A former intensive care unit (ICU) nurse in Oregon was arrested on June 13, 2024, for allegedly diverting liquid fentanyl and replacing it with tap water. The Medford Police Department (MPD) said in a news release that the former nurse was arrested after a lengthy investigation into allegations of drug diversion between 2022 and 2023.
The investigation began after hospital officials noticed a surge in central line infection cases among ICU patients. After an internal review, the hospital provided information to MPD, indicating that all identified cases were isolated to the ICU and occurred within a specific date range. Investigators found that the former nurse, who had left the hospital in July 2023, had access to each of the affected patients. Concerns arose that she had diverted liquid fentanyl meant for patients and replaced it with tap water, resulting in serious infections.
MPD investigators spent months pouring through volumes of hospital records and interviewed nearly 100 people including doctors, nurses, patients, and many of those affected. Due to the magnitude of the case and its impact on victims, the police department assigned multiple full-time detectives to the investigation. The known infections were narrowed down to the period between July 2022 and July 2023, exclusively within the ICU.
The Jackson County District Attorney’s office reviewed MPD’s findings, and on June 12, 2024, a grand jury indicted the former nurse on the 44 counts of second-degree assault. The charges encompass all patients affected by her alleged criminal actions.
Compliance Perspective
Issue
Drug diversion poses an increasing challenge in healthcare settings. Licensed staff with access to controlled medications are particularly vulnerable to engaging in fraud and theft of controlled substances if they develop a substance abuse issue. It is crucial for healthcare leaders to recognize the signs of substance use disorder involving controlled substances and to respond promptly and appropriately to any instances of drug diversion.
Discussion Points
- Review your policies and procedures on preventing, identifying, and responding to drug diversion. Update as needed.
- Train appropriate staff on actions that can be taken to prevent, identify, and respond to any suspicion of drug diversion. Provide education on the impact of drug diversion on residents as a form of abuse and neglect, staff responsibility to report concerns immediately, and the consequences of theft of controlled substances. Document that the trainings occurred, and place the signed document in each employee’s education file. Med-Net Academy offers all clients three PowerPoint training programs in the Substance Use category. Visit MNA to access all three. Additionally, in the Fraud, Waste, and Abuse Category of MNA, a program titled Drug Diversion: What Every Facility Needs to Know is available for viewing by all clients.
- Periodically audit to ensure that all controlled substances are accounted for on each shift, and that proper documentation of controlled substances has occurred. Your consultant pharmacist can be included in this effort.
*This news alert has been prepared by Med-Net Concepts, LLC for informational purposes only and is not intended to provide legal advice.*
