What Happened
A licensed practical nurse at DeMay Living Center in Newark, New York, diverted nearly 500 narcotic pills from fourteen nursing home residents by falsifying the records that were supposed to show the drugs had been given to patients.
Ashly Erb, 26, was investigated by the New York Attorney General's Medicaid Fraud Control Unit and the state Department of Health's Bureau of Narcotics Enforcement after discrepancies surfaced in resident medication records at DeMay Living Center. The investigation found that over roughly a month, Erb completed records indicating she had administered narcotic drugs — including 94 oxycodone pills taken from a single resident alone — to fourteen separate residents, when she had in fact diverted a total of 493 pills for her own use.
Erb pleaded guilty to one count of petit larceny on June 3, 2015, and was promised a conditional discharge if she completed substance-abuse treatment and avoided rearrest. She failed to meet those conditions, and on January 6, 2016, a Wayne County judge sentenced her to 99 days in jail.
What Went Wrong
A single nurse was able to falsify administration records for fourteen residents before the facility's own recordkeeping caught up with her. Key failures included:
- Medication administration records were not cross-checked against pain scores or clinical response, so falsified "administered" entries went unquestioned.
- No routine reconciliation compared the volume of narcotics withdrawn for a resident against what the resident's care plan and prescriber orders called for.
- The facility had no mechanism to flag a single nurse's involvement in withdrawals across an unusually high number of different residents' medications.
How It Could Have Been Prevented
- Cross-check documented narcotic administration against resident pain assessments and clinical response, flagging mismatches for review.
- Reconcile controlled-substance withdrawals against individual residents' prescribed regimens on a recurring, facility-wide basis rather than only when a complaint arises.
- Flag any single staff member associated with narcotic withdrawals across an unusually large number of different residents in a short period.
- Treat a conditional discharge or diversion-related plea by a licensed employee as grounds for mandatory reporting to the state nursing board, independent of the criminal case outcome.
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.
- Why Controlled Substance Count Reconciliation Stops Diversion — Closing the gap between dispensed and administered doses.
- More Diversion Case Studies — Additional documented cases of healthcare drug diversion.