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?

Nurse Training Issues

Nurses need to be trained to treat patients and all their needs, as required. Nurses cannot pick and choose which chores they need to do on which patient, nor do they get to arrange the timeframe that suits them best. Often a case load of needy patients means that the nurse will be juggling various needy patients as well as performing paperwork responsibilities, charting, and intaking new patients at the same time. Not to mention answering the phone and dealing with walk-in clients.

Nurses must be ready to say “yes” to every task. They may be reassigned to other wards or areas as needed. Nurses must groom their computer and Internet research skills to match today’s technological advances. There will be slow days and there will fast days, but nurses are responsible for treating all patients at the highest level of care no matter what their time limitations are.

For example, in a clinical care situation in training, a nurse might have to alter the setting on a EKG machine or test out various pharmaceutical applications on a patient to achieve the best result for lowered blood pressure. But the time and physical availability for results and communications in real time versus training environment may not match the situation reality. Phones on the ward training, another nurse needing help, or a new admission coming onto the scene may distract a nurse.

Nursing students have a training experience that is simple cases of ongoing treatment cases. but in reality medical care plans are much more complex. Patients may be resistant to treatment or not observant of dietary restrictions or their rest order as given by the physician. Nurses on the job often give qualified objections because they have not had a chance to speak with the doctor before issuing pain or treatment medications to a patient they have never seen before. Patents are likewise alarmed they are not seen or given a consultation before a dosage regiment is instituted.

Nurses are the key communicators in this scenario. Nurses in this instance carry more responsibility to review both the patient set of criteria and the data involved with possible side effects of a drug. They must weight this information against the patient’s benefit, versus the entire set of pharmaceuticals being introduced to the patent’s bloodstream. Often a nurse can spot a contraindication before anyone else, and the thrust is upon them to do so. Nurse must also counsel the patient and asses them psychologically at all time. When shifts change, nurses must convey both verbally and in writing the most timely changes in patient assessment to the next charge nurse. These must be done in accurate medical terminology in a transparent style.

Is the patient a physical threat to themselves or others? Is the effect of any change or restriction in medication or privileges affecting them negatively? Are they speaking to themselves or others in a manner that shows a change in self esteem or motivation to heal? Some patients may create incidences of panic disorder and need to be housed a negative ion chamber. A psychological evaluation referral is appropriate at this time. They may try to not take their medication, create obstacles to treatment, or become even more ill. Student nurse skills must adapt and grow to meet the situation.

It is hard to train a nurse for the variety of challenges and issues that come up for their patients in this kind of scenario. Occasionally physicians will be flexible and change to the individual care plan will be made. It is vital to the medical outcome that these circumstances be communicated to the next nurses and on-call physicians. Being able to perform simple tasks like recording dosages and medical administration while balancing management of multiple patients can get tricky.

Nurse Training Tips

Nurses need to be trained how to treat patients and fulfill all their needs Nurses cannot pick and chose which chores they need to do on which patient nor do they get to arrange their timeframe that suit them best. Often a case load of staff nurse means that the patient will be juggling various jobs or needy patients they like. There is much more to nursing than giving shots or checking histories, and nurse must be ready at all times to perform all needed nursing tasks to as many patients as are required. The reality is that in medical institutions situations exist with multiple charge patient realities.
Nurses are involved in physical administration of medicines, nursing bedridden patients, charting and file administrations. his involves witnesses pharmaceutical tracking, supply ordering, LVN communication,  as well as  medicines, review of patient symptoms, and room administration. Conflicts may come up, paperwork confusions, and records administration problems that nurse must deal with and treat patents all the while. May nurses grow accustomed in training to addressing single charge situations. But in reality, medical institutions
Nursing involves all facets of the patient experience and as well as performing history and readings resolutions. The paperwork responsibilities, reporting of charting, and intaking new patients at the same time can overflow within timed shifts more often than not.
Nurses who are not well trained to perform these duties will find themselves putting in extra unpaid hours keeping up. it is not unusual to see charge nurses working unpaid overtime completing records, updating charts, and finishing up with patients. Many institutions running on thin budgets will discharge nurses after a census, and nurses must complete their shift charting and other communication and patient treatment responsibilities on their own honor.
They may be reassigned to other wards or areas as needed. There will be slow days and there will fast days, but nurses are responsible for treating all patients at the highest level of care no matter what their time limitations are. The time sensitivity of all duties a nurse performs means they must be completed whether time permits or not. Therefore a nurse must involve themselves with each patient outside the minimums of ward responsibility to make sure adequate care is administrated.
For example, in a clinical care situation in training, a nurse might have to alter the setting on a EKG machine or test out various pharmaceutical applications on a patient to achieve the best result for lowered blood pressure.  But the time and physical availability for results and communications in real time versus training environment may not match the situation in reality. Phones do not ring on the ward training, another nurse needing help, or a new admission coming onto the scene may distract a nurse.
In training, a nurse does have to deal with the  professional responsibilities and commitments. Outside training the career comes to the fore. Outside training a nurse will be assessed at all times for professional advancement and adequacy.Nurse who take too long over rote task like takin vitals get a reputations for being “spacy”, not very good at time management, and get complaints from patients about lack of communications and poor medical skills.
The nurse must support requests from the team and the charge nurse no matter how many requirements their charges have currently running. The nursing team will often offer additional training for things like vein location for putting in a line, or even best placement of equipment for taking vitals. But past a certain point poor training becomes evident and staff will officially take note a nurse is incompetent or unhelpful handling multiple charges.
Nursing students have a training experience that is of simple academic cases of ongoing treatment cases. But in reality, medical care plans are much more complex. Handling people is involved. Patients may be resistant to treatment or not observant of dietary restrictions or rest orders as given by the physician. Nurses without good people skills, nurse swith no experience dealing with patients, and nurses without a complete understanding of the pathology involved will offer career damage unless they absorb the training required.
Nurses on the job often give qualified objections because they have not had a chance to speak with the doctor before issuing pain or treatment medications to a patient they have never seen before. Patients are likewise alarmed they are not seen or given a consultation before a dosage regiment is instituted.
Nurses in this instance carry more responsibility to review both the patient set of criteria and the possible side effects of a drug versus the entire set of pharmaceuticals being introduced to the patent’s bloodstream. Often a nurse can spot a contraindication before anyone else, and the thrust is upon them to do so. Nurses must also counsel the patient and asses them psychologically at all times.
When shifts change, nurses must convey the most timely changes in patient assessment to the next charge nurse. These must be done in accurate medical terminology in a transparent style.If nurses on the next shift have poor training and fuzzy communication skills, the primary nurse’s best contribution is the maximum value to the patient ad the medical caregiver. The nurse’s clarity of thought, mission to deliver the best nursing possible, and the motivation to promote healing can transform the most basic training into a sterling bonus advantage for the patient.
Nurses must assess patients in an ongoing manner. Is the patient a physical threat to themselves or others? Is the effect of any change or restriction in medication or privileges affecting them negatively? Are they speaking to themselves or others in a manner that shows a change in self esteem or motivation to heal? These observations are important and training in them will take place over the course of a nursing career.
Some patients may create incidences of panic disorder and need to be housed a negative ion chamber. They may try to not take their medication, create obstacles to treatment, or become even more ill. Student nurse skills must adapt and grow to meet the situation. Academic training will not train a nurse to speak to a patient in crisis.
It is hard to train a nurse for the variety of challenges and issues that come up for their patients in this kind of scenario. Occasionally physicians will be flexible and changes to the individual care plan will be made. It is vital to the medical outcome that these circumstances be communicated to the next nurses and on-call physicians. Being able to perform simple tasks like recording dosages and medical administration while balancing management of multiple patients can get tricky.But adequately trained nurses will meet and surpass their challenges to succeed and shine.