First lawsuit filed against hospital where multiple patients reportedly died after receiving tap water through IV lines

By Stephanie Srakocic | Fact-checked by Jessica Wrubel
Published March 8, 2024

Key Takeaways

  • Contaminated tap water at the Asante Rouge Regional Medical Center in Oregon led to a spike in central line infections in 2022 and 2023.

  • Deaths at the hospital have been linked to a nurse who swapped patients' fentanyl IVs for the hospital’s tap water.

  • A criminal investigation is ongoing, and multiple lawsuits are expected.

Asante Rogue Regional Medical Center in Medford, OR, is at the center of a criminal investigation, OSHA investigation, and lawsuit following water-based infections and deaths on its campus.

Starting near the end of 2022, the hospital saw a spike in central line-associated bloodstream infections. Infections occurred primarily in patients being cared for in the hospital’s intensive care and coronary care units; both units are in an older section of the facility.[]

Questions about water quality at Asante were raised in response to the increase. At the time, the hospital denied any current issues with their water quality. They assured the press and public that they’d taken steps to reduce infections in a statement that read:

“From September through December 2022, several central line infections in the ARRMC critical care units were linked to waterborne bacteria. Currently, there is no known water contamination at ARRMC or any of our facilities.”[]

Oregon Health Authority data shows that there were 15 central line infections in 2022 and 14 in 2023. That’s double the previous recent high of seven seen at Asante in 2020 during the height of the COVID-19 pandemic. In most recent years, only one or two infections were reported.[] 

In the spring of 2023, OSHA began investigating Astane’s water supply. According to OSHA records, online testing of the tap water from the ICU and CCU at Astane read as highly likely to contain harmful bacteria. Additionally, records show that Asante advised staff on best practices related to contained tap water in September 2022, following the first reports of a spike in central infection. Initial Asante memos to staff focused on the drug-resistant Stenotrophomonas maltophilia bacteria. 

Contaminated water used in IV lines

Now, the first of what’s expected to be several lawsuits has been filed against Asante. However, the $11.5 million wrongful death suit filed by the estate of a 65-year-old cannabis company founder, Horace E. Wilson, who died at Asante in 2022, is about more than the contaminated water. It’s been alleged that multiple patients in the ICU and CCU received tap through their IV lines in 2022 and 2023 when a nurse, Dani Marie Schofield, used it to replace fentanyl. A criminal investigation into these allegations is ongoing.[][] 

Multiple families involved are reportedly working with lawyers to file charges of wrongful death against Asante for the deaths of several patients treated by Schofield in 2022 and 2023.

Stories include patients such as 36-year-old veteran Samuel Allison, who came to Asante in the fall of 2022 for liver failure treatment. Reportedly, Allison had stabilized but then developed an infection and died within days. Retired transportation planner Barry Samsten also developed an infection that quickly turned fatal while being treated at Asante in 2022. The 74-year-old had been admitted for a bedsore. Both families were later told by Asante officials that pain medication had been tampered with and switched with tap water.[] 

According to Oregon Board of Nursing records, Schofield agreed to a voluntary license suspension in November 2023. In December 2023, Asante contacted the Medford police about a former employee who they believed had been stealing opioid pain medication and replacing it with tap water. No charges have yet been filed against Schofield.[] 

On March 5, 2024, Medford legal firm Schlesinger & deVilleneuve announced it was working with over 50 people affected by the water-based infections at Asante. According to the firm, 34 of those cases involve wrong death. Attorney David deVilleneuve stated:

“The hospital does, in fact, believe that a certain group of people were victims of drug diversion and, specifically, that tap water was put into their IVs, so the hospital has some information that’s pretty strong to indicate that this, in fact, did happen and it was one of their nurses.”[]

Healthcare professionals and substance use

Substance use disorder is a well-documented concern among nurses and other health care professionals. It’s commonly estimated that around 10% of healthcare professionals have a substance use disorder. Clinical staff are in a position that makes substance use a multi-faceted problem. Being under the influence of a substance can negatively impact patient care and can put patients at risk of serious harm. Nursing roles and similar clinical positions also provide access to opioids and other controlled substances.[]

The Joint Commission reports that fentanyl is the most commonly diverted opioid. Other opioids commonly illegally obtained on the job by healthcare professionals include hydrocodone, methadone, oxycodone, morphine, and codeine. Antipsychotics such as Risperidone and Quetiapine, as well as benzodiazepines such as Clonazepam and Lorazepam, are also frequently diverted.[] 

In a 2019 report on drug diversion in healthcare facilities, the Joint Commission warned of the high likelihood that only a small percentage of healthcare professionals who deliver medications are ever caught. The organization urged all healthcare professionals to be on alert for substance use and medication diversion among their colleagues, writing:

“Direct observation is vital to detecting diversion and may be the only way to identify an impaired colleague. In organizations where controlled substances are used, all staff should be educated [with a] comprehensive controlled substances diversion prevention program, including leadership oversight, legal and regulatory requirements, monitoring and surveillance, automation and technology, and pharmacy controls[].

Healthcare facilities must have systems to facilitate early detection. These systems can include video monitoring of high-risk areas, active monitoring of pharmacy and dispensing record data, as well as having staff who are aware of and alert for behaviors and other signs of potential diversion activity.”

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