What Happened
Wendy M. Parmenter, a licensed practical nurse at Rolling Hills Health Center in Topeka, Kansas, stole morphine prescribed for a 105-year-old dementia patient and diluted it with tap water.
Parmenter had already pleaded guilty in 2010 to stealing hydrocodone at a different nursing home, Flint Hills Care Center in Emporia, Kansas, and had been placed on pretrial diversion for that offense. She went on to work at Rolling Hills Health Center, where in November 2010 she stole morphine prescribed for an elderly patient suffering from dementia and chronic pain, adding tap water to the bottle to conceal that she had taken the drug.
She pleaded guilty to tampering with a consumer product and adulteration of a drug. On February 3, 2012, she was sentenced to three years in federal prison and, under her plea agreement, agreed to surrender her nursing license and never reapply for one.
What Went Wrong
A nurse already facing a prior diversion-related charge was able to obtain a second nursing position and divert medication from a vulnerable dementia patient. Key failures included:
- A pending pretrial diversion for a prior drug-related offense did not prevent the nurse from being hired into another role with controlled-substance access.
- Medication intended for a cognitively impaired patient who could not reliably report inadequate pain relief was not independently verified for tampering.
- Bottle-level dilution was not caught through routine reconciliation of dispensed volume against documented administration.
How It Could Have Been Prevented
- Screen for pending drug-related charges or pretrial diversion agreements, not just convictions, during pre-employment background checks for clinical staff.
- Apply heightened medication-integrity checks for patients who cannot reliably self-report pain control, such as those with dementia.
- Reconcile opioid bottle volumes against the medication administration record on a routine, unannounced basis.
- Report suspected diversion to the state nursing board immediately so it is reflected before the individual is hired elsewhere.
Related Guidance
- Employee Screening & Fitness for Duty — DEA screening requirements (21 C.F.R. §1301.90) for staff with controlled substance access.
- Hospital Diversion Prevention Checklist — Facility self-assessment covering medication administration record reconciliation.
- 15 Red Flags of Drug Diversion — Behavioral and transactional indicators of diversion by clinical staff.