Drug Diversion for Personal Use
A call to the director of nursing by the nurse manager at 7:15 a.m. reported that 45 oxycodone tabs were missing from a card, but not missing in the count. Information was transferred from one page of the narcotics book and signed for by two nurses. Two cards of 45 tablets each had been received, but only one card was actually signed in. The other card containing 45 tablets of oxycodone was diverted for personal use. The protocol was ignored for transferring from the original page in the narcotics book to a new page. An investigation was launched to determine what happened to the 45 missing tablets. Two nurses were suspended pending the outcome of the investigation. Several attempts to contact the nurse suspected of diverting the narcotics were made, and she was either unavailable or said she could not come to the facility to give a statement. The other nurse was not accused of diverting, but she did not follow procedure by failing to check the number of tablets before signing the transfer from the original page in the narcotics logbook. The suspected nurse at times indicated she gave medications ordered to be given every 6 hours more often at every 4 hours.
All residents receiving narcotics had new pain assessments conducted. Nurses were cautioned that residents may not have actually been getting their pain medications for some time, should be carefully monitored, and may need their prescriptions adjusted.
The Police and the Department of Public Health (DPH) were notified. The suspected nurse was asked to produce the missing card and informed that the police, DPH, and Department of Justice Drug Enforcement Division (DEA) were notified, and that the DEA planned to notify the Boards of Nursing and Pharmacy.
All nurses who perform narcotics counts were reeducated regarding the correct protocol. The pharmacist performed a facility-wide audit, and new narcotic books were implemented. The nurse who did not divert, but who did not follow protocol, was terminated due to a history of other poor performance. The nurse suspected of the drug diversion was also terminated.
