Suspected Diversion by a Colleague
You are the LPN working a 1500–2300 shift. At 1830, three of the four patients assigned to RN Colleague report pain scores of 8–9/10 within an hour of receiving IV morphine that the colleague documented as "given, effective." The automated dispensing cabinet history shows the colleague removed 6 vials of fentanyl and 4 vials of morphine in the last 4 hours and documented "wasted" on 3 vials without a co-signature. Her speech is slurred, she is unsteady on her feet, and she asks you, "Can you sign as witness on these two wastes? I'm behind and I just need to catch up." She also offers to "take the pain meds off your hands" for your patients. The charge nurse is in a meeting off the unit and the house supervisor is covering three buildings. Your state requires nurses to report conduct that endangers patients.
1. What are your immediate priorities for the patients, and what will you do in the next 15 minutes?
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Patient safety comes before the colleague, the paperwork, and the awkwardness.
Assess all four of her patients now: pain level and response, level of consciousness, respiratory rate and depth, SpO2, blood pressure, and skin color. Assume the documentation is unreliable and that they may have received little or no analgesia - or an unknown amount. Give no additional opioid from anything she has handled; withdraw your own medications from the cabinet under your own login so the chain is intact, and treat their pain per the existing orders after assessment. If any patient shows respiratory depression or oversedation, stay with them, apply monitoring, and call the provider.
Ask a second licensed nurse to assist and witness your assessments. Do not leave her alone with medications or with access to the cabinet. Call the charge nurse and house supervisor now rather than waiting for the meeting to end - escalate to whichever supervisor can respond first.
2. How do you handle the request to co-sign the waste and the offer to medicate your patients?
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Refuse both, directly and briefly. Co-signing a witness statement for a waste you did not personally observe is falsification of a controlled-substance record; it exposes you to board discipline and, more importantly, it conceals a pattern that may be harming patients. Say plainly: "I can't sign for something I didn't see."
Do not let her administer any medication to your patients. If she is already preparing or holding medications for them, take them from her and re-verify against the orders yourself. Her judgment is impaired, and an error would be your responsibility as well as hers to report.
Avoid a public confrontation and do not accuse her of anything you cannot support, but do not delay escalation either. Speak quietly, keep her in view, and get another nurse or the charge nurse to the unit immediately. Move the waste vials and her keys out of reach by asking the charge nurse to take custody per policy.
3. Who do you notify, what do you document, and what are your legal and ethical obligations here?
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Notify the charge nurse and house supervisor immediately, then the unit manager and, per policy, pharmacy and security for a controlled-substance count and audit; many facilities also require an immediate drug screen. Your state requires reporting conduct that endangers patients, and the nurse practice act and board rules may also require referral to a peer assistance or impaired-nurse program. Treatment and licensing consequences are the board's role, not yours - but reporting is yours.
Document objective facts only: times, direct observations (slurred speech, unsteady gait), exact quoted statements, the request to witness a waste, the waste entries without a co-signature, your patient assessments and interventions, and every person notified with the time. Do not alter her records and do not access charts of patients you are not caring for.
Ethically, do not promise secrecy and do not gossip with staff. Confidentiality does not extend to protecting a colleague from the consequences of conduct that is harming patients. Do not confront her alone or abandon her in a way that delays patient care, and do not accept responsibility for tasks that require the license you do not hold.