What Happened
A registered nurse in a hospital intensive care unit was terminated in 2016 after a medication log review showed an atypically high rate of fentanyl removal and documentation errors, including unaccounted amounts of fentanyl, lorazepam (Ativan) and hydromorphone and 66 of 669 medications not scanned as given to a patient or wasted.
The nurse denied wrongdoing and sued the hospital for wrongful discharge, breach of contract and defamation. The South Dakota Supreme Court upheld summary judgment for the hospital, finding no evidence it recklessly disregarded the truth when it reported the suspected drug diversion; the Board of Nursing investigated and ordered counseling, and other agencies reported to took no action.
What the Record Shows
Terminated in 2016; sued for wrongful discharge, breach of contract and defamation; circuit court granted the hospital summary judgment, upheld by the South Dakota Supreme Court; the Board of Nursing investigated and ordered counseling, while other reported agencies took no action.
Why It Matters for Diversion Programs
This entry comes from a news source rather than a federal enforcement release, and it is recorded as reported: Alleged diversion: a medication log review showed an atypically high fentanyl removal rate; a review of 16 charts found 12 areas of concern, including unaccounted amounts of 275 micrograms of fentanyl and 3 milligrams each of lorazepam and hydromorphone, and 66 of 669 medications not scanned as administered or wasted.. Board and news records are a lagging indicator - by the time a licensing authority or a reporter learns of a diversion, the diversion was normally detected internally first, which makes each entry a signal that inventory reconciliation, waste observation or dispensing oversight failed earlier.