A Wisconsin woman was sentenced on September 14, 2023, to 15 months in prison, 1 year of supervised release, and fined $30,000 due and payable immediately. She had pleaded guilty earlier to one count of product tampering while employed as a registered nurse at a hospital in November 2021.
The defendant tampered with vials of fentanyl by withdrawing the drug from the vials and replacing it with saline and then resealing the vial stopper with what appeared to be superglue. She then put the tampered vials back into the Pyxis machine, an automated medication dispensing system, so that the tampered fentanyl vials would be available for use with other patients at the hospital. An audit of the Pyxis transactions in the defendant’s name revealed that she had an excessive pattern of fentanyl overrides and wastes when compared to other employees in 2021. When confronted by hospital management in November 2021 with this discrepancy, and asked to take a drug test, she refused and instead resigned from her position at the hospital.
At the sentencing hearing, the defendant expressed remorse for her actions and noted that her illegal conduct was driven by her addiction to opioids. She indicated that the harm she caused to her patients by her actions will haunt her for the rest of her life.
In imposing sentence, the judge told the defendant that he understood that she acted out of character because of her addiction. However, he also noted that her decision to steal fentanyl, and then tamper with the vials and return them to the medication dispenser for use with patients, was the reason he was sentencing her to prison. He explained to her that her actions harmed others and she needed to face the consequences for those actions.
Compliance Perspective
Issue
Experts estimate that 10–15 percent of our nation’s population struggles with impairment from alcohol or drug dependency. Nurses, as part of this statistic, are distinct due to their ability to access drugs in the workplace. Because as many as one in ten nurses could be affected by a substance use disorder, it is critical that each facility implements a proactive diversion-prevention program. The consequences of failure to do this include a negative impact on residents’ quality of care, legal and ethical concerns, and potential for high scope and severity citations once a diversion problem is uncovered. Nurses who divert medications have developed a number of ways to conceal diversion. Efforts must identify 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. Med-Net Academy (MNA) offers all clients three PowerPoint training programs in our new category of Substance Use. Visit MNA to access all three. Additionally, a program titled Drug Diversion – What Every Facility Needs to Know is available in the Fraud, Waste, and Abuse Category of MNA and is available to all Med-Net clients.
- 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.*
