A 30-year-old woman of Grand Island, NY, who was convicted of tampering with a consumer product, was sentenced to serve 37 months in prison. Between February and June 2018, the woman, who had worked as a registered nurse (RN) at a hospital, tampered with and stole controlled medications, including Dilaudid, from various medication dispensing machines located throughout the hospital, which tracked and held controlled substances meant for patients. She did so to satisfy her addiction. The RN utilized the patient medical record database to search for patients specifically prescribed hydromorphone, because to access the dispensing machine, she had to first access patient profiles. At times, she would divert vials of controlled medications from the dispensing machine and not administer the medication to any patient.
On June 27, 2018, a scheduled vacation day, the RN was observed accessing a dispensing machine, carrying a backpack, and exiting a medication room in which she was not assigned. It was later determined that she had accessed the drawer for hydromorphone. She was subsequently placed on administrative leave and resigned in lieu of termination.
From June to July 2018, there was a spate of waterborne infections at the hospital, during which six patients became ill. An investigation by the hospital concluded that tampering of compounded hydromorphone vials was the cause.
The sentencing was the culmination of an investigation by the Food and Drug Administration, Office of Criminal Investigations; the Federal Bureau of Investigation; the New York State Department of Education, Office of Professional Discipline, and the New York State Attorney General’s Office.
Compliance Perspective
Issue
Failure to prevent diversion of residents’ prescribed controlled medications by staff who sell or take the drugs for their personal use may be considered abuse, neglect, misappropriation, and fraud, in violation of state and federal regulations. Staff who divert medications have developed a number of ways to conceal diversion. Facilities should implement a proactive diversion-prevention program which identifies the types of medications most likely to be taken, signs that diversion has taken place, and signs of impairment.
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.
- Periodically audit to ensure that all controlled substances are accounted for 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.*
