All long-term care facilities are obligated to implement the new process of storing and securing controlled substances in terms of the new Department of Health and Human Services Centers for Medicare & Medicaid Services (CMS) guidelines which was first implemented November 28, 2017.
The most important change is that of requiring frequent—and possibly even daily—reconciliations to detect losses. However, the question will inevitably arise as to how exactly drug diversions will be detected. To aid in this process, it is helpful to consider a number of real, recent cases—all of which contain tell-tale characteristics for which administrators need to be on the lookout.
Case Study 1: A licensed nurse in Providence, R.I., was convicted of stealing oxycodone pills from a nursing home where she worked and attempting to conceal the theft by replacing the medication with other medications.
Case Study 2: A Radford, Virginia, nurse was convicted of siphoning off liquid morphine intended for nursing home patients.
Case Study 3: Three nurses at a North Dakota hospice were convicted of stealing medication, diluting medication, and giving morphine instead of the more potent hydromorphone that was prescribed to manage pain.
The common tactic here is medicine substitution, either with less effective drugs or saline solution placebos. In all three of these cases there would have been complaints from the residents that the medication they were receiving was not working. In other words, an immediate sign of concern for any administrator or director of nursing should be sudden and unexpected complaints of increased pain from residents.
Case Study 4: A Salem, Ohio, nurse was convicted of stealing painkillers and forging documents to cover the theft.
Case Study 5: A Council Bluffs, Iowa, nurse was convicted of stealing 10,000 pain pills from residents and tampering with records to cover up the theft.
Case Study 6: A Brownwood, Texas, nurse was convicted of stealing narcotics from a nursing home using a forged prescription.
In these three cases record tampering was used to conceal the crime. The increased record reconciliation process as outlined in the new CMS guidelines is specifically designed to alert administrators to anomalies in the documentation, and the tell-tale signs to look for here are unexpected increases in medication orders, or orders in excess of what patients might reasonably require.
Another common form of drug diversion crime is simple theft from existing stock. A review of published cases in this regard shows that the majority of instances occur in this fashion and are difficult to detect because of the lower quantity of medications being stolen. Detecting these thefts is a major focus of the new CMS regulations, which specify that when medication is not under secure lock and key—that is, when it is being distributed—it requires stricter personal control.
In order to be fully compliant, a facility must ensure:
- Medication room access is limited to authorized individuals
- Medication carts are locked and secured when not in use
- Discontinued medications are removed from the medication cart/room as soon as possible and are destroyed or returned per individual State requirements
- All multi-dose vials are dated when opened and are discarded with 28 days or according to the manufacturers’ instructions
Next in this series:
– How to manage and report cases of drug diversion.
Previously:
– New CMS Controlled Substance Control Guidelines
– New CMS Rules on the Management of Controlled Substances
