Drug Diversion Case Studies

The previous article on drug diversion explored the ways in which professionals in the nursing occupation respond to temptation by stealing medication from patients. This occurs when environmental security in a hospital, nursing home, or home health situation is not sufficient to detect and/or prevent this crime. Drug diversion is doubly dangerous because in some cases the patient suffers. The therapeutic value designed into the patients’ care plan is degraded severely by drug diversion.
Nurses who pocket or take medications cheat their patients of needed pharmaceuticals. But the nurses may also succumb to the near-universal lure of addictive pill-taking behaviors that impair their ability to think clearly and conduct their nursing activities responsibly. Opiate addiction is a global problem, and nursing can be a gateway career for addicts.
Drug diversion occurs when a nurse makes a decision to go against his or her better judgment. When this happens, day to day patient care is compromised. Since single-staff nursing plans don’t allow for auditing, the problem of pilfered medications will get much worse before it gets any better. Detection is the first method of arresting drug diversion. Symptoms of missed medications may blend with the patient’s pain spikes or be termed mood swings by distracted nursing staff.
Patients who vocalize extra pain or think that the nurse missed a pill may be disregarded.
Nurses who practice drug diversion may be in a position to target patients that nurses dislike and have no sympathy for. It may be some time before patient complaints are heeded and med counts correlated. And many nurses may move on before any official action can be taken.
Official complaints are the second step to take action against suspected drug diversion. Yet an official investigation by state or local nursing agencies is cumbersome and time consuming. And nursing homes go to great lengths to cover up their internal problems. When faced with legal liabilities a hospital may nullify patient lab reports or other evidence the patient’s care was impaired.
In instances when drug diversion takes place in home health scenarios, the abuse may never be discovered. The privacy and isolation of a home health environment are ideal elements for a nurse planning drug diversion. In any case, the patient will suffer. And the family members may never know why the patient is struggling for relief.
The third method to control drug diversion is peer policing. Nurses must take a stand from inside their community to cite and counsel nurses guilty of this crime. Leaders on every nursing staff should set an example of how to intervene and/or report drug diversion suspicions. Nurses who witness palmed medications should document what they see, and report the incident to the human resources director or the State Nursing Board. Anonymous complaints are allowed.
The most likely medication targeted by nurses for drug diversion is narcotics, painkillers, and opioids. These medications can alter mood and hinder feeling “down” effectively. Nurses practicing drug diversion are in fact trying to medicate themselves.
These pharmaceuticals are not only targeted for personal use. Drugs like Fentanyl, Dilaudid, Vicodin, Morphine, and others are highly marketable among addicts. Nurses may use pilfered drugs as currency among junkies with access to illegal street drugs. When a nurse is desperate enough for cash, students looking to maintain a high grade point average are good cash customers for diverted drugs. Students who reject shady contacts and promote a drug-free persona can utilize their nurse contact on the sly for ‘lifestyle enhancements’.
Case Study #1
Valery Gomez is an LVN working 4 days a week at a metropolitan hospital with high patient turnover. Valery started working six months and ago nursing is her first job. Her husband prefers her to have weekends off and her two children are taken care of on the days she works by her husband’s mother and family. Valery Gomez usually works the morning day shift.
Although initially Valery is bright, funny, and congenial, lately her personality when dealing with patients has changed. After twelve months on the job her nursing skills have not improved. Among the nurses hired in tandem with her, most have risen to supervisor or specialized posts. Valery’s peers have graduated to more complex work responsibilities,
It has been observed by the nurses on staff that Valery is often ” sitting doing nothing” and shoulders little of the actual individual tasks requied of desk nurses, and her charting and case load is usually poor or unfinished.
Lately several incidents with patients and Valery have brought unwelcome scrutiny to her employer from the County Health Department. The Ombudsman has received complaints about problems with Valery’s patient, problems that remain unresolved despite past counseling. Valery shows no remorse for causing great difficulty for other nurses and extreme physical stress to some of her patients.
Valery rarely lends a hand to any other nurses. She exhibits fits of temper when meds are requested and denys patients their needed painkillers without explanation. Valery makes a practice of hanging around the desk when the med-cart is adjacent and unattended. Valery recently has requested changes to her work assignments to shifts where the majority of staff wre gone.
While Valery made comments initially that she prefers a schedule with weekends free, now Valery has requested work on Saturday and Sunday. This is when most of the staff are gone. One of the patients, Nancy Lee, remarks that in private conversation Valery always told her that Valery’s husband wants her free on the weekends to entertain and care for the children.
Nancy Lee is a patient who recieves very heavy pain medication for multiple conditions. Nancy Lee has documented painful needle sticks from Valery. The Nursing Director has counseled Valery about not delaying Nancy’s med pass routine unnecessarily. The D.O.N. has repeatedly received complaints of Valery denying Nancy Lee her needed medication.
Valery alone of the many med-pass nurses resists the instruction to inform Nancy Lee how many Fentanyl she has left on her pain management precription. Mancy Lee has made complaints to the State Nursing Board about the matter.The local authorities have substantiated Nancy’s complaints.
Nancy Lee is articulate, alert, and ambulatory. She notices that paperwork in her chart written by Valery is inaccurate and incrimminating documentation concerning incidents with Valery has been removed. Nancy Lee hears from other nurses that Valery has refused to chart for them on occasion and also has refused to cooperate with requests from other nurses to perform tasks for them while they do her work.
Nancy Lee steps outside her roomn one day and observes that Valery Gomez visits the trash room frequently. Since the housekeeping staff normally do this, Nancy wonders why Valery alone of all the nurses disappears from the nursing desk floor while on duty. In the past, when Valery was Nancy’s nurse strange pills would be found in the floor. Nancy wonders why Valery avoids the closed circuit camera view so often.
In the past, Nancy Lee has noticed that many of the CNA staff hide in the supply room or the trash room and text to friends, play video games, or talk and use their cellphones. Nancy feels strobgly that Valery Gomez has been pilfering and experimenting with pain medications intended for the patients.
Nancy feels that Valery watches for opportunities to steal, hide, and ingest patient medication while on the job. Nancy has noticed that
Valery has lost weight and taken an interest in a handsome young nurse new to the facility. Nancy sees Valery drift through the weekend avoiding family responsibilities.
Suddenly it is found and told to Nancy that repeated impropriety concerning her pain medication has caused the med cart run out many months in a row. The pharmacy cannot account for the errors.

Nancy wants the D.O. N. to order a drug test for Valery after a weekend where the nurse repeatedly goes into the trash closet. Nancy sees Valery glaze over while another nurse is calling her name. Nancy sees a pill hit the ground after Valery comes out of the trash closet. When the good looking male nurse calls in sick, Nancy notices that Valery loses all interest in her work, snapping at peopke and gruffly answering the phone.
Does Nancy have the right to do this? How should the D.O.N. respond? How should the other nurses at the facility act at this time? Who should act, what should they do, and when does this become an investigative problem for police? How do the three methods to limit drug diversion, as outlined above, operate here?
Case Study #2
In a large hospital near Los Angeles, one of the patients in the SNF Alice. has noticed something disturbing. In the morning at 5:45 a.m. every day moans and screams start rising from the patients in the other rooms. The nurses tell this patient that many of the other patients are addicts who start yelling for their opiates and pain drugs too early. The nurses say that if they start giving out the pain medication for other patients too early, the next day the same thing will happen again and the patients will use up all their pain medication too early. The patient observes that there are no general administrator on duty at this time of the day.
After three months,the same thing happens very day. The patient notices how the exact same staff work the 11 to 7 a.m. shift daily even though alternates regularly appear on the other two shifts. Alice notices the call lights and alarm sounds series at this time, unlike at any other time, are often allowed to build and be ignored. The charge nurse responsibilities are shared beteeen a close knit group of nurses.
Soon the patient believes that the hospital does not know anything about how bad this problem seems. After months of different patients coming in and out the sane phenomena occur. On the day and afternoon shift the moans and screams do not recur as they during the “dawn patrol”.

Over time the patient fears that the hospital has suppressed recording this issue. Alice thinks that these SNF patients acting in this manner and reporting pain is being concealed and not documented so that their staffng acuity will not shift. This appears to be a cost cutting measure administered when no officials, visitors, or ancillary hospital staff can witness the outcry at dawn.

What questions should the hospital adminstrators be asking about why so many patients in the SNF are demonstrating this scale of pain indicators without a investigation or compassionate care response? What responsibilities does the facility have to monitor quality of care?

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