H: Reporting Form Outlinesdocx DIVERTED DRUGS INITIAL REPORT SCREEN 1. 2. 3. we Occurrence date Format the date as, Occurrence time Please provide in military time format. Occurrence ?rst known date i This is the date that anyone in your facility/ agency became aware of the occurrence, not the date that the person responsible for reporting occurrences became aware. Reported by Reporter phone Report first received date This is entered by the system and can only be changed by a member of the Occurrence Team Report late reason If you have a reason for reporting an occurrence late, please include the information here. The determination regarding if an occurrence is reported late is made by the investigator, not the system. Initial Occurrence Report: Please provide a brief description of what is being alleged. REMEMBER, DIVERSION OF MEDICATION DOES NOT HAVE TO BE PROVED TO BE REPORTABLE. PAT INFORMATION (This is the only category that does not require a patient/resident/client.) 1. U) Patient/resident/cljent ID This is a unique identi?er. You can use a medical record number, the last four digits of a social security number, initials, or anything that would identify the individual to you if we were to contact you in the future. Gender . Age ALLEGED PERPETRATOR INFORMATION This screen is not available unless ?Yes? is checked concerning if a perpetrator is identified on the FACILITY ACTION screen. You will have two choices here, ?Add Patient/Resident? or ?Add Staff/Other?. Options for ?other? are included. PERPETRATOR INFORMATION (Patient/Resident/Client) 1. ID A unique identifier such as medical record number, last 4 digits of a Social 23 H: Reporting Form Outlinesdocx Security number, initials, or anything that would identify the individual to you if we were to contact you in the future about this person. 2. Gender 3. Age 4. Alleged perpetrator?s physical and cognitive status as it is relevant to the occurrence. (if you have chosen this perpetrator selection, you are reporting that a resident/patient/client diverted medications. If this is not the case, return to the Perpetrator screen and choose ?Staff/Other?. 5. Does the alleged perpetrator have a history of behavior problems? Yes or No If yes, please describe the behaviors. 6. Has the alleged perpetrator been involved in other diversion occurrences in the past 12 months? Yes or No If yes, enter the occurrence numbers and dates for all diverted drug occurrences. 7. Is there a care plan for the alleged perpetrator?s behaviors? Yes or No If yes, what is the care plan? 8. What changes, if any, were made to the alleged perpetrator?s treatment regime and/or care plan as a result of the occurrence? Provide a narrative. PERPETRATOR INFORMATION (Staff/Other) 1. Relationship to client The choices are: Staff Pool Staff Pool Family Visitor Other/Unknown (You must add information to a text box describing ?Other? or providing information as to why it is ?Unknown?. 2. Was the alleged perpetrator arrested or receive a citation? Yes or No or Unknown If known, what charges were ?led? THE FOLLOWING QUESTIONS ONLY PERTAIN TO STAFF PERPETRATORS 3. Is the staff member/pool staff licensed and/or certi?ed? If yes, what license/certi?cations do they hold? Please include the license/certification or QMAP ID numbers if known. Include the full name of the staff member/pool staff. WCLUDE THE FULL NAME OF THE STAFF PERSON even if they are not licensed, certi?ed, or have a QMAP ID number. 4. What actions were taken concerning the staff member/pool staff following the investigation? (For example: termination, increased supervision, or education). Please describe the actions. 5. Were reference checks completed on the staff member/pool staff? Yes or No 24 H: Reporting Form Outlinesdocx If yes, please describe any problems identi?ed in the reference checks. If not, why not? Were background checks completed on the staff member/pool staff? Yes or No If yes, please describe any problems identi?ed in the background check. If not, why not? Has the staff person/pool staff been involved in any other drug diversion allegations? Yes or No If yes, please describe. DESCRIPTION OF OCCURRENCE 1 2. 3. 4. Name, type and quantity of missing medication(s). How and when did the facility determine the medication was missing? Where was the medication kept at the time of the disappearance? Was the occurrence witnessed? Yes or No If yes, by whom? FACILITY ACTION 1. 2. 5? Date investigation started. Describe whom you interviewed and the results of the interviews. (If you report this occurrence to the police, please provide the name of the police department and the case number. There is no text box specifically for this information, so this box would be a good place to include the police information.) Provide a summary of patient/resident/ client interviews. Provide a summary of staff interviews. Provide a summary of family/other interviews. Describe the documentation you reviewed and the results of the reviews. Was drug screening of staff conducted as a result of the discovery of diversion? Yes or No If yes, what was the result? What was the conclusion of the facility? Include whether or not the allegation was substantiated, not substantiated, or inconclusive. Was any individual(s) identi?ed as the alleged perpetrator of the diversion? Yes or No If yes, the perpetrator screen will generate at this time. Were facility policies and procedures followed? Yes or No If no, please explain. What interventions were put into place to prevent a recurrence? Please describe. NOTIFICATIONS 1. Who was noti?ed? Please check all that apply: 0 Board of Nursing 25 H: Reporting Form Outlinesdocx 0 Medical Examiners 0 Pharmacy Board a Physician 0 Ombudsman 0 Family/ Guardian 0 Coroner Other (Describe or name other entity or agency noti?ed) a Pool Agency (Name of agency and phone number) 0 Police Department 26 COLORADO Department of Public Health 3 Environment Dedicated to protecting and improving the health and environment of the people of Colorado OCCURRENCE SUMMARY REPORT Facility: - CENTURA HEALTH-PORTER ADVENTIST HOSPITAL Initial Report ID: 10010424001 Date of Occurrence: 01/04/2010 Report Timely: Yes Type of Occurrence: Diverted Drugs DESCRIPTION OF OCCURRENCE: On 1/04/10 the facility determined a diversion of Hydromorphone had likely occurred. FACILITY ACTION: The facility conducted an internal investigation. The facility notified Drug Enforcement Administration and Pharmacy Board. The facility received a call from police, wWWa?membeLhadbem?ound deag J'mheL?apartmemiiere were nine vials of Hydromorphone in her apartment. The facility began an investigation. An audit of medical charts of patients this staff member had cared for was conducted. The investigation found numerous medications that were su5picious due to being undocumented or the frequency or dose was suspicious. They included Hydrocodone. Hydromorphone and Oxycodone. Interviews of patients revealed no complaints about the care the staff member had given and no complaints about pain management. The facility has made adjustments to their audit system and provided staff education regarding drug diversion. DEPARTMENT FINDINGS: The Department reviewed the facility's report and supplemental documentation and found that the facility acted appropriately by reporting the occurrence, notifying the appropriate persons and agencies, conducting an investigation, making adjustments to their audit system and providing staff education. No deficient practice was cited. The Department will review this occurrence prior to any survey or upon receipt of any complaint that may be filed against this facility. Date initial report sent to facility: 02/04/2010 FACILITY COMMENT: Following receipt of the above summary, no additional comments were submitted by the facility. Date initial report released to public: 02/18/2010 CENTURA HEALTH-PORTER ADVENTIST HOSPITAL 10010424001 DENVER POLICE DEPARTMENT NARRATIVE TEXT HARDCOPY 2011?484166 ACCEPTED BY DA - 3599?0 DRUG - PCS - OTHER DRUG ARREST MADE 0R CITATION ISSUED :u . o: \\9311'/ f?w? m: - n. - DRUG - PCS - OTHER DRUG DETECTIVE SUPP REPORT INITIAL Preliminary Investigation: [Notified of Diversion at Denver Health HOSpital by HR. Follow-up Investigation: [On Oct 7th, 2011, Denver Health Hospital male Nurse Shaun Fitzsimmons RN, was working in the Adult Unit at the Hospital from 19:00 23:00 hrs. A patient in his care was complaining of head pain at approximately 19:30 the patient had a scalp wound RN Fitzsimmons went to the Pyxis machine and withdrew one 5 mg tablet of Oxycodone at 19:48 He then documented in the Medication Administration Record that the patient received one tablet of 5 mg Oxycodone at 20:21 hrs. At approximately 23:40 hrs, RN Fitzsimmons had left for the evening and the patient approached the oncoming RN complaining that he was still in pain. The 2nd RN asked the patient when his last dose of pain medication was and he told her around 8:30 P.M. . The 2nd RN went to the Pyxis machine to withdraw Oxycodone for the patient and saw that Oxycodone was removed by Nurse Fitzsimmons at 23:37 hrs, after the time he was to have left the unit. The 2nd RN then checked the Medication Administration Record and noted that the only Oxycodone for the patient documented was at 20:21 hrs. This RN then went to the charge nurse who did a quick Pyxis machine report from 19:00 23:00 of Nurse Shaun Fitzsimmons Pyxis machine controlled substance with drawls and discovered that there were multiple narcotics removed on different patients which were not documented in the Medication Administration Record as being given to the patients. At this point, the unit manager, employee services and Pharmacy were called and Risk Management was paged. Nurse Fitzsimmons was notified via telephone that he was immediately being placed on investigatory leave. On Oct 10th, 2011 RN Shaun Fitzsimmons was interviewed by the unit manager and an employee service representative when he admitted to diverting 4 Oxycodone for his personal use. He wrote in his statement that he did not normally work a four hour shift but that Sunday, Oct 7th he did, He wrote that he took 5 tablets out of the Pyxis machine, gave one to a patient who was fixated with a For: M08019 Printed On: Apr?13-2016 (Wed.) Page 1 of 3 DENVER POLICE DEPARTMENT :59. NARRATIVE TEXT HARDCOPY 2011?484166 ACCEPTED BY DA - 3599-0 DRUG - PCS - OTHER DRUG ARREST MADE 0R CITATION ISSUED wound on his head and was delusional, and charted it, and kept the other 4 for his personal use. He stated he did not use it while working, but after his shift. He claimed he did not use the Oxycodone while at work or caring for patients. The final paragraph of his written statement RN Shaun Fitzsimmons wrote I would like to apologies for my mistake at this time. I understand the severity of what I have done. I have since contacted the Peer Assistance programs for enrollment. I wish to receive treatment, and hopefully save my license, so I can continue in the career I love On Oct 14th, 2011 the Pharmacy completed an audit of Nurse Shaun Fitzsimmons? Pyxis machine usage spanning the 13 months he was employed with Denver Health. It was discovered that there were many incidents where narcotics were removed for patients and not documented as having been given to the patient. On Oct 17th, 2011, Nurse Shaun Fitzsimmons was officially terminated from Denver Health and the HOSpital Authority. An audit conducted by the Denver Health Pharmacy found that during Nurse Fitzsimmons 13 month employment with Denver Health Hospital that 485 doses of controlled substance?s were checked out by Nurse Fitzsimmons and were not documented as being given to the patients and are unaccounted for. The controlled substances consisted of Oxycodone, Hydrocodone, Hydromorhone, Morhhine and which are all Federal Schedule II narcotics, along with Lorazepam, Clonazepam and Diazepam which are Federal Schedule IV narcotics. On Nov lst, 2011, Detective Terry Demmel 78007, who handles the prescription fraud and medical diversions for the Narcotics Bureau of the Denver Police Dept, went to Denver Health Hospital and met with RN Clinical Risk Manager Ann Marie Stuart who provided your affiant with copies of the audit and Nurse Shaun Fitzsimmons statement concerning the diversion of controlled substances by a medical professional. When Detective Demmel inquired as to the possibility that patients with severe pain issues were deprived of pain medications they were to receive, she answered Yes that does appear to be the case . Detective Demmel prepared an arrest warrant for the person of RN Shaun Fitzsimmons DOB 11/11/1977, Soc Sec for the offense of CR8 18?18?415 Obtaining Controlled Substances By Fraud Deceit; a Class 5 Felony, that was signed by Judge Andrew Armatas on Nov 7th, 2011 at 3:50 P.M. Judge Armatas put a $5,000 bond amount on the arrest warrant. Detective Demmel contacted Shaun Fitzsimmons by phone with Shaun being fully cooperative and agreeing to turn himself in. For: M08019 Printed On: Apr?13?2016 (Wed.) Page 2 of 3 7 DENVER POLICE DEPARTMENT NARRATIVE TEXT HARDCOPY 2011-484166 ACCEPTED BY DA - 3599-0 DRUG - PCS - OTHER DRUG ARREST MADE OR CITATION ISSUED On Nov 22nd, 2011 Shaun came to Police and surrendered himself as scheduled. He stated he was in a Nurses rehab program through the Nursing Board and was receiving treatment. He has no prior arrests. On 12/01/2011 Detective Demmel presented this case to the Drug Court D.A's who accepted the case for filing on Shaun Fitzsimmons DOB 11/11/1977 for the offense of CR8 18-18?415 1 Obtaining Controlled Substances By Fraud Deceit; a Class 5 Felony. Case Disposition: [Cleared By Arrest; Case Filed. Author:P78007 - DEMMEL, TERRY V. (Inactive) Related datezNov-30?2011 (Wed.) 953 END OF HARDCOPY For: M08019 Printed On: Apr-13-2016 (Wed.) Page 3 of 3