Nurse swaps patient’s medicine with tap water, then he dies in pain, lawsuit says

A patient hospitalized with broken ribs and a damaged spleen seemed to be getting better — until his condition “took a turn for the worse” in an intensive care unit, according to a lawsuit filed over his death.

After falling about 10 feet from a ladder, 65-year-old Horace E. Wilson was admitted to Asante Rogue Regional Medical Center in Medford, Oregon, where he died a month later on Feb. 25, 2022, the lawsuit says.

A nurse was supposed to administer Wilson fentanyl to ease his pain, but she swapped the medication with tap water, the lawsuit filed Feb. 26, 2024, says.

The nurse is accused of diverting the fentanyl and replacing the missing medication — which Wilson was to receive through an infusion — with the “non-sterile” water. By doing so, she introduced bacteria into his bloodstream, according to a complaint.

The bacteria infected Wilson’s body and “became essentially impossible to eradicate,” the complaint says.

Wilson began having “unexplained high fevers” and experienced sepsis, leading to his organs failing and brain dysfunction, according to the complaint.

“Eventually, Horace Wilson was weaned from sedation and recovered enough mental function to communicate to the ICU staff that he no longer wished to live this way,” the complaint says.

He was in pain before he died because he wasn’t administered fentanyl, according to the complaint.

Wilson’s wife, Patti L. Wilson, is suing Asante and the nurse, accusing them of causing her husband’s death.

The lawsuit seeks up to $10 million in damages for Wilson’s “pre-death pain and suffering,” $975,000 for medical costs and $500,000 for his family’s “untimely loss,” the complaint shows.

McClatchy News contacted Asante for comment on Feb. 28 and didn’t receive an immediate response. Contact information for the nurse wasn’t available.

A police investigation

In December 2023, Asante reported to the Medford Police Department that one of its former employees may have stolen prescription medications meant for patients, the department said in a Jan. 3 news release.

“There was concern that this behavior resulted in adverse patient care, though the extent of the impact on those patients is yet to be determined,” police said.

The former employee wasn’t named in the news release.

Police have launched an investigation, which they described as “complex and ongoing.”

On Feb. 26, Medford Lt. Geoffrey Kirkpatrick told The Oregonian that “we’re holding off on releasing anything because a lot of it is really unclear.”

‘We want accountability’

The nurse named in the lawsuit agreed to stop practicing as a nurse on Nov. 22 in relation to a pending investigation, according to Oregon Board of Nursing records, The Oregonian reports.

Attorney Justin Idiart is representing the lawsuit. He told McClatchy News on Feb. 28 that he represents nine others who were patients at Asante in similar cases.

He said he’s evaluating several other cases.

“We want accountability from Asante and (the nurse) for these patients and future patients when they don’t meet the standard of care we expect going to a hospital,” Idiart said.

McClatchy News is not identifying the nurse because she has not been charged, according to The Oregonian.

Wilson improves in the ICU, then worsens

When Wilson entered the ICU on Jan. 27, 2022, following his fall from the ladder, his spleen was bleeding and had a laceration, the complaint says.

The organ was surgically removed the next day during a splenectomy, according to the complaint.

From Jan. 29 to Feb. 2, he “appeared to be improving,” the complaint says.

However, he began to worsen on Feb. 3, and his body started showing signs that it was fighting an infection, according to the complaint.

The nurse who was tasked with administering fentanyl to Wilson wrote in a chart that she gave him the drug on multiple occasions, beginning on Jan. 29, the complaint says.

The medication “would have alleviated the pain he experienced” prior to his death if he had received it, according to the complaint.

The lawsuit says Asante previously learned one of its nurses was diverting controlled substances from August 2016 through July 2017.

“Asante knew or should have known of the high likelihood of opioid diversion by one of its employees for their own use given the prevalence of such acts throughout the United States,” the complaint states.

In December 2022, a former nurse was sentenced to three years and one month in federal prison after prosecutors said she replaced medication meant for cancer patients with water in Buffalo, New York, McClatchy News reported.

As a result, six patients were exposed to bacteria and developed waterborne infections, according to court records.

When Wilson died at the hospital, his family, including his children, and friends were at his side, The Oregonian reported.

He had six children, including five who are alive, Idiart told McClatchy News.

Wilson was known by his nickname, “Buddy,” and described as a devoted father in his obituary, according to The Oregonian.

After a career in technology, which allowed Wilson to travel the globe, he established Decibel Farms, a cannabis company in Jacksonville, Oregon, in 2016, according to the newspaper.

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