What Happened
Kurt Vasquez, an advanced nurse practitioner and registered nurse placed on contract in a hospital catheterization lab, diverted fentanyl, midazolam, and propofol meant for patients undergoing procedures.
Vasquez was placed at the hospital as a contract nurse in summer 2019 and shortly after began a scheme to obtain more fentanyl, midazolam, and propofol than scheduled catheterization procedures actually required. Between June and September 2019, he kept the excess medication for his own use. On some occasions he falsely documented in patient charts that he had administered drugs that were never given, and at other times he took filled syringes, used the drugs himself, and then falsely stated the syringes had been used on a patient.
Vasquez was sentenced on September 18, 2021, to three months' imprisonment for illegally obtaining fentanyl through fraud and deception while working in the hospital's catheterization lab.
What Went Wrong
A short-term contract clinician was able to over-order sedation medication and falsify charting without early detection. Key failures included:
- No reconciliation compared medication ordered per catheterization procedure against the standard dosing range for that procedure type.
- Charted administration was accepted without verification against the syringe pull and waste record for the same encounter.
- Contract and travel staff were not subject to the same onboarding-period monitoring as permanent staff during a documented higher-risk transition period.
How It Could Have Been Prevented
- Set per-procedure dosing benchmarks for catheterization lab sedation and flag orders that exceed the expected range.
- Reconcile charted administration against syringe pulls and documented waste for every procedure, not just on exception reports.
- Apply heightened diversion monitoring to newly placed contract and travel clinicians during their first weeks in a facility.
- Require a second clinician to verify and co-sign controlled-substance waste in procedural areas like the catheterization lab.
Related Guidance
- Tough Issues — High-risk scenarios with annotated SQL for analyzing dispense-to-administer gaps.
- 15 Red Flags of Drug Diversion — Behavioral and transactional indicators including falsified charting.
- Hospital Diversion Prevention Checklist — Hospital self-assessment covering procedural-area medication controls.
- Employee Screening & Fitness for Duty — DEA screening requirements (21 C.F.R. §1301.90) for staff with controlled substance access, including contract and travel clinicians.