Nursing Diversion The Implications for Patients and Hospitals

1. Nursing Diversion The Implications for Patients and Hospitals

2. Discussion Points • Pervasiveness of drug diversion by nurses • Impact of drug diversion on patients • Importance of investigation and proper reporting of diversion cases • Common methods of drug diversion • Patient harm and tampering • OIG exclusion authority

3. Many Forms • MD, pharmacist diversion • Doctor shoppers in ER • Stolen script pads and forged prescriptions • Patient’s family • Unauthorized drug cabinet access (ie,unit secretary) • Handlers of sharps containers

4. Discipline of Nurses Substance abuse is a leading reason for discipline of nurses across the country Drug diversion is the number one substance abuse-related infraction

5. Scope of Problem One area of prescription drug abuse that is often overlooked, but perhaps the most important, is the diversion of prescription drugs from health facilities such as hospitals and nursing homes. The reason that this form of diversion is important is that oftentimes innocent patients are the ultimate victims of this type of drug diversion. Nursing personnel constitute the bulk of this type of pharmaceutical diversion. In the late 1990’s, our Cincinnati unit was arresting a nurse about once a week for diverting drugs from health facilities. There are many methods used by the diverting nurse, methods that are often not discovered until the abuser has reached incredible doses of controlled substances. Burke.http://associationdatabase.com/aws/NADDI/asset_manager/get_file/3143

6. Tennessee Drug Diversion Task Force • Collaboration between local, state and federal law enforcement, governmental state agencies and healthcare professionals dedicated to the safe and proper use of prescription medication. • Relationships developed in a non-adversarial venue • Trust and sense of duty fostered • Win/win

7. Reporting is Essential for Patient Safety and Diversion Intervention “I am usually discussing not only the horrors that can occur in our nation’s health facilities, but the common practice of those criminal acts not being reported to law enforcement or even regulatory boards. Unfortunately, many times the practice is to dismiss or accept the resignation of the violating health professional. This opens the door for abuse at the employee’s next facility and fails to address the underlying cause—addiction.” Burke http://www.pharmacytimes.com/publications/issue/2009/July2009/drugdiversionandabuse-0709/

8. Reporting Requirements • Must report to DEA immediately The registrant shall notify the Field Division Office of the Administration in his area of any theft or significant loss of any controlled substances upon discovery of such theft or loss. • Must report to Law Enforcement-issues of abuse/neglect/reckless endangerment, fraud, crime on premises • Must report to State Licensure Board Any nurse who knows of any health care provider’s incompetent, unethical or illegal practice MUST report that information through proper channels.

9. Why Don’t We Hear More? Drug diversion by health care providers is universal among institutions in the United States • Fear of negative publicity • Fear of State and Federal agency involvement • Justification that terminating the employee is enough

10. Drug Diversion Impact on Patients • Impairment puts patients at risk (reckless endangerment) • Strong likelihood of denying patients appropriate pain relief (abuse of a vulnerable individual) • Falsification of records (fraud) • Theft (Class D Felony-TN)

11. Reflection • OR records now online to view contemporaneously with surveillance data • All diversion taken through “critical event” review • Multidisciplinary core team determines when patient harm is evident • Change from 2 mg to 1 mg hydromorphone syringes house-wide

12. Omnicell Controlled Substance Dispensing • Sophisticated Omnicell Controlled Substance Surveillance System • Comprehensive daily monitoring

13. Dispensing System Drug Cabinet • RN signs on with unique username and password • RN verifies count and enters # of units withdrawn • 2 users required for “waste” or return

14. Daily Report • All Issue/Waste transactions for each department/user • Incorrect counts • Staff that are statistically significant in withdrawals for the day • Instances in which a drug was removed without a recognized order (medication override) • Drugs issued in unusually large quantities • Drugs issued in unusually close time proximity • Drugs issued to discharged patients

15. Daily Report

16. Methods of Diversion Removal of medication when not needed • Often initial method of diverting • Very difficult to detect • Falsification of records Removal of duplicate dose • May not be caring for patient Removal of fentanyl patches Removal too frequently • Ordered q 4 hrs, removed q 2 hrs Removal of medication without order • Medication override • Falsification of “verbal order” Removal and use from inconspicuous vessel

17. Methods of Diversion Failure to waste • Unwasted medication kept for self (proper waste procedure is to waste upon removing) Substitution in administration and wasting • Substitution of look-alike pills • Saline substituted for injectable medication • Potential for tampering charges Removal from PCA and drip lines Removal under sign-on of colleague • Stolen password • Left alone when colleague is signed in Removal of unspent syringes from sharps boxes Pilfering patient medications brought from home

18. Diversion Investigation Tools • Interview of nurse • Drug cabinet Transaction reports (User, Witness, Patient, Item reports) • Dispensing Practices Report • Medical records • Refused order reports and/or MD interviews

19. Monthly Report

20. Diversion Investigation Tools • Patient complaints and survey results relating to pain management • Urine drug screen • Interview with MRO • Locator reports • Employee time records • Interview with patients • PSN or “incident” reports

21. Locator Reports

22. When Diversion Suspected • Nurse immediately removed from patient contact • Drug cabinet access discontinued • Initial interview of nurse including review of medical records and drug cabinet data • Urine drug screen • Suspension pending conclusion of investigation

23. No Tolerance When diversion is confirmed: • Termination for gross misconduct • Reporting to all relevant state and federal agencies • Referral to Professional Assistance Program • Rebilling

24. Our Efforts at Prevention Surveillance by neutral examiner Treatment of high abuse risk noncontrolled substances as controlled substances (cyclobenzoprine, carisoprodol, tramadol) All partially used controlled substance doses from surgery submitted to OR Pharmacy for wasting OR pharmacist does random refractometry on 10% or more of all surgery waste; focused refractometry when indicated All orders for controlled substances which are not accepted by the physician are reviewed by Pharmacy and Compliance All patient complaints and survey responses relating to unrelieved pain are reviewed by Compliance and Nurse Managers

25. Our Efforts at Prevention Nurse Managers make daily “pain” rounds to ensure there are no patients with pain management concerns Liberal “reasonable suspicion” policy Use of “locator” reports Diversion training for all new nursing staff Education of all staff (not just clinical) Annual diversion training for all nursing staff Regular training for nursing leadership Educational outreach offered to nursing schools statewide CEO Summit

26. Nurse tells patient to "man up" and steals pain meds before surgery Kidney surgery that MD described as being painless "You're gonna have to man up here and take some of the pain. We can't give you a lot of medication. You're going straight into surgery.” Tube inserted through incision and into kidney. Patient screamed-almost lurched up off of the table, one of the technicians had to hold him down. Casareto leaned into his ear and said loudly, "Go to your beach . . . go to your happy place. Casareto was slurring her words, being inattentive, and even, reportedly, falling asleep. Had to be ordered to give pain meds. Afterwards, hospital employees found two empty and unauthorizedsyringes in syringes in Casareto's scrubs. When confronted,Casareto opted to resign rather than take a drug test. SarahMay Casareto is accused of being the nurse from hell.​

27. Nurse tells patient to "man up" and steals pain meds before surgery Plea deal • Entered an Alford plea of guilty to a fifth-degree controlled substance crime for possession of fentanyl. • Judge withheld the guilty plea. • After three years' probation, the case will be dismissed and her record will be wiped clean. • No jail time and no fine. Reporting • Hospital failed to report this event and alluded to the surgeon being responsible for allowing this to happen in this case.

28. Surgical Nurse Boulder Community Hospital Ashton Paul Daigle 108 counts of tampering with a consumer product 67 counts of creating a counterfeit controlled substance for allegedly stealing fentanyl Over 300 potential victims Sentenced to 54 months in federal prison followed by 3 years supervised release

29. Tampering • Took pain medication from people going into surgery • Used syringes replaced with tap water or saline • Dirty needles placed back on the surgical trays for use-tainted by hepatitis • Over 20 patients infected • Plea bargain rejected • Sentence-30 years Kristen D Parker

30. Patient Harm and Tampering Patient Harm • Diversion of scheduled (non prn) doses • Documentation of pain while diverting doses meant for patient • Impairment resulting in patient harm or reckless endangerment • Confession Tampering In most cases proof limited to: • Confession • Covert surveillance

31. Relevant Mandatory OIG Exclusions

32. Relevant Permissive OIG Exclusions

33. Information about OIG Exclusion Program: http://www.oig.hhs.gov/fraud/exclusions.asp Search OIG List of Excluded Providers: http://exclusions.oig.hhs.gov/ Detail about Exclusion Criteria: http://www.oig.hhs.gov/fraud/exclusions/authorities.asp Reporting convictions: Email: sanction@oig.hhs.gov Telephone: (410) 281-3060 Fax: (410) 265-6780 Mailing Address: HHS, OIG, OI Exclusions Staff 7175 Security Boulevard, Suite 210 Baltimore, MD 21244 OIG Exclusion Contact Information

34. Upcoming NADDI Conference: May 10-11, 2012 Health Facility Diversion Conference Holiday Inn Hotel & Convention Center Pigeon Forge, TN May 10, 2012Conference Agenda – Day 1Criminal Prosecution of Diversion & Tampering CasesLaw Enforcement & Health Facility InvestigationsDiversion Techniques & Prevention Procedures in     Healthcare InvestigationsCase Study May 11, 2012Conference Agenda – Day 2Methods of Institutional DiversionCoordinating Investigations in Healthcare FacilitiesProfile of the Nurse AbuserCase Study Conference Registration-$150 *Lunch is included in the registration cost Kimberly New, RN, BSN JD University of Tennessee Medical Center Compliance Specialist (865) 305-9116 Knew@utmck.edu