What Happened
A licensed practical nurse at Elcor Nursing and Rehabilitation Center in Horseheads, New York, diverted nearly 200 Percocet pills from eight elderly residents by recording that she had given them medication she had actually kept for herself.
The nurse, 45, was investigated by the New York Attorney General's Medicaid Fraud Control Unit and the state Department of Health's Bureau of Narcotics Enforcement. Over roughly a one-month period, she completed medication administration records showing that she had given narcotic pain medication to eight separate residents at Elcor Nursing and Rehabilitation Center, when she had in fact diverted the pills — including 46 Percocet tablets from a single resident — for her own use.
She was arraigned on May 20, 2015 on eight counts of falsifying business records, eight counts of petit larceny, and one count of criminal possession of a controlled substance. The Attorney General announced her guilty plea on August 12, 2015.
What Went Wrong
A nurse was able to falsify medication records for eight different residents over a month before the diversion was caught. Key failures included:
- Administration records were accepted at face value without verification against residents' actual pain relief or clinical status.
- No routine audit compared how often a single nurse's residents ran short on controlled substances relative to peers on the same unit.
- Falsified paper documentation was not cross-checked against the facility's controlled-substance count records in real time.
How It Could Have Been Prevented
- Verify narcotic administration against resident pain assessments and follow-up response, not just the written record.
- Audit controlled-substance shortages and unusual administration patterns by nurse and by unit on a recurring basis.
- Reconcile paper medication administration records against physical controlled-substance counts each shift, rather than relying on documentation alone.
- Require a second staff member to witness administration of controlled substances to long-term care residents whenever feasible.
Related Guidance
- Diversion prevention checklist — Self-assessment covering nursing home controlled-substance controls.
- 15 Red Flags of Drug Diversion — Behavioral and recordkeeping indicators of diversion by clinical staff.
- Waste Documentation Policies — Witnessed waste and documentation requirements for controlled substances.
- More Diversion Case Studies — Additional documented cases of healthcare drug diversion.