What Happened
Jolene Larsen, a licensed practical nurse and unit supervisor at Merry Haven Care Center, a Snohomish, Washington nursing home providing hospice care, removed morphine sulfate from patients' prescription vials and replaced it with tap water.
Between November 2009 and May 2010, Larsen took morphine intended for hospice patients so she could consume it herself, refilling the vials with tap water to disguise the missing volume. At least one diluted dose was administered to a patient, whose pain went untreated until additional medication was given.
Larsen pleaded guilty to tampering with a consumer product. On March 7, 2011, she was sentenced in U.S. District Court in Seattle to one year in prison and three years of supervised release.
What Went Wrong
A supervisor with routine, trusted access to hospice patients' opioid supply was able to dilute medication undetected for months. Key failures included:
- Vial-level reconciliation was not sufficient to catch dilution of the drug itself, as opposed to outright missing volume.
- Hospice patients' unrelieved pain was not escalated as a possible signal that prescribed medication was not reaching them at full strength.
- A unit supervisor's own controlled-substance handling was not subject to independent verification separate from the staff she supervised.
How It Could Have Been Prevented
- Periodically test the actual concentration of dispensed liquid opioids against expected potency, not just the volume remaining in the vial.
- Treat unexplained or recurring breakthrough pain in hospice patients as a diversion red flag warranting medication verification, alongside a clinical response.
- Apply independent, randomized audit of controlled-substance handling to supervisory staff as well as front-line staff.
- Restrict single-nurse, unwitnessed access to opioid vials for vulnerable patient populations such as hospice patients.
Related Guidance
- 15 Red Flags of Drug Diversion — Behavioral and transactional indicators including unexplained breakthrough pain reports.
- Diversion prevention checklist — Facility self-assessment covering controlled substance handling in hospice settings.
- Employee Screening & Fitness for Duty — DEA screening requirements (21 C.F.R. §1301.90) for staff with controlled substance access.
- Tough Issues — High-risk scenarios with annotated SQL for analyzing dispense-to-administer gaps.