HospitalInspections.org

Based on document reviews and staff interviews the hospital's administrative staff failed to ensure the nursing staff identified and reported 1 of 1 nurse exhibiting symptoms of possible impairment (RN D). Failure to identify a nurse exhibiting symptoms of impairment resulted in the hospital staff allowing RN D to provide patient care while appearing impaired, potentially resulting in RN D providing inappropriate care to patients, potentially making medication errors, or potentially placing patients at risk of death. The hospital identified an average of 917 patients in the Outpatient Care Center (OPCC) per month.

Findings include:

1. Review of the policy "Substance Abuse Screening," revised 10/15/2020, revealed in part "Genesis Health Systems ensures tht all employees perform their duties safely and efficiently. Persons who are under the influence of illegal substancs endanger patients, co-workers, and themselves ... All leaders are responsible for addressing any instances of Reasonable Suspicion regarding suspected substance abuse ... A leader will immediately initiate the following process when reasonable suspicion of drug use, admission of drug use, or theft of drugs occur ... The leader will complete the "Reasonable Suspicion Observation Checklist." The employee will be suspended during investigation."

2. Review of a writted report dated 12/10/2020, RN H documented that on 12/2/2020, RN D informed RN H that RN D had not slept the night before and appeared fatigued. RN D's eyes kept closing while RN D was talking and RN D appeared unable to stay awake during conversations. RN D's pupils appeared dialated (a sign of possible opiate drug use). During the conversation, RN D repeatedly said "I'm not on drugs" unprompted. RN H noted RN D's atypical behavior, but did not report RN D's behavior to the department's management.

3. During an interview on 12/16/2020 at approximately 4:00 PM, RN E revealed that on 12/02/2020 in the early morning, RN D told RN E that RN D could not keep their eyes open and RN D did not want anyone to think RN D was "high." RN E asked RN D why RN D could not sleep, and if RN D took anything to help RN D sleep. RN D replied, "no." RN D could not keep their eyes open during the conversation with RN E.

RN E reported the situation with RN D to Charge Nurse F. Charge Nurse F told RN E to report the situation to the OPCC Department Manager. RN E notified the OPCC Department Manager about RN D's behavior. About an hour after RN E notified the OPCC Department Manager about RN D's behavior, RN D went to the nurses' station and wanted a break and RN D appeared anxious. RN E informed the OPCC Department Manager that RN D frequently went to their car during RN D's breaks.


4. Review of a writted report dated 12/10/2020, PCT G documented that on 12/2/2020, RN D appeared sleepy and could not keep their eyes open while talking to others. During the prior month, RN D would leave during their shift to go to their vehicle. PCT G informed Charge Nurse I about RN D's behavior.

5. During an interview on 12/10/2020 at approximately 11:00 AM, Charge Nurse F revealed that on 12/2/2020, RN D reported they needed to take a break, because RN D was feeling stressed. Charge Nurse F agreed to watch RN D's patients for a few minutes, while RN D went to the bathroom. Then, RN D sent Charge Nurse F a text message, indicating that RN D needed to leave work and go home. Charge Nurse F asked the OPCC Department Manager to help Charge Nurse F find RN D. Charge Nurse F and the OPCC Department Manager looked for RN D and found RN D sitting on the floor in the bathroom. After the OPCC Department Manager sent RN D home, Charge Nurse F discovered that RN D failed to document the care RN D provided to RN D's patients.

6. During an interview on 12/17/2020 at approximately 11:25 AM, the OPCC Department Manager revealed that a staff member informed the OPCC Department Manager about RN D's behavior. The OPCC Department Manager did not feel the staff member's concerns were warranted and the OPCC Department Manager did not take any actions to investigate the staff member's concerns.

7. Review of the hospital's Code N Team investigation revealed that RN D had stolen approximately 160 vials of Dilaudid (hydromorphone, a potent IV opiate pain medication). On 12/1/2020, Charge Nurse F and the OPCC Department Manager found RN D on the bathroom floor and sent RN D home. Between the time RN D left the bathroom (11:15 AM) and when RN D clocked out (11:24 AM), RN D stole an additional 2 vials of Dilaudid. The OPCC Department Manager did not conduct an investigation into RN D's behavior until 12/3/2020 (the next day after RN D left the department, and had stolen approximately 160 vials of Dilaudid). The OPCC Department Manager did not complete the "Reasonable Suspiscion Observation Checklist."

Based on document review and staff interviews, the acute care hospital's administrative staff failed to ensure staff followed the hospital's policy regarding creating unusual occurrence reports when patients made allegations of abuse for 1 of 1 reviewed incidents of possible dependent adult abuse (Patient #1) on the East Adult Behavioral Unit. Failure to follow the hospital's policy on creating unusual occurrence reports could potentially result in the hospital staff failing to identify trends and other patterns in unusual occurrences, which could potentially allow the hospital staff to prevent other patients from experiencing harm following an unusual occurrence. The hospital staff admitted approximately 516 patients in their East Adult Behavioral Unit per year.

Findings include:

1. Review of the policy "Unusual Occurrence Report", revised 2/5/2019, revealed in part, "All unusual occurrences will be reported and processed in a consistent and timely manner ... Reporter: Completes Unusual Occurrence Report with concise, factual information ... Definitions: Unusual Occurrence: Any occurrence which creates actual or potential harm, actual or potential risk of liability or any loss or damage of property or a violation of another person's rights. An unusual occurrence may involve any patient, visitor, staff member, student, physician or equipment".

2. During an interview on 12/1/2020 at approximately 11:00 AM, the Nursing Standards Specialist revealed that on 8/3/2020 at approximately 9:00 PM, a female patient made an allegation to the nursing staff that a male staff member had sexually abused her on 7/31/2020. The Nursing Standards Specialist reported that the nursing staff followed the appropriate procedure and notified the Charge Nurse and the appropriate hospital leadership. The hospital staff began an investigation into the patient's allegation of sexual abuse. The nurse who received the patient's allegation of sexual abuse did not complete an occurrence report, since the hospital's legal team was involved in the investigation.

3. During an interview on 12/1/2020 at approximately 4:15 PM, the Nursing Standards Specialist revealed they lacked documentation indicating that Patient #1's nurse notified Patient #1's physician on 8/3/20 that Patient #1 accused a staff member of sexually assaulting Patient #1.

4. During an interview on 12/8/2020 at approximately 2:00 PM, RN A revealed that on 8/3/2020 at approximately 9:00 PM, Patient #1 reported to RN A that PCT B (Patient Care Technician) allegedly sexually abused Patient #1 on 7/31/2020 at approximately 8:00 PM. After Patient #1 reported the incident to RN A on 8/3/2020, RN A notified Charge Nurse C (a nurse who is helps supervise other nurses on the unit) and the Behavioral Unit (BU) Department Manager. After Patient #1 made the allegation of sexual abuse by PCT B, RN A did not recall if they notified Patient #1's physician about the allegation of sexual abuse nor RN A recall if they documented anything in Patient #1's medical record about Patient #1's allegation of sexual abuse. Patient #1 denied any injuries from the sexual abuse and didn't report the incident until 3 days later, so RN A did not perform a physical examination of Patient #1 to determine if they suffered any injuries during the sexual abuse. RN A did move Patient #1 to a room closer by the nurses' station, so the nursing staff could provide closer observation for Patient #1. RN A did not complete an occurrence report regarding Patient #1's allegation of sexual abuse.

5. During an interview on 12/8/2020 at approximately 4:30 PM, Charge Nurse C revealed RN A notified Charge Nurse C about Patient #1's allegations of sexual abuse on 8/3/2020. Charge Nurse C did not document any of the information RN A provided to Charge Nurse C, as Charge Nurse C expected RN A to document the information, as RN A was providing care to Patient #1 on 8/3/2020. Charge Nurse C did not speak with Patient #1 and did not know if RN A notified Patient #1's physician about the allegation of sexual abuse. Charge Nurse C did not know the hospital's policies regarding incidents which happened in the hospital, and didn't know what to do with Patient #1's allegation of sexual abuse, so Charge Nurse C contacted the BU Department Manager to address the incident.

6. During an interview on 12/10/2020 at approximately 10:00 AM, the BU Department Manager reported if a patient reported an allegation of sexual abuse, the BU Department Manager expected the patient's nurse to notify the patient's physician about the allegation of abuse and expected the patient's nurse to complete an unusual occurrence report. The BU Department Manager did not know if the hospital had a process to guide the staff on how to handle an allegation of sexual abuse by a patient, and the BU Department Manager would rely on the patient's physician to determine the need for the patient to undergo a physical examination following the allegation of sexual abuse.

I. Based on document review and staff interview, the acute care hospital's administrative staff failed to:

1. Ensure the hospital must have a pharmacy under competent supervision and pharmacist must be responsible for developing, supervising, and coordinating all the activities of the pharmacy services. Please refer to A-0492.

2. Ensure the hospital staff identified a drug diversion, failed to potentially identify drug diversions in the ED, and failed to address identified shortcomings in the system on a hospital-wide basis upon identification of a drug diversion. Please refer to A-0494.

The cumulative effect of these systemic failures resulted in the hospital's inability to ensure staff provided safe patient care and lacked the ability to identify impaired behavior and prevent unauthorized access to medications for personal use or distribution potentially resulting in criminal behaviors and risking the safety of patients. The census upon entrance was 226 patients.



II. While on-site, the survey team identified an Immediate Jeopardy situation and notified the administrative staff on 12/22/2020 at approximately 4:00 PM. The hospital staff removed the immediacy on 12/23/2020 at 02:15 PM, prior to the survey team exiting the complaint investigation, when the administrative staff took the following actions:

a. Genesis will conduct five (5) controlled substance transaction audits per week. A Controlled Substance Override report will be compiled and audited by the departmental Manager/Supervisor every 2 weeks. All items measured will be accounted for as defined: Total Amount Administered + Any Amount Wasted = Total Amount Issued. Unusual practices will immediately be escalated up to the departmental chain of command.

b. All Outpatient Care Center (OPCC) staff were required to review the Controlled Substance policy, Diversion policy, and a key points summary document.

c. At daily staff meetings referred to as "huddles," Leaders of all nursing units were instructed to direct that all nurses must log off the AMDS before walking away from the AMDS. Moving forward, Genesis will assess the need for corrective action for any deviations from this requirement.

d. Mandatory online education courses were assigned to all nurses, Patient Care Techs, Pharmacy Staff, Physical Therapists, Occupational Therapists, and Social Workers at Genesis Medical Center - Davenport. The courses discussed how to recognize the behaviors, signs and symptoms of an impaired colleague, and about how to report an employee suspected of being under the influence of a substance while at work.

e. An email blast referred to as a "Safety Alert," containing educational components related to identifying potential impairment of colleagues and how to report concerns about impairment, will be sent out system-wide

f. An email blast referred to as a "Safety Huddle Message of the Week" will be sent out system-wide to reinforce policies respecting controlled substances, diversion, employee impairment and reporting on an impaired colleague. The Safety Huddle Message of the Week is discussed during all daily safety huddles occurring throughout the health system.

g. Departmental Managers/Supervisors working in patient care areas will perform ten (10) random audits per day of AMDS time-out vs. user log-out. All employees are expected to manually sign-out and any suspicious practice will immediately be escalated up to the departmental chain of command, Chief Nursing Officer, and Pharmacy Director.

h. Medication room door access reports showing the previous week's activity will be sent to managers of Cath Lab and OPCC each Monday morning. Managers will review any entrances into medication areas on dates that their department is closed. Managers will follow-up with individuals and/or that individual's leaders to determine the reason for access to the medication area during closed times.

i. OPCC AMDS override access for Dilaudid will be removed immediately. All AMDS override items will be reviewed to remove infrequently used items.

Based on document review and staff interviews, the pharmacist failed to create and implement 1 of 1 proactive programs to identify potential drug diversions. Failure to create and implement a proactive drug diversion program led to at least one nurse stealing over 150 doses of Dilaudid (Hydromorphone), in a 3 month period, without the hospital staff detecting the nurse diverted the medication. The hospital identified the diversion impacted over 67 patients.

Findings include:

1. Review of the policy "Diversion of Hospital Drug Supplies by Hospital Personnel," effective 9/2020, revealed in part, "All indications of potential drug diversion by hospital staff will be immediately acted upon ... Diversions of medication (particularly controlled substances) from Medical Center stock or patient-specific supplies for unauthorized use is prohibited, illegal, a potential patient dependent adult abuse ... Whenever indications of a potential drug diversion arise ... leaders in the involved department(s) and the pharmacy department will initiate immediate action ... The "Indications of Potential Drug Diversion Investigation Report" ... will be used to guide the investigative process ..."

2. Review of the policy "Automated Medication Distribution System (AMDS)," revised 4/2020, revealed in part, "Automated Medication Distribution Systems (AMDS) shall be used as storage, dispensing, and charging system for medications, to promote proper and safe medication use ... Override: A process of bypassing the pharmacist review of the medication order when assessment of the patient indicates that a delay for a review would harm the patient. Overrides are restricted to urgently needed medications to prevent patient harm and will require an override reason prior to removal of the medication ... Individual access codes and passwords should not be shared ... Users are required to logout prior to walking or stepping away from the AMDS."

3. Review of the policy "Controlled Substance", revised 05/2020 revealed in part, "The Pharmacist in Charge...is responsible for ensuring compliance and accountability at the assigned site ... The manager of any department or unit that uses or stores controlled substances is accountable for ensuring policies and safeguards related to their proper storage, use, documentation and maintenance of records are followed ... Diversion of drugs ... from Medical Center stock or patient-specific supplies for unauthorized use is illegal, prohibited ... All waste of controlled substances must be witnessed and recorded by two licensed healthcare professionals."

4. Review of the policy "Security and Storage of Medications (Non-Pharmacy)", revised 6/2020, revealed in part, "Genesis Medical Center will provide a systematic process for maintaining security of medications in all areas ... Control of access to medication storage areas is the responsibility of the manager of that area, including procedural areas ... The manager of the area will monitor compliance ..."

5. During an interview on 12/16/2020 at approximately 10:00 AM, the Pharmacy Director revealed the hospital previously had implemented a system to detect drug diversions, where the hospital's AMDS automatically calculated the average number of narcotic medications each nurse removed from the AMDS. The AMDS then calculated the standard deviation for each nurse (a measure of how far each nurse's medication dispensing practice is from the average nurse). The old system allowed the Pharmacy Director to review each nurse's drug dispensing practice and see if the nurse was engaging in possible drug diversion (a nurse stealing medication), as a nurse with a higher standard deviation number would indicate a nurse removing significantly more medications than the average nurse, and allow the hospital's administrative staff to investigate the situation.

The Pharmacy Director indicated they discontinued utilizing the hospital's prior system to detect drug diversions, as the Pharmacy Director felt the old system created too many false positives (instances where the system indicated the nurse was possibly stealing medication, but the nurse was not stealing medication).

The Pharmacy Director felt the float nurses (nurses not assigned to a specific department and work in whichever department needs assistance at the time) had a higher rate of dispensing medications than nurses permanently assigned to a specific department. Since the float nurses had a higher rate of dispensing medications, the Pharmacy Director did not consider that float nurses could possibly steal medications, and thus did not monitor their dispensing practices.

The Pharmacy Director revealed that the pharmacy did not provide any oversight to the medication dispensing practices of nurses permanently assigned to the Emergency Department (ED). The ED nurses had a physician in the ED at all times, and since the ED nurses often received orders from the ED physician, the pharmacy did not need to monitor any of the controlled substances in the ED to ensure the ED nurses did not steal medications.

The AMDS automatically generated a "Dispensing Practice Report" each month and automatically sent the report only to the department's nurse manager of the unit containing the automated medication dispensing cabinet. The Pharmacy Director expected the department's nurse manager to review the Dispensing Practice Report for any discrepancies or unusual medication withdrawals. If the department's nurse manager identified any discrepancies or suspicious medication withdrawals, the department's nurse manager would contact the Pharmacy Director with their concerns, and the hospital's administrative staff would begin to investigate the situation.

The Pharmacy Director failed to identify that if the department's nurse manager only reviewed the medication dispensing practices of nurses working on their unit, the department's nurse manager would not get a complete picture of the medication dispensing practices of float nurses (as they worked on many units, and subject to review by many department's nurse managers), and likely would not identify if the float nurses stole medications from the hospital.



6. Review of the "Medication Override Report, for 9/25/2020 through 12/2/2020, for the Outpatient Care Center (OPCC) revealed the following:

a. During the month of October 2020, RN D removed at least 10 doses of Dilaudid (Hydromorphone, a strong opiate IV pain medication) from the AMDS without documenting they administered the medication to a patient (a strong indicator RN D stole the medication), affecting at least 8 patients.

b. For the week of 11/2/2020 through 11/9/2020, RN D removed at least 6 doses of Dilaudid from the AMDS without documenting they administered the medication to a patient, affecting at least 5 patients.

c. For the week of 11/10/2020 through 11/13/20, RN D removed at least 14 doses of Dilaudid from the AMDS without documenting they administered the medication to a patient, affecting at last 9 patients.

d. For the week of 11/16/20 through 11/20/2020, RN D removed at least 28 doses of Dilaudid from the AMDS without documenting they administered the medication to a patient, affecting at least 15 patients.

e. For the 2 days of 11/23/2020 through 11/24/2020, RN D removed at least 16 doses of Dilaudid from the AMDS without documenting they administered the medication to a patient, affecting at least 10 patients.

f. On 11/26/2020 (Thanksgiving, when the OPCC department was closed), RN D removed at least 10 doses of Dilaudid from the AMDS without documenting they administered the medication to a patient, affecting at least 2 patients.

g. On 11/27/2020 (the day after Thanksgiving), RN D removed at last 10 doses of Dilaudid from the AMDS without documenting they administered the medication to a patient, affecting at least 3 patients.

h. On 11/29/2020 (a Sunday, when the OPCC department was closed), RN D removed at least 11 doses of Dilaudid from the AMDS without documenting they administered the medication to a patient, affecting at least 2 patients.

i. On 11/30/2020, RN D removed at least 7 doses of Dilaudid from the AMDS without documenting they administered the medication to a patient, affecting at least 5 patients.

j. On 12/1/2020, RN D removed at least 7 doses of Dilaudid from the AMDS without documenting they administered the medication to a patient, affecting at least 6 patients.

k. On 12/2/2020 (the day RN D was sent home since RN D couldn't keep their eyes open at work), RN D removed at least 9 doses of Dilaudid from the AMDS without documenting they administered the medication to a patient, affecting at least 3 patients. RN D removed 3 of the 9 doses of Dilaudid after RN D clocked out for the day.

The Medication Override Reports from 9/25/2020 through 12/2/2020 indicated RN D stole approximately 155 vials of Dilaudid from the hospital.



7. During an interview on 12/17/2020 at 11:25 AM, the OPCC Department Manager acknowledged the pharmacy sent them a Medication Override Report each month. However, the OPCC Department Manager did not realize their job included reviewing the Medication Dispensing Report until 12/3/2020 (the day after the OPCC Department Manager sent RN D home because RN D could not keep their eyes open at work).

8. During an interview on 12/22/20 at 2:15 PM, the Pharmacy Director acknowledged the hospital staff identified that RN D stole over 150 doses of Dilaudid (over 2 months after RN D first started stealing medication). The Pharmacy Director felt that the hospital staff did a good job detecting RN D stealing medication and the hospital staff could not have detected RN D stealing medication any faster.

Based on document review and staff interviews, the hospital's administrative staff failed to ensure 1 of 1 pharmacy had a mechanism to detect drug diversions and minimize the time frame of the diversion. Failure of the pharmacy to detect a drug diversion resulted in at least one nurse diverting approximately 150 doses of Dilaudid (Hydromorphone) over a 3 month period. The hospital identified the diversion impacted approximately 67 patients.

Findings include:

1. Review of the policy "Controlled Substance", revised 05/2020 revealed in part, "The Pharmacist in Charge...is responsible for ensuring compliance and accountability at the assigned site ... The manager of any department or unit that uses or stores controlled substances is accountable for ensuring policies and safeguards related to their proper storage, use, documentation and maintenance of records are followed ... Diversion of drugs ... from Medical Center stock or patient-specific supplies for unauthorized use is illegal, prohibited ... "

2. Review of the policy "Automated Medication Distribution System (AMDS)," revised 4/2020, revealed in part, "Automated Medication Distribution Systems (AMDS) shall be used as storage, dispensing, and charging system for medications, to promote proper and safe medication use ... Override: A process of bypassing the pharmacist review of the medication order when assessment of the patient indicates that a delay for a review would harm the patient. Overrides are restricted to urgently needed medications to prevent patient harm and will require an override reason prior to removal of the medication ... Individual access codes and passwords should not be shared ... Users are required to logout prior to walking or stepping away from the AMDS."

3. During an interview on 12/16/2020 at 10:00 AM, the Pharmacy Director revealed the hospital previously had implemented a system to detect drug diversions, where the hospital's AMDS automatically calculated the average number of narcotic medications each nurse removed from the AMDS. The AMDS then calculated the standard deviation for each nurse (a measure of how far each nurse's medication dispensing practice is from the average nurse). The old system allowed the Pharmacy Director to review each nurse's drug dispensing practice and see if the nurse was engaging in possible drug diversion (a nurse stealing medication), as a nurse with a higher standard deviation number would indicate a nurse removing significantly more medications than the average nurse, and allow the hospital's administrative staff to investigate the situation.

The Pharmacy Director indicated they discontinued utilizing the hospital's prior system to detect drug diversions, as the Pharmacy Director felt the old system created too many false positives (instances where the system indicated the nurse was possibly stealing medication, but the nurse was not stealing medication).

The AMDS automatically generated a "Dispensing Practice Report" each month and automatically sent the report to the department's nurse manager of the unit containing the automated medication dispensing cabinet. The Pharmacy Director expected the department's nurse manager to review the Dispensing Practice Report for any discrepancies or unusual medication withdrawals. If the department's nurse manager identified any discrepancies or suspicious medication withdrawals, the department's nurse manager would contact the Pharmacy Director with their concerns, and the hospital's administrative staff would begin to investigate the situation.


4. Review of the "Medication Override Report, for 9/25/2020 through 12/2/2020, for the Outpatient Care Center (OPCC) revealed the following:

a. During the month of October 2020, RN D removed at least 10 doses of Dilaudid (Hydromorphone, a strong opiate IV pain medication) from the AMDS without documenting they administered the medication to a patient (a strong indicator RN D stole the medication), affecting at least 8 patients.

b. For the week of 11/2/2020 through 11/9/2020, RN D removed at least 6 doses of Dilaudid from the AMDS without documenting they administered the medication to a patient, affecting at least 5 patients.

c. For the week of 11/10/2020 through 11/13/20, RN D removed at least 14 doses of Dilaudid from the AMDS without documenting they administered the medication to a patient, affecting at last 9 patients.

d. For the week of 11/16/20 through 11/20/2020, RN D removed at least 28 doses of Dilaudid from the AMDS without documenting they administered the medication to a patient, affecting at least 15 patients.

e. For the 2 days of 11/23/2020 through 11/24/2020, RN D removed at least 16 doses of Dilaudid from the AMDS without documenting they administered the medication to a patient, affecting at least 10 patients.

f. On 11/26/2020 (Thanksgiving, when the OPCC department was closed), RN D removed at least 10 doses of Dilaudid from the AMDS without documenting they administered the medication to a patient, affecting at least 2 patients.

g. On 11/27/2020 (the day after Thanksgiving), RN D removed at last 10 doses of Dilaudid from the AMDS without documenting they administered the medication to a patient, affecting at least 3 patients.

h. On 11/29/2020 (a Sunday, when the OPCC department was closed), RN D removed at least 11 doses of Dilaudid from the AMDS without documenting they administered the medication to a patient, affecting at least 2 patients.

i. On 11/30/2020, RN D removed at least 7 doses of Dilaudid from the AMDS without documenting they administered the medication to a patient, affecting at least 5 patients.

j. On 12/1/2020, RN D removed at least 7 doses of Dilaudid from the AMDS without documenting they administered the medication to a patient, affecting at least 6 patients.

k. On 12/2/2020 (the day RN D was sent home since RN D couldn't keep their eyes open at work), RN D removed at least 9 doses of Dilaudid from the AMDS without documenting they administered the medication to a patient, affecting at least 3 patients. RN D removed 3 of the 9 doses of Dilaudid after RN D clocked out for the day.

The Medication Override Reports from 9/25/2020 through 12/2/2020 indicated RN D stole approximately 155 vials of Dilaudid from the hospital. The documentation revealed that RN D signed into the AMDS and stole approximately 142 vials of Dilaudid using RN D's AMDS log-in information. RN D stole an additional approximately 13 vials of Dilaudid by waiting for another nurse to forget to sign out of the AMDS and remove the medication under the other nurse's AMDS log-in information.

Review of patient records revealed that the RN D stole the Dilaudid the majority of the time by logging into the AMDS under RN D's log-in information, selected a patient who was either in surgery (under general anesthesia) at the time (and not under RN D's care) or an outpatient who's name was in the AMDS since the patient would require intermittent admission to the hospital for cancer treatment or another outpatient treatment.

RN D stole 31 doses of Dilaudid on Thanksgiving and the following weekend, when the OPCC department was closed and RN D was not scheduled to work at the hospital.



5. During an interview on 12/28/2020 at 2:00 PM, the Pharmacy Director revealed that the pharmacy staff had restocked the Dilaudid in the OPCC AMDS over the Thanksgiving weekend. The pharmacy staff did not identify any concerns or "red flags" about a staff member removing medications from the AMDS or the pharmacy staff needing to restock an AMDS over a holiday weekend for a closed unit, as the AMDS automatically generated a request for the pharmacy technicians to restock the AMDS, and the pharmacy technicians viewed restocking an AMDS as a routine task.

The Pharmacy Director acknowledged the hospital currently lacked a system to identify if a nurse's medication dispensing practice suddenly increased (like RN D's did, which is a strong indicator of a nurse stealing medication). If the pharmacy staff wanted to monitor the changes in a nurse's medication dispensing practice, the pharmacy staff would need to manually run a report to identify any changes. The Pharmacy Director acknowledged the pharmacy lacked an effective system to identify if a nurse was stealing medication from the hospital.