What Happened
Joanna Dacri, a nurse at a nursing care facility in Worcester, Massachusetts, stole oxycodone tablets prescribed to three patients and covered her tracks by substituting look-alike pills.
From February to June 2014, Dacri stole numerous oxycodone tablets prescribed to three separate patients at the facility. To keep the theft from being noticed, she surreptitiously replaced the missing oxycodone with other, similar-looking tablets — specifically antihistamine and antidepressant pills — so the patients' medication counts and pill appearance would seem unchanged.
Dacri pleaded guilty on November 5, 2015, to one count of acquiring and obtaining oxycodone by deception. The charge carried a maximum sentence of four years in prison, one year of supervised release, and a $250,000 fine, with sentencing scheduled for January 29, 2016.
What Went Wrong
A nurse was able to substitute look-alike pills for stolen oxycodone across three patients for months before the scheme surfaced. Key failures included:
- Pill appearance was relied on as a proxy for identity verification, with no routine confirmation that dispensed tablets matched the prescribed medication.
- Medication counts for individual patients were not reconciled closely or frequently enough to catch a pattern of substitution across multiple residents.
- No witness or second-check requirement existed for administering or counting Schedule II medications to these patients.
- There was no mechanism to detect that patients receiving oxycodone were not getting adequate pain relief, which can be an early clinical signal of tablet substitution.
How It Could Have Been Prevented
- Require two-nurse verification and count for administration of Schedule II medications in long-term care settings.
- Train staff to recognize and escalate patient reports of unrelieved pain despite a documented opioid dose as a possible diversion signal.
- Periodically spot-check dispensed tablets against known imprint/appearance references for high-risk medications.
- Reconcile individual patient medication administration records against pharmacy dispensing records on a recurring basis, not only at audit time.
- Rotate medication-pass assignments to reduce any one nurse's sustained, unsupervised access to the same patients' controlled substances.
Related Guidance
- Diversion Prevention Checklist — Self-assessment covering witnessing, waste documentation, and administration controls.
- 15 Red Flags of Drug Diversion — Behavioral and transactional indicators including patient complaints of poor pain control.
- Patient Complaints: An Overlooked Signal — Why unrelieved pain reports can indicate diversion.
- Employee Screening & Fitness for Duty — DEA screening requirements (21 C.F.R. §1301.90) and pre-employment vetting for staff with controlled substance access.