.
Perrin pleaded guilty in September 2019 to one count of tampering with a consumer product, specifically the Schedule II controlled substance morphine. On December 18, 2019, she was sentenced by a federal judge in Boston to 54 months in prison followed by three years of supervised release.
What Went Wrong
- A dying patient's own medication supply was tampered with undetected. The substitution of cough syrup for morphine went unnoticed until after the patient's death.
- No potency or volume check caught the dilution. Bottles reduced to a fraction of their labeled strength continued to be administered to the patient without anyone verifying content against the label.
- A single nurse had unsupervised access to a hospice patient's personal supply of controlled substances between administrations.
How It Could Have Been Prevented
- Require two-person verification when accessing or administering a hospice or long-term-care patient's personal controlled-substance supply.
- Periodically weigh or test patient-specific controlled-substance liquids against their expected volume and potency, especially for hospice patients on standing morphine orders.
- Train nursing home and hospice staff to recognize a patient's unexplained lack of pain relief as a potential sign of medication tampering or diversion, not just inadequate dosing.
- Implement chain-of-custody documentation for controlled substances stored at a patient's bedside in long-term-care settings.
Related Guidance
- 15 Red Flags of Drug Diversion — Indicators of tampering and diversion in long-term-care and hospice settings.
- Long-Term Care Diversion Prevention Checklist — Self-assessment for nursing home and hospice medication controls.
- Patient Notification After Drug Diversion — When and how to notify patients and families affected by tampering.
- Diversion Case Registry — Related cases of nurse tampering with patient medications.