Hospital drugs leading to hospital highs
Author: Chris Vanderveen
Published: 2:48 PM MDT May 23, 2016
Updated: 9:51 PM MDT May 23, 2016
INVESTIGATIONS 4 Articles

Shortly before she was escorted out of the hospital that had been her employer for 15 years, Angela Ann Good brought a manager into a restroom across from a nurse’s station and opened up a linen drawer and revealed a secret stash.

According to a police report, she picked up a used syringe, a tourniquet and an empty vial of Versed. Minutes later, she left Platte Valley Medical Center for good.

Months later, staff at the hospital informed investigators they believed they had discovered a much more elaborate con.

It would come to represent one of the largest diversions of drugs inside a Colorado hospital in years, which included 686 vials of fentanyl and 476 bottles of Versed. It represents one of 414 suspected cases forwarded to the state since 2010.

9Wants to Know spent months analyzing hundreds of reports and discipline records to get a better idea of what’s going on behind hospital walls after the high-profile arrest of Colorado surgical technician Rocky Allen. Allen’s suspected drug theft led Swedish Medical Center to tell 2,900 patients to get tested for hepatitis and HIV as a precaution.

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Among our findings:

  • The most potent drug found in Colorado hospitals – fentanyl – is also the most stolen.
  • Once every two weeks, a Colorado hospital fires an employee on suspicion of drug diversion
  • Fewer than 20 percent of employees we found tied to drug diversion cases were ever criminally prosecuted
  • Nearly half of employees tied to drug diversion cases still have active licenses to practice in Colorado
  • As long as a hospital reports a suspected drug diversion to the state, the Colorado Department of Public Health and Environment appears satisfied hospitals are doing enough

Have a tip about this story? Email Chris Vanderveen at chris.vanderveen@9news.com.

EXPLORE

Hospital drugs leading to hospital highs

INVESTIGATIONS
Chapter 1

‘I ASKED HER THREE TIMES TO LEAVE MY ROOM’

Five months after the Navy sent him to work at a NATO hospital in Kandahar, Afghanistan, Rocky Allen started stealing fentanyl.

via GIPHY

Court records show in 2011 the then-Hospital Corpsman confessed to using a wire normally used to repair broken bones to help him break into lockers containing the drug that’s significantly more potent than heroin.

“I picked the lock on the lockers. I’d seen the providers – I knew that’s where they kept their narcotics,” Allen said during a Special Court Martial on May 17, 2011. “I wanted to take them personally and try to kind of escape being here in Kandahar."

The military reduced his rank and sentenced him to 90 days of confinement. Eventually, the military would shorten that to 30 days.

On Oct. 27, 2011, Lakewood Surgery Center in Washington state hired Allen to work as a surgical technician. By Dec. 1, 2011, Allen was gone. Staff suspected he had been trying to steal fentanyl, according to court records.

Over the course of the next four years, Allen managed to hopscotch from job to job in hospitals in Washington, California, and Arizona.

Each time, hospital staff either suspected Allen was stealing drugs or actually caught him in the act, according to court records, and each time, hospital staff quietly let him go.

At Northwest Hospital in Seattle in 2012, a housekeeper saw Allen taking a sharps container filled with used needles and medications into a bathroom.

At Scripps Green Hospital near San Diego, Allen pulled a syringe out of his sock when confronted by staff.
“When asked what [he] was planning on doing with the syringe of fentanyl, he said he was going to inject it,” according to a motion filed by federal prosecutors in Colorado.

John C. Lincoln Medical Center fired Allen in 2014 shortly after staff, according to court filings, found him passed out in a bathroom with an empty syringe by his side. Once revived, he “was not coherent and kept repeating the same things over and over.”

A drug test would reveal the presence of fentanyl, according to his termination letter.

Repeatedly, 9Wants to Know has asked that hospital why state or police investigators were never notified. A spokesperson said last week: “Because this matter is the subject of a lawsuit, we are not going to provide additional comment.”

Denver attorney James Avery represents patients who spent time at the hospitals where Allen worked.

“I think it’s outrageous it wasn’t reported to local law enforcement [in Arizona],” Avery said. “The way they protect their reputations is by denying they have a problem.”

A year after passing out in the Arizona hospital bathroom, Allen started working inside Swedish Medical Center in Colorado.

Months later, federal prosecutors say, hospital staff found fentanyl in his system after a staff member saw him in an unassigned operating room. They fired him and alerted 2,900 patients they needed to get tested for hepatitis B, hepatitis C, and HIV. Allen had previously admitted to other employers he had a yet-to-be-specified bloodborne pathogen.

Denver attorney Hollynd Hoskins represented some of the 18 patients infected with hepatitis C in 2008 when surgical technician Kristen Parker stole drugs from Rose Medical Center using used syringes.

HealthONE Colorado owns both Swedish and Rose.

“It’s devastating to be back here again after what happened at Rose Medical Center,” Hoskins said. “Clearly, hospitals are not doing enough to prevent this from occurring.”

In the medical world of multi-million dollar budgets and splashy promotional campaigns, Hoskins believes hospitals need to be less concerned about damaged reputations and more concerned about safety.

“Hospitals have a history of putting profits over patient safety, and unfortunately, hospitals have an incentive to bury this information,” Hoskins said.

The Colorado Hospital Association believes, at least when it comes to Allen’s employment in Colorado, Swedish Medical Center did the right thing by finally making the Allen case public.

Also, CHA President Steven Summer told 9Wants to Know the work of thousands of health care employees shouldn’t be overshadowed by the Allen case.

“There are tens of thousands of people who come to work every day in our hospitals who are committed to doing the right thing for their patients,” Summer said.

That is almost certainly the case, but a three-month-long 9Wants to Know investigation suggests a small percentage of employees continue to steal drugs from dozens of Colorado hospitals on an annual basis.

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No hospital rivals Presbyterian/St. Luke’s Medical Center when it comes to a high rate of reported drug diversions, but the large number doesn’t seem to indicate a problem.

In fact, buried in the cumulative data from the Denver hospital is a story of a facility that makes a habit of reporting even seemingly insignificant cases.

For example, in July 2015, the hospital sent two drug diversion reports to the state. The two reports were for two missing tablets of oxycodone.

Both instances were almost certainly not the result of drug theft, but a result of an auditing system that managed to find seemingly small discrepancies with medication counts. Even still, the hospital notified the Denver Police Department in both cases.

The hospital was never required to do so, but it did it anyway.

Taunie Cable-Schuster knew something wasn’t right the moment an unfamiliar nurse came into her room at Parker Adventist Hospital.

The nurse, dressed in scrubs Cable-Schuster had never seen, made a beeline toward a pain pump that was delivering dilaudid, which is a highly addictive pain medication.

“She started to open it, and I said, ‘What are you doing?’” Cable-Schuster said. “I asked her three times to leave my room. Three times. I don’t think [the nurse] thought I was alert at all.”

Cable-Schuster buzzed her call button, and that’s when she said the nurse ducked out of the room. When other nurses arrived, Cable-Schuster was angry.

“I wanted them to call the police,” she said.

A state report obtained by 9Wants to Know shows staff found propofol in the nurse’s locker and fentanyl, dilaudid and morphine in her urine.

That nurse was subsequently fired but was given a reprieve by the hospital when a manager told an investigator with the Parker Police Department the hospital was no longer going to cooperate with the criminal investigation the following month.

“She advised they were going to handle it as a personal matter and could not discuss it further,” read a police report.

Then, the case was dropped.

“I don’t find that acceptable,” John Burke with the International Health Facility Diversion Association said. “A crime was committed.”

“We handled this case appropriately,” a spokesperson for Parker Adventist wrote in a statement sent to 9Wants to Know.

The hospital refused an offer for an on-camera interview.

The statement also said: “Parker Adventist Hospital cooperated, which is why there is a police report. We regret that we are unable to share further details around this case.”

Burke saw things differently, however.

“When you don’t [work with police], you send a patient on, and it’s a recipe for disaster,” Burke said.

The nurse who walked in Cable-Schuster’s room still has an active nursing license, although it has some unspecified restrictions attached to it.

9Wants to Know identified 56 employees accused of drug diverting since 2010. Nearly half of those employees still have their nursing licenses.

In addition, prosecutions are rare. Fewer than 20 percent of the diverters we identified were ever charged, and none received a prison or jail sentence.

Chapter 2

‘1,100 MISSING VIALS, NO STATE INVESTIGATION’

Angela Ann Good’s 15 years working at Platte Valley Medical Center came to an abrupt end when a manager walked her out of the hospital on Feb. 24, 2015.

The hospital’s leadership suspected drug diversion, but they weren’t able to immediately quantify the extent of the theft.

Four months later, a manager at the hospital informed an Adams County Sheriff’s Office investigator the hospital had finally managed to figure it out.

Between October 2014 and February 2015, the hospital reported 686 missing bottles of fentanyl and 476 missing bottles of midazolam (also known as Versed).

The theft amounted to approximately 10 vials a day.

While the hospital also refused an offer for an on-camera interview, a spokesperson for the hospital supplied this statement:

“We have always had drug-diversion protocols and measures in place. Unfortunately, people who are addicted to drugs will stop at nothing to get them. Our job is to continually find ways to stay one step ahead, as evidenced by our quick action, cameras and surveillance equipment, and DEA-informed best practices. For example, we installed active surveillance software that is new to the pharmacy/healthcare industry and identifies unusual patterns of medication access via automated dispensing machines.”

Dr. Larry Wolk heads the Colorado Department of Public Health and Environment. CDPHE is the main state agency tasked with making sure hospitals are adequately protecting patient safety when it comes to drug diversion.

9Wants to Know asked Dr. Wolk if hospitals can be trusted to do the right thing.

“They’re in the business of patient care. So, yes, we can trust hospitals,” Dr. Wolk replied.

Yet, of the 414 suspected diversion cases reported to CDPHE since 2010, only two hospitals have been investigated further by the state. It’s a rate of less than .05 percent.

CDPHE found deficiencies in how Swedish Hospital tried to prevent diversions shortly after the Rocky Allen case went public in February. In addition, in 2013, CDPHE found deficiencies in the diversion protocols at Estes Park Medical Center.

A statement from a spokesperson for CDPHE said, generally, CDPHE “does not cite deficiencies in drug diversion occurrences if our findings indicate the hospital has adequately addressed any concerning patient care issues … and established more stringent monitoring methods to prevent drug diversions.”
Good’s case at Platte Valley apparently never met the criteria.

9Wants to Know asked Dr. Wolf if more than 1,000 missing vials would constitute a systemic problem.

“It depends on the circumstances,” Dr. Wolk replied.

Good has not yet replied to numerous requests for comment. Shortly after she lost her job in Colorado, she moved to Florida and received a nursing license there while she was under criminal investigation in Colorado.

For three months, Good was free to practice nursing in the Fort Myers area.

Chapter 3

‘I WOKE UP IN THE ER’

9Wants to Know created a database of all reported diversions to the state since 2010. The list, 414 suspected occurrences long, details a sordid tale of drug theft and illegal behavior. Among the cases:

  • In 2013, an RN was seen taking medication from a patient in the oncology unit at Littleton Adventist
  • In 2011, an RN who had already been fired three times for suspected drug diversion admitted to stealing 206 vials of fentanyl from Longmont United
  • In 2011, 207 syringes of fentanyl were determined to be missing and stolen inside Medical Center of Aurora
  • In 2010, a staff member was found in an in a bathroom with an empty syringe at Penrose St. Francis in Colorado Springs
  • In 2013, an RN’s theft of fentanyl at Poudre Valley led the hospital to warn 200 patients to get tested for hepatitis C
  • In 2012, 1239 tablets of Viagra went missing at Poudre Valley

9Wants to Know contacted nearly a dozen diverters over the course of this investigation. Many spoke on the phone, but only one agreed to go on camera if we agreed to hide his identity.

He said his addiction began years ago.

“I saw my patients getting relief from the narcotics, and I thought maybe I could just try it,” he said.

It started small. A few pills here and there.

Four years later, however, he said he was getting high from fentanyl every two hours.

“It gives you an immediate feeling of relief from pain and anxiety,” he said.

One day, he passed out in a hospital bathroom. Staff found him unconscious and sent him to the emergency room.

“I was so controlled by my addiction that I really didn’t care if I lived or died,” he said.

It didn’t take long for the hospital to fire him.

“It was, ‘You can’t work here again,’ and ‘good luck with the rest of your life,’” he said. “The hospital itself, I thought, cut me off. There was no offer of support there. There was no comfort to be found there.”

He said stealing fentanyl was easy.

“Many times, it was simply a matter of walking into a room and withdrawing it right from a patient’s bag,” he said.

Other times he would take what’s known as the waste. Hospital protocol typically calls for employees to “waste” excess medication while being watched by another employee.

The standard isn’t always followed.

Many times, he said, the hectic environment in the hospital wouldn’t allow for it. Other times, employees felt it insulting to have to watch a coworker get rid of the medication.

“Are you glad you were finally caught?” asked 9Wants to Know.

“I am,” he replied.

He, like many employees, managed to keep his nursing license, but the current restrictions essentially keep him from working in a hospital.

The local police department was notified of the theft, but prosecutors never charged him.

“I have been given a second chance. I have been given this opportunity to have my life again,” he said.

Chapter 4

SEARCH FOR DIVERSIONS REPORTED AT YOUR PROVIDER

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