On March 19, 2021, an Illinois RN was sentenced to serve six years in federal prison for tampering with morphine intended for hospice patients and using the morphine herself. After the RN is released from prison, she will remain on supervised release for an additional three years.
According to court documents, on July 20, 2018, a standard internal audit at the skilled nursing facility found an emergency medication control box was missing a bottle of morphine and nine tablets of an opioid medication.
In the same skilled nursing facility, on July 23, 2018, it was reported that a resident’s morphine bottle appeared to have been tampered with ― the dropper was not in the packaging, the bottle had been opened, and the color of the medication was lighter than normal. Also, the morphine bottle appeared to contain more liquid than it should have contained.
Two nurses at the skilled nursing facility reported that one of the RN’s appeared lethargic, was slurring her words, and seemed to be staring into space.
On August 4, 2018, staff discovered another emergency medication control box had also been tampered with. The flap on the box of a bottle of morphine in the emergency supply appeared to be bent, and the safety seal on the bottle had multiple puncture holes.
On August 5, 2018, the RN under suspicion was terminated. When she was interviewed by investigators, she admitted to consuming residents’ morphine, infrequently at first, but eventually daily. In addition, she admitted that she used the morphine and then diluted the remainder with tap water.
The RN pleaded guilty on October 26, 2020, to two counts of tampering with consumer products, specifically bottles of morphine, from May 2018 till early August 2018.
Staff at the skilled nursing facility recalled that during the time period that the RN admitted to stealing the morphine, several residents experienced difficulty with pain management while receiving end of life care.
FBI Special Agent in Charge Sean M. Cox stated, “ Registered Nurses are some of our most trusted professionals in the health care industry. Unfortunately, this case is representative of the dangers associated with addiction. When an individual does not seek help, they endanger the lives of those whom they entered the profession to protect. Tampering with prescription medication is taken very seriously by the FBI. We will use all available resources to bring to justice those who intentionally jeopardize the health of others.”
Issue:
Drug diversion is a growing problem in healthcare. Licensed staff who have access to opioid and other controlled medications are at risk for developing a controlled substance problem. All leaders in healthcare should be aware of the warning signs of a controlled substance disorder and be prepared to control any acts of drug diversion properly and quickly.
Discussion Points:
- Review your policy and procedures on two-person accounting for controlled substances and protocols for preventing and reporting suspected drug diversion. Update as needed.
- Train all appropriate staff on the process for two-person accounting for controlled substances with every change of nursing personnel on duty, actions that must be taken to prevent drug diversion, and what should be done if drug diversion is identified. Provide education on the consequences of theft of residents’ medications. Document that these trainings occurred, and file the signed document in each employee’s education file.
- Routinely conduct supervised count of controlled substances to ensure staff are adhering to the facility’s procedure for two-person accounting for all controlled substances, including those discontinued medications awaiting final disposition. Audit to ensure documentation in the MARs agrees with distribution logs for controlled medications. Interview residents receiving controlled pain medications to ensure it is administered to them and that it relieves their pain.
