Diverting Drugs by
Staff Nurse Poses Serious Contamination
and
Infection Threats to Patients
Recently, three patients in a New York Cancer Center contracted a rare blood infection within one week, causing red flag concerns for medical professionals in the facility. Further investigation revealed that six people in the center were treated last year after becoming ill by the waterborne bacteria Sphingomonas paucimobilis. The bacteria is commonly found in water and soil but rarely leads to bloodstream infections, even in patients like those with cancer who have compromised immune systems.
After looking outside the facility for the potential source of the bacteria and not finding any answers, the facility turned its investigation inward toward employees. The source was quickly discovered after finding several syringes that tested positive for the bacteria—those syringes contained an opioid known as Dilaudid. When the records for keeping track of controlled substances were reviewed, they revealed drug diversion by a nurse who repeatedly and inappropriately accessed the locked drawer containing the medication. The investigators concluded that the nurse had removed some of the narcotic and replaced it with ordinary tap water, which resulted in the contamination.
Another nurse at the facility later recalled seeing the accused nurse open her locker and more than a dozen insulin-type syringes falling out onto the floor. The witness said the syringes were “used, recapped, and had blood at the ends.” According to this same nurse, the accused nurse was acting very strangely—like “a cat on a hot tin roof.”
It was reported that the accused nurse accessed the automated medication dispensing system, Pyxis, on other floors and during times when she was not on duty.
The residents who contracted the infection were effectively treated with antibiotics and although they ultimately died, it is not believed their deaths were caused by the infection.
The Federal Drug Administration (FDA) and the Federal Bureau of Investigation (FBI) conducted a joint investigation and found that between February and June 2018, 81 patients were not given their proper medications.
Compliance Perspective
Failing to monitor employees who have access to controlled medications to prevent diversion of those drugs for personal use or private gain and the injecting of patients with non-sterile syringes containing waterborne bacterium may be considered abuse, neglect, and misappropriation; immediate jeopardy; and provision of sub-standard quality of care, in violation of state and federal regulations.
Discussion Points:
- Review policies and procedures regarding preventing unauthorized access to controlled medications.
- Train staff to report anything suspicious regarding medication records or unusual behavior in staff that may indicate potential drug abuse or diversion. Provide training that demonstrates types of behaviors exhibited by persons illegally using or diverting drugs and also the potential life-threatening effects and additional pain and suffering that diverting and tampering with medications can have on patients/residents.
- Periodically audit the medication reconciliation process to determine if protocols are being followed and to note any evidence that tampering with drugs has occurred.
