A Boston registered nurse (RN) has pled guilty to one count of tampering with a consumer product and one count of obtaining a controlled substance by fraud and deception. The RN was working in a nursing home when she tampered with morphine that was prescribed to a resident under her care.
On November 6, 2020, the RN was working the night shift on a dementia unit in the nursing home. During the shift she removed morphine and added water to the remaining liquid in the bottle that was prescribed to a resident under her care. The nurse working the next shift administered the diluted morphine before it was discovered that it had been altered through tampering.
The charge of tampering with a consumer product carries a sentence of up to 10 years in prison, up to three years of supervised release, and a fine of $250,000. The charge of obtaining a controlled substance by fraud and deception provides a sentence of up to four years in prison, up to one year of supervised release, and a fine of $250,000. The RN is scheduled for sentencing in August 2022.
Issue:
Drug diversion is a growing problem in healthcare. All leaders in healthcare should be knowledgeable in the warning signs of a controlled substance disorder. Nurses should be trained in identifying the signs that a coworker may be under the influence or that controlled medications are not managed according to facility protocols. Licensed staff who have access to controlled substances are at particular risk for committing fraud and theft of controlled substances when they have an addiction disorder. All staff should be made aware of resources available in their community for treatment of a controlled substance disorder. Healthcare leaders should be prepared to act quickly if drug diversion is suspected.
Discussion Points:
- Review your policy 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.
