What Happened
A nurse at Governor's Center, a nursing facility in Westfield, Massachusetts, tampered with a bottle of morphine prescribed to a hospice patient.
In January 2018, the nurse removed morphine from a bottle prescribed to a hospice patient and diluted the remaining liquid with another substance. The patient received diluted doses of her prescribed pain medication in the days shortly before her death. After ingesting the diverted morphine, the nurse was observed to be significantly impaired while continuing to provide care to patients at the facility.
She was charged in October 2020 and pleaded guilty to one count of tampering with a consumer product, a charge carrying up to 10 years in prison, three years of supervised release, and a $250,000 fine. Sentencing was scheduled for June 2021.
What Went Wrong
A dying hospice patient received diluted pain medication in her final days, and the nurse who diverted it continued providing direct patient care while visibly impaired. Key failures included:
- Morphine volume was not verified against the prescribed amount before or after each administration, allowing dilution to go unnoticed.
- Visible staff impairment on shift was not identified or acted on in real time, despite being described as significant enough to be observed by others.
- A hospice patient nearing end of life had no realistic ability to report that her pain relief felt inadequate, removing a natural detection safeguard.
How It Could Have Been Prevented
- Verify liquid morphine volume against the prescribed and previously recorded amount at each administration, with any shortfall investigated immediately.
- Train supervisors and coworkers to recognize and immediately act on signs of staff impairment during a shift, with a clear, low-friction reporting process.
- Apply heightened scrutiny to end-of-life pain management, where patients are least able to advocate for themselves if their medication has been diverted.
- Require fitness-for-duty checks when a colleague's behavior raises concern, rather than relying on the employee to self-report.
Related Guidance
- Employee Screening & Fitness for Duty — Recognizing and responding to signs of staff impairment.
- 15 Red Flags of Drug Diversion — Behavioral and dilution indicators.
- Diversion Prevention Checklist — Adaptable to nursing facility and hospice settings.
- Diversion Case Registry — Other hospice and nursing-facility diversion cases.