On the night of February 9-10, 1980, a registered nurse placed by a temporary help agency worked a shift at a Washington, DC hospital. Under the hospital's narcotics procedures, all narcotics were counted at each shift change, and because the smallest unit of Demerol was 50 mg, any surplus had to be wasted in the presence of a second nurse who signed the control sheet. The nurse signed out 50 mg of Demerol, recording that 25 mg was given to a patient, but no witness signature for the wasted balance was obtained.
The discrepancy surfaced at the 7:00 a.m. handoff. The incoming nurse questioned the entry, and the charge nurse began to sign as a witness but crossed out her signature when asked whether she had actually seen the disposal. Later that morning the head nurse discovered the patient had received no Demerol and that the patient's prescription had expired two weeks earlier. The nurse told the associate director of nursing that she had read the wrong patient's records and had wasted the entire dose, and admitted failing to have the amount witnessed. The hospital referred the matter to the police narcotics branch, and an indictment followed on charges of forging prescriptions and fraudulently obtaining narcotics; the nurse was later acquitted of those criminal charges.
The DC Nurses' Examining Board charged professional misconduct in June 1980. At the April 1981 hearing, the nurse testified that the charge nurse had said the patient needed pain medication, that the surplus was squirted into the air, and that the remaining Demerol was carried in a uniform pocket during rounds and wasted at the end of the shift. The charge nurse denied telling her the patient needed medication and said no one witnessed any disposal. The Board found the nurse not credible, found the 50 mg unaccounted for, and in July 1981 suspended the license for two years. The nurse was already on Board probation from a 1977 incident involving self-injection of a controlled substance at another hospital.
On appeal, the DC Court of Appeals found the Board had erred in limiting cross-examination of the charge nurse but held the error harmless because the nurse's own admissions supported the finding. The court affirmed the two-year suspension on March 29, 1983, noting that a nurse entrusted with narcotics is held to a standard commensurate with that role and that the Board could have revoked the license outright.