Connecticut DPH board revokes Waterbury nurse’s license after overdose finding

The Department of Public Health board voted to revoke the registered nurse license of Kalina N. Beckford, RN, on March 5, 2025, after finding she administered a morphine infusion at a rate far above the physician’s order, which investigators say resulted in a patient’s death.

The board’s decision followed testimony from Michelle Durante, director of risk management at Waterbury Health, and the admission into evidence of Department and board exhibits including medical records, pump logs and a toxicology report. The vote on remedy was 4–1 in favor of revocation; Lisa Freeman cast the lone dissenting vote.

The case concerns an incident on Nov. 5, 2024, at Waterbury Hospital. Department staff attorney Julianne Kataya told the board the physician’s order called for “an infusion rate of 2 milligrams of morphine per hour” with adjustments every 15 minutes up to a maximum of 10 milligrams per hour. Kataya said records show Beckford programmed the pump to infuse at 100 milligrams per hour, that a pump “soft limit” alarm appeared and was overridden, and that about an hour later the morphine bag was empty, the patient was found unresponsive and the patient died approximately two hours later. Kataya said the medical examiner’s report listed cause of death as morphine intoxication.

Michelle Durante testified she led Waterbury Health’s internal investigation and that her review of pump logs, medical records and staff interviews supported the department’s account. “Our investigation determined that the RN… did not properly follow the standards of medication administration, ultimately, ending in a fatal outcome for our patient,” Durante testified. She explained that the hospital’s IV pump system uses soft limits as a safety reminder and that Beckford did not question or stop after the soft-limit alert.

The board entered evidence as follows: board exhibits 1–4 (notice of hearing, USPS tracking of certified mailing, statement of charges and a prior summary suspension order) and Department of Public Health exhibits 1–9 (complaint from Waterbury Hospital; sealed excerpts of medical records; a death certificate and toxicology report entered under seal; a root cause analysis; personnel-file excerpts; the DPH investigative report; a letter of representation from Thomas K. Mitchell Hoffler; and an engineering report of pump use). Attorney Kataya asked the board to revoke Beckford’s license or otherwise discipline her under the statutes cited in the statement of charges.

The hearing record shows an early procedural sequence in which a motion to deem the allegations admitted was made, passed by roll call, then later vacated after board counsel Liz Bannon noted that the respondent’s earlier written representation included a denial and recommended the board proceed on the merits. After counsel’s clarification, the board rescinded the earlier deeming order, admitted the Department’s exhibits, heard testimony from Michelle Durante and then voted on factfinding.

Board member Cindy (surname not specified in the record) led the fact-finding motion. The board found that the Department proved the allegations on the statement of charges, citing the pump history, root cause analysis and the hospital complaint. On remedy, Cindy moved for revocation; Lisa Freeman proposed assessing a monetary penalty as well but the final recorded motion and vote were for revocation only. The roll call on revocation recorded ayes from Cindy, Sal (given name in the record), Camille (given name), and Chair Gina Reiner; Freeman voted no. The chair announced, “the remedy for this case of Kalina M. Beckford is for revocation.”

Transcript and exhibits show several contextual details the board discussed during remedy: the patient-to-nurse assignment that night was 1 to 6 on a medical–surgical unit; hospital policy requires a witness nurse and titration/assessment for high-risk infusions; the pump log showed multiple alarms (including occlusion and air-in-line) that investigators say were not resolved in a manner that prevented the overdose. Board members debated system pressures and staffing but focused their decision on the nurse’s actions and prior corrective-discipline history recorded in the personnel file and investigative report.

The board also directed the hearing office to issue a written order reflecting its actions in related procedural items earlier in the meeting, including vacating a prior summary suspension order in a separate matter; hearing staff confirmed they would prepare that order.

The board announced the revocation for the record and moved on to the remainder of its agenda, including a public comment period and adjournment.