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More than two years after news broke that a nurse in Medford may have swapped tap water for fentanyl in patients’ IVs, allegedly leading to infections linked to a dozen or more patients’ deaths, a 303-page federal investigation obtained by The Lund Report detailes a series of safety lapses that endangered patients.
Chief among the investigators’ findings: For more than a year, starting in May 2022, coworkers were flagging and documenting suspicious behavior on the part of one nurse in the Intensive Care Unit, or ICU. But not until July 2023 did hospital management take action that led to the nurse’s firing.
Citing internal hospital documents, investigations and interviews with coworkers and managers at Rogue Regional Medical Center — along with three unannounced inspections starting in January 2024 — the federal report cites repeated “systemic failures” and concluded the hospital featured “limited capacity” to provide “safe and adequate care.”
Asante administrators and employees at the hospital failed to address the recurring suspicious behavior of a nurse in any concerted way, even when some of that behavior was caught on video, according to the report. At times that behavior included falling asleep on the job or, at other times, seemingly ignoring a manager's instructions to protect patient safety.
Managers failed to account for missing drugs. Hospital administrators failed to establish a system that would effectively detect, much less control, infections and outbreaks even as the deaths mounted. Nor were the policies they established followed.
Asked for an interview or their perspective on the federal investigation by The Lund Report, Asante officials did not respond. For two years they've largely declined to comment on the situation.
Of the 45 or more patients who suffered infections at Rogue Regional Medical Center between July 17, 2022 and July 18, 2023, at least 19 died, according to the report.
The report comes as a former nurse at Rogue Regional, Dani Marie Schofield, faces 44 counts of second-degree assault in a criminal trial scheduled to begin later this year. Prosecutors say patients were harmed because Schofield replaced the fentanyl that was prescribed with non-sterile tap water.
Schofield has pleaded not guilty to the charges. Reached by The Lund Report in January 2024, Schofield denied wrongdoing and said she quit of her own volition. “The truth will, I’m sure, come out,” she said.
The federal report does not name Schofield or other employees, often referring to them using acronyms based on their job title. The report refers to the nurse suspected of diversion as “RN4.”
The federal investigation conducted by the Centers for Medicare & Medicaid Services, known as CMS, was obtained under the federal Freedom of Information Act. It traces the evolution on parallel tracks of hospital staffers’ drug diversion suspicions and responses, along with rising awareness of mounting blood infections. Finally, the two developments converged for hospital leaders in a manner the federal report indicates was months overdue.
David DeVillenueve, a Medford attorney who's filed several lawsuits in the case, said that despite his firm's lengthy investigation of the situation, much of the report's contents surprised him.
“Pretty shocking,” he said. “The hospital had numerous, numerous opportunities to where they should have known, and they should have done something. And they didn't. And people got hurt because of it.”
Drug theft suspicions surfaced as infections increased
The first documented concerns about RN4’s behavior surfaced in May 2022, according to the report. In a hospital document dated May 17, a bedside nurse describes RN4 apparently emptying a syringe of Dilaudid, an opioid painkiller, into a waste bin while pouring saline into the bin.
The bedside nurse said they “did not see that [RN4] was depressing the [flange] of the syringe,” and then RN4 turned away and seemed to be protecting something in a jacket.
When the bedside nurse checked the bin for used needles, the Dilaudid syringe wasn’t present. When the bedside nurse confronted RN4 about the missing syringe, RN4 laughed and said it was there. Upon the bedside nurse’s second inspection, the syringe could be seen.
“I spent the remainder of my shift watching [RN4] closely for impairment,” the bedside nurse told an internal reviewer. “I reported all of these observations and concerns to leadership."
That same month, according to the report, the hospital started to notice infections in the intensive care unit. By the end of September 2022, the report says, it had identified a “cluster” of such infections, all involving organisms that ‘could grow in liquids such as tap water.” They were infections involving “organisms we had never seen in our careers,” according to one employee.
Despite having identified the outbreak, hospital administrators didn’t report it to the Oregon Health Authority until seven months later, on April 19, 2023, according to the report. “The hospital failed to report the outbreak to either the local public health authority or the state public health authority in a timely manner,” federal investigators concluded.
More of RN4’s coworkers reported their concerns. An undated hospital document includes multiple reports between mid-May and early December 2022 of “behaviors and activities suspicious for drug diversion,” as well as reports of RN4’s apparent “impairment.”
A report of an informal “coaching” session with RN4 from September 2022 reviewed several cases of missing medications and noted that RN4 hadn’t followed approved procedures for handling narcotics. Additional cases of drug mishandling, the coaching document said, “may result in disciplinary action.”
“The hospital failed to report the outbreak to either the local public health authority or the state public health authority in a timely manner.”Conclusion from Federal Investigators' report
“The hospital failed to report the outbreak to either the local public health authority or the state public health authority in a timely manner.”Conclusion from Federal Investigators' reportDespite such internal reviews, the federal report says, no documentation exists to show that pharmacy managers or the hospital rapid response diversion team was notified, nor that there was any follow-up investigation.
The lack of hospital follow-up is a recurring theme throughout the federal report. The connection between RN4 and the apparent drug diversion wouldn’t be made for another year.
An email to the supervisor of the intensive care unit on Dec. 13, 2022 compiled observations of multiple coworkers, who wrote that RN4 “is very rude, unwilling to collaborate, short-tempered ... we have all noticed a change in [their] behavior in the past few months ... seems angry all the time ..." The same month, hospital video captured RN4 falling asleep at a desk while drinking from a water bottle. RN4 was observed multiple times to be very sleepy, and to take extended, unexplained bathroom breaks, leaving patients unattended.
A Dec. 28 report, apparently made by the supervisor of the intensive care unit, noted some “missing volumes” of fentanyl, which led a supervisor to closely observe RN4 for several hours during a shift. During that time, the supervisor noticed a syringe of unusual size in RN4’s pocket, RN4’s unusually slow gait, and a period of standing, swaying in a patient room and “not interacting with anything.” Meanwhile, the patient, who was intubated, seemed distressed, grimacing and gripping the bed’s siderails, but RN4 didn’t seem to notice, according to the federal report.
The supervisor was so concerned that they brought RN4 to their office and said RN4 must submit to a “fit for duty” exam.
Drug test for nurse omitted fentanyl
Despite management referring the nurse for a Dec. 28, 2022 “fit for duty” evaluation along with a drug test, both steps were botched, according to the report.
Again, the federal report notes, “there was no documentation that reflected [the appropriate report] had been completed. There was no further documentation of investigation into these concerns including with respect to RN4's assigned patient(s), potential presence and extent of harm related to RN4's lack of awareness and response to their intubated patient's symptoms of distress.”
The hospital, federal investigators concluded, failed “to ensure each patient's rights were protected and promoted, including the right to receive care in a safe setting…Those failures contributed to patient harm and created the likelihood of harm to other patients.”
The drug test was another issue. One internal document reported that RN4’s drug screening in December “came back negative.” However, according to the federal report, “The drug test did not include testing RN4 for fentanyl.”
The report quoted an individual described as Asante’s “chief legal officer” saying that “RN4 should have been tested for fentanyl but was not.” Not only that, the hospital diversion team should have been called in sooner and an evaluation done of RN4, the employee added, “but ‘culturally’ there was a gap.”
Despite the accumulating concerns, RN4 was given a glowing performance review for the year ending Dec. 31, 2022. “[RN4] is a top-notch critical care RN .... combines sound theoretical knowledge with strong clinical skills to provide excellent patient care,” the review reads. “[They are] honest and kind, acting with integrity ... We are so lucky to have [them in] ICU!" RN4 “exceeds expectations” in all categories, according to the review.
Supervisors and peers had concluded RN4’s behaviors “were a medical issue,” according to the federal report. They were advised by human relations to continue to watch and take notes.
According to the federal report, an ICU manager was asked if any plan was developed at this point “to address RN4's concerning behaviors in order to ensure patients received safe care when RN4 was assigned to and caring for patients.” The manager’s response was that “no plan had been put into place.”
By that time, according to the report, at least nine patients who were treated and infected had died.
More reports led to a firing
Concerns about RN4’s behavior continued to accumulate throughout the first half of 2023. One internal report described RN4’s suspicious movements in a patient room and, when confronted, RN4 said they didn’t remember being in that room, while conceding it was possible.
Meanwhile, volumes of fentanyl continued to be missing or unaccounted for.
Other staffers described the nurse’s frequent, extended bathroom breaks and absence from patients they were supposed to be attending. In one case, one of RN4’s patients pulled out an IV tube.
In an internal document described the launch of another inquiry into RN4's fitness for nursing duty, one employee said they never know “which RN4 is going to show up.”
On July 25, 2023, a manager told investigators, they again spoke to the nurse about leaving their patients unattended, reminding them that with some patients on oxygen pumps, “if that pump stops ... it only takes a few seconds for [their] patient to suffer harm. Even if [RN4] thinks [they are] only going to be gone for a few minutes using the bathroom, that could be life or death for someone if their IV pump stops.”
On July 26, 2023, RN4 was told they must submit to a drug screen. This time, RN4 refused. An internal document showed that RN4’s employment was terminated on that day.
The federal investigation indicated the hospital’s handling of the nurse’s situation was too little, too late: “Hospital staff and others observed numerous incidents of behaviors and activities suspicious for drug diversion, impairment, and other patient safety concerns involving RN4 and ICU patients. Behaviors and activities were documented for over a year beginning at least May 2022 through July 2023 when the nurse's employment terminated. Prevention, identification, investigations, and response to those incidents that reflected potential abuse, neglect and patient harm, were not conducted or were not timely, clear and thorough to ensure they did not recur.”
Complicating things, according to the report, may have been Asante’s failure to internally account for drugs and potential diversion by facility — instead aggregating them across the system’s hospitals in Medford, Grants Pass and Ashland.
"I didn't give data by hospital,” a pharmacy manager told the federal investigator. “We were not separating out the data. We manage our [drug diversion] surveillance as a system."
Connection to infections took months
Meanwhile, infections had continued to mount.
During the first half of 2023, the hospital continued to notice a pattern of intensive care patients becoming infected. On April 27, 2023, hospital staffers met with the hospital infection prevention unit at the Oregon Health Authority, which alerted hospital staff to the possibility that the infections were linked to tap water and drug diversion, according to the report.
At least 12 patients had died with infections before that meeting; another seven died afterward, according to the federal report.
Still, the report noted, “although behaviors and activities were documented for over a year beginning at least May 2022, there was no documentation that reflected nursing leadership was notified until 01/10/2023, which was eight months after initial concerns were identified.”
In September and October of 2023, according to the federal report, Asante hired an infectious disease expert from UCLA to study the pattern of infections, and the expert concluded that the “root cause” of the infections may have been drug diversion — depriving patients of their prescribed medications and substituting something else.
After that conclusion, the hospital started reviewing internal records, including time cards, and “determined that each patient who experienced an infection had been prescribed IV administration of fentanyl and that one nurse, RN4, was associated with the care of all involved patients,” according to the report.
Before November 2023, "We had no clue it was tied to the RN," a hospital staffer told investigators, according to the report.
As the federal investigators noted, “the hospital made no association between RN4's drug diversion and [infections] until November 2023, seven months after the meeting with [the Oregon Health Authority] in which potential staff drug diversion and increased [infections] were discussed.”
Families notified, lawsuits and indictment follow
Starting in November 2023, about 18 months after the first suspicions arose about RN4, Asante reached out to the affected patients or their surviving family members to explain the infections.
After January 2024, when federal investigators began their investigation, they found that hospital managers could not consistently provide a date for when the hospital infection control unit identified the outbreak of infections associated with its Intensive Care Unit. In different interviews, the hospital provided four separate dates for when that realization occurred, investigators wrote: “September 2022, October 2022, April 2023, and October 2023.”
The federal report characterizes the inconsistencies as “further evidence” that the hospital infection control unit “failed to fully develop, implement, or follow systems and processes to detect, investigate and control infections and outbreaks.”
Eleven lawsuits were filed on behalf of at least 14 patients, some of them citing Schofield by name as the alleged perpetrator. Many of the suits have since settled and the rest are on hold pending Schofield’s criminal case. That tally does not include any claims that were settled by patients or their families prior to filing in court.
Schofield’s nursing license expired in April 2024, having been relinquished for the previous five months due to a pending investigation by the Oregon State Board of Nursing. That investigation was subsequently put on hold due to the criminal case. In January 2024, Schofield told The Lune Report that she’d been cooperating with the board’s investigation.
Schofield, who has continued to maintain her innocence of all allegations, is scheduled for an eight-week trial starting Sept. 14.
CMS’s conclusions from its early 2024 surveys were finalized on March 25, 2024 in a “statement of deficiencies,” a form normally shared with a hospital for correction. They don’t appear to have been relayed to the public.
Following a follow-up visit in April 2025, the feds found that Asante “had implemented processes and systems to the extent that deficiencies … were determined to be corrected and it was back in substantial compliance” with the federal agency’s conditions of participation in the Medicare and Medicaid programs.
Asked why Asante leadership did not share information with the public about the federal safety concerns — as other hospitals have done after federal inspections and similar revelations — CEO Tom Gessel and other Asante executives did not respond.
This story was originally published by The Lund Report, an independent nonprofit health news organization based in Oregon. It is republished with permission.