Missing Fentanyl Patches: A Case of Drug Diversion?
A physician contacted the skilled nursing facility director of nursing (DON) because he was concerned about the number of prescriptions he was being asked to write and inquired about where they were being used. He was particularly curious about Fentanyl patches he ordered that had not been placed on a resident for whom they were prescribed.
The facility performed an audit of all prescriptions, and they appeared to be accurate. Because of the physician’s concern that a resident had not received the Fentanyl patches he prescribed, the DON checked to determine if the prescription was filled and if the facility received it. When she looked online, it was noted that the facility had received the patches. The pharmacy was contacted, and they informed the DON that the patches were delivered to one of the facility’s nurses. The pharmacy sent over the form that the nurse signed when the patches were delivered.
The DON checked the narcotic book and noted that two other medications delivered at the same time were noted, but the seven Fentanyl 50 mg. patches were never entered. The same nurse (Nurse #1) noted the order, sent the fax, and received the delivery. When asked about the missing Fentanyl, Nurse #1 said she never thought twice about not signing it in. She normally is at the desk and brings the controlled medications to each nurse when she receives a delivery. The video cameras were not functioning, so they were not helpful in clarifying the issue. Nurse #1 has been employed at the facility for 14 years and is well-respected by the physicians. She said she gave the Fentanyl to Nurse #2.
The facility staff looked at the medication book and noted that there are cross-offs and the entries looked sloppy. Nurse #2 works the night shift and gives medications after her shift, then waits to count until 8 or 8:30 AM. She always appears very tired, which could be because she is a night nurse. Every time there was a discrepancy in the medication book, Nurse #2 had an explanation for it. Proper procedure for controlled substances was not followed by either nurse, so both nurses were suspended pending the outcome of the investigation.
The police were notified and asked to investigate, and a report was sent to the DEA. The facility reviewed their policies and procedures for receiving and dispensing medications, and it was noted that the procedure requires a 2nd nurse’s signature to verify the receipt of a narcotic. In this instance, Nurse #1 was the last one to handle the medication. Nurse #1 signed for the medication when it was delivered, it was in her possession, and there is no signature to indicate that she passed it on.
