Failure to Prevent Employment of Nurse with Active Disciplinary Action for Drug Diversion
Penalty
Summary
The facility failed to ensure that it did not employ a nurse with an active disciplinary action on her professional license due to a history of drug diversion. Nurse #13 was hired despite having restrictions on her license imposed by the North Carolina Board of Nursing (NCBON) following an incident in 2021 where she admitted to diverting Oxycodone and having a substance abuse disorder. The facility was aware of these restrictions at the time of hiring, as they had obtained documentation from the NCBON outlining the disciplinary measures and employment limitations, including prohibitions on supervisory roles and certain types of employment. During her employment, Nurse #13 was involved in an incident where multiple Oxycodone tablets could not be accounted for while she was responsible for the care of Resident #2. The investigation revealed discrepancies in the number of tablets received and administered, with Nurse #13 unable to reconcile the missing medication or provide an adequate explanation. The facility reported the suspected drug diversion to the state agency and subsequently suspended and terminated Nurse #13. Interviews with facility staff and the NCBON compliance case analyst confirmed that Nurse #13's license restrictions were still in effect at the time of her hire and during the incident. The restrictions included specific employment limitations due to her participation in the Alternative Program for Chemical Dependency. Despite these known restrictions and her disciplinary history, the facility proceeded with her employment, which led to the deficiency identified in the report.