$4.5 Million Fine for hospital where two nurses died of overdoses.

The University of Texas Southwestern Medical Center has agreed to pay $4.5 million to resolve allegations that its violations of the Controlled Substances Act allowed hospital staff to divert fentanyl and other dangerous drugs from the hospital, announced U.S. Attorney for the Northern District of Texas Chad E. Meacham.

The civil settlement – which also includes an extensive corrective action plan – is the culmination of a three-year-long joint DEA and U.S. Attorney’s Office investigation of UTSW’s handling of controlled substances, which began in December 2018 after two UTSW nurses overdosed on fentanyl and died at UTSW’s Clements University Hospital.  This marks the largest settlement involving allegations of drug diversion at a hospital in the state of Texas and the second largest in the nation.

These fines were levied after this report appeared in the Dallas Morning News in December 2018:

Patricia Norman, a nurse, lay in a bathroom stall, a syringe in her hand and track marks on her arm. She died from an overdose of fentanyl, a potent painkiller meant for patients.

Some 16 months later, a second nurse, Iyisha Keller, was found in a different bathroom at Clements, with a syringe in her arm. She had overdosed too, and died from the same drug.

Patricia Norman began showing signs she might be using drugs in 2016. Norman had worked in the cardiac intensive-care unit at Clements since early 2015.

Norman denied using drugs, her brother said. When he asked her about syringes and empty medicine vials he found in their apartment, Norman would say she’d forgotten to throw them away at work.

In May 2016, Highland Park police and paramedics responded to a call around 7:30 p.m. on Mockingbird Lane near the Dallas North Tollway, about three miles from Clements. Norman had worked that day. She was found unconscious inside her gray Honda Accord, along with a used syringe, records show. A bystander broke the car’s window to get Norman out; rescue personnel started CPR and Norman regained a pulse. When she awoke, she told paramedics she was using a prescription medicine for neck pain. She also said she had injected herself with an anti-nausea drug and taken some Xanax. The ambulance took Norman to Parkland Memorial Hospital’s emergency room, just down the street from Clements. Highland Park police did not investigate whether Norman had used illicit drugs, Lt. Lance Koppa said. As the officer at the scene saw it, no crime had occurred, Koppa said.

Less than two months later, Dallas police found Norman unconscious in her car, again after work and a few miles from Clements. A tourniquet was on her left arm and a needle was on her lap, records show. Rescuers again broke a window to get into Norman’s Honda. Records show that to revive her, they had to use naloxone — a drug used to reverse opioid overdoses. This time, rescuers took Norman to the emergency room at Clements. According to the police report, officers knew she worked there, and spoke to a supervisor about the incident. Dallas police took the needle and tourniquet to an evidence room and referred the case to their narcotics division.

Norman’s mother, Jeri Van, gave The News a medical report that Norman had submitted to a supervisor. The report, printed just a few hours after Norman got to the hospital, lists “Drug Overdose” in a section called “Chief Complaint.” According to the report, a urine test was negative for opioids, but experts say such tests are not always a perfect indicator.

Norman told her brother that her colleagues helped her keep her job, he said. She didn’t explain how. “They knew she was a hard worker,” Mark Norman said, “and they covered for her.” UT Southwestern said it would be inappropriate to comment on an allegation that didn’t include names or other details. Dallas police never pursued the case. A department spokesman said the syringe was empty, so there was nothing to go on.

Norman died six months later after overdosing in a Clements restroom, at age 32. She was discovered late in the evening, still wearing scrubs from her day’s work. Norman’s mother and boyfriend told investigators from the medical examiner’s office that she had been seeing a doctor for blackouts but that she wasn’t using illicit drugs. The medical examiner ruled her death an accident, due to an overdose of fentanyl.

UT Southwestern reported to state and federal regulators that on Dec. 15, the day Norman died, an employee stole fentanyl from the hospital.
CLEMENTS HOSPITAL DRUG THEFT REPORT (p. 1)
Selected portion of a source document hosted by DocumentCloud
This report shows the hospital reported “employee pilferage” of a vial of fentanyl, on the same day nurse Patricia Norman died in one of the hospital’s restrooms of an overdose. She was found wearing her work scrubs, with a syringe in her hand and track marks on her arm. UT Southwestern declined to identify the employee in the report.
University officials declined to identify the employee to The News.

According to state records, UT Southwestern told the Texas State Board of Pharmacy that the employee was a nurse. The university declined to comment on the pharmacy board’s findings.

After Norman died, university police obtained the syringe from her June episode, Dallas police records show. University officials said tests of the syringe came back negative for controlled substances.

Other details of UT Southwestern’s police investigation are unclear. In response to a request by The News, the university withheld 22 pages of a 25-page police report, citing state law.