Not so Nightingale
LPN at local nursing home charged with stealing pain medication from patients
A Tidioute woman is behind bars after allegedly stealing prescribed pain medication from more than 15 patients at a Warren nursing home.
According to investigators, that included switching liquid morphine prescribed to a terminally-ill cancer patient with a similar color of Gatorade.
Kellie A. Gentz, 30, 256 Thomas Lane, Tidioute, was charged by the Pennsylvania Attorney General on Thursday.
Investigators allege in the criminal complaint that Gentz “took… Morphine liquid pain medication (roxanol) and Fentanyl from a medication bottle prescribed to a cancer patient.” They indicate Gentz then took the morphine and “replaced the liquid with similar in color Gatorade to create a fraudulent inventory” before returning it to her medication cart.
Gentz also “administered liquid Gatorade as if (it) was morphine to a terminally ill cancer patient,” the affidavit states.
Investigators said Gentz “also withdrew controlled substances Hydrocodone, Oxycodone and Tramadol from an automated medication machine on 110 occasions without administering them involving 17 care dependent patients.” She “destroyed inventory records, re-sealed medication bottle seals and re-taped Fentanyl packages after using the medication.”
The AG’s office was contacted by the City of Warren Police and the Warren County District Attorney’s Office on January 25 for “investigative assistance” on an “information (that) indicated a nurse who was employed at the facility was suspected of stealing medications.”
The facility is the Kinzua Healthcare and Rehabilitation Center located at 205 Water St., Pennsylvania Ave. in Warren.
The affidavit of probable cause filed on Thursday indicates that City of Warren police were initially contacted regarding the investigations on January 23.
A complaint from the director of nursing at the facility “indicated the facility was missing two to three 30 milligram Morphine tablets and discovered two empty Fentanyl packages.”
Later that day, additional medications were discovered missing after the nursing director “reviewed dispensing reports.”
City police reported then that “Nurse Kellie Gentz was identified as the nurse who withdrew the medications and failed to document they were administered.”
Two days later, police learned that nursing home staff found “four bottles of liquid Roxanol (morphine) prescribed to a hospice cancer patient tampered with. The plastic cap seals appeared to have been cut and resealed with tape.” Police retrieved the bottles the next day where he was then told that two fentanyl patches were found to be missing. “The packages were sliced open on the back and were resealed with a small piece of tape…. Both the Fentanyl and Morphine discrepancies were discovered on a medication cart assigned to Kellie Gentz.”
The affidavit details the winding road that resulted in nursing home staff – and law enforcement – gathering enough information to bring charges against Gentz.
The following narrative comes from the affidavit.
On January 20, nursing home staff discovered missing morphine tablets prescribed to a 91-year-old diagnosed with osteoarthritis. The nursing director said a supervisor reported that three morphine tablets prescribed for that patient “were missing from the medication cart.”
The pills were not located during a “med round,” when medications were dispersed to patients. At that point, staff began a search of the facility.
Shortly after that, the supervisor told the director that “the Morphine medication inventory sheet was also missing from the medication cart.”
The facility reached out to their medication supplier who was able to “confirm the medication discrepancy” happened at the Kinzua facility. “The correct amount of Morphine was prescribed… (and) was properly filled with the correct amount and was delivered to Kinzua….”
The nursing director contacted each of the nurses who worked during the previous day “and was still unable to locate the three missing morphine pills.”
A medication count on January 19 conducted by Gentz and another nurse turned up correct counts. The director said the morphine may or may not have been counted “due to the inventory sheet and medications both completely missing.” The director “reported when the Morphine inventory sheet was removed or missing from the medication cart, the oncoming nurse would not have knowledge the medication previously existed therefore she would not look for a medication to count.”
On the 20th, the director contacted all of the nurses who worked with that medication cart “to return to the facility to submit to urinalysis drug testing.” Three returned and tested negative. Gentz allegedly did not respond to five to 10 calls plus voice messages and text messages.
Gentz allegedly contacted the facility the next day and said she could not come in for the drug test because her son was sick. She reported to work the following morning and “started to perform her regular duties until she was stopped and questioned about the missing morphine.”
The supervisor on shift reported “Gentz denied taking the medication and submitted to a urine test with a negative result.”
The nursing director then contacted the medicine supplier to request dispensing reports from October 3, 2017 to January 23, 2018. The director then said the reports revealed that “Gentz had been withdrawing lots of medications from the ADU (automatic dispensing unit) machine for patients who were not her patients, who were never her patients that resided in a different wing of the facility.”
The nursing director reported “Gentz was pulling medications for approximately twenty-one patients she wasn’t assigned to,” medications including oxycodone, hydrocodone and tramadol.
Gentz was called into a meeting with nursing home staff, the nursing director reported, on January 23.
The nursing director “stated Gentz broke down and started crying and stated, ‘It was me. I relapsed.'” A supervisor said Gentz admitted to taking the morphine.
“Gentz provided a written statement indicating she took five Morphine tablets, two Fentanyl Duragesic patches and removed several medications from the ADU machine without administering them to patients.”
The investigator reported in the affidavit that they reviewed the dispensing reports.
“The controlled substance medications withdrawn by Kellie Gentz not documented as administered to patients occurred 110 times involving 17 different patients.”
That wasn’t all that was uncovered, though.
According to the affidavit, two empty bottles of morphine were discovered that were prescribed to an 89-year-old female patient suffering from laryngeal cancer.
The patient had been at the facility for approximately one week before she was ultimately transferred to UPMC Hamot “in the attempt to regulate and manage her pain,” investigators state in the affidavit.
The nursing director reported that the patient returned to the facility on January 5 and her “pain began to increase again” and her dosages were subsequently increased.
The director told investigators that Gentz was “suspended from employment” on January 23 and that, on the 24th, a new shipment of morphine was received and two dosages were administered to the patient. The patient then “was reported to be in a sedated state and described very sleepy and passed out.”
At that point, the director reported, it was “realized the previous bottles of Roxanol were tampered with” and two more bottles were found with tampered seals.
The director reported that “the liquid in the bottles smelled like sweet cough syrup” but that “Roxanol (morphine) has almost an odorless medication smell.”
The affidavit states that two additional foil packs of fentanyl were discovered on the 25th “and were observed to have been opened with a cut on the back of the package, with the patch removed and resealed with a small piece of tape.”
The nursing director reported contacting Gentz on January 28 “to collect a more detailed statement” and “Gentz admitted to removing the Roxanol from the bottles and replaced the liquid with strawberry Gatorade” and “stated she removed seven milliliters of Roxanol and replaced it with seven milliliters of Gatorade.”
Another altered bottle of morphine was discovered on Feb. 4 and a subsequent lab test of the substance was found to be diluted, according to the affidavit.
The investigator reported that they spoke with Gentz on May 22.
“Kellie Gentz reported she was previously employed at Kinzua Healthcare in Warren and she was employed there on and off (between 2008 and 2018) as a licensed practical nurse,” the investigator wrote in the affidavit. “Gentz stated she withdrew medications from the machine and took them without administering them to the individual patient. Gentz stated she mainly withdrew Vicodin and Percocet…. Gentz stated she utilized her own user name and password to access the machine and provide the access information,” admitting that the conduct occurred between the middle of November 2017 and January 23, 2018.
“Gentz stated she usually used the medications while she was working and sometimes took them home for her own personal use later. Gentz stated she removed the medications from their package, consumed them and then shredded the packages.”
The investigator told her how many times medications were withdrawn and not documented administered to a patient. “Gentz reported it was possible she withdrew that amount,” the affidavit states, “she didn’t keep track of how many times. Gentz stated she withdrew medications using several different patient names. Gentz stated she just picked patients who were prescribed narcotics.
“Gentz stated she took Fentanyl, Roxanol and Morphine from her assigned medication cart. Gentz stated when she took Morphine from the cart, she removed the entire inventory sheet along with the medication as if the medication never existed. Gentz stated the Fentanyl she took was in patch form. The patches were twelve microgram patches and she used the Fentanyl by chewing on the patches.”
According to the affidavit, Gentz also stated that “she drank the Roxanol and then replaced it with strawberry Gatorade. Gentz stated that she purchased strawberry Gatorade because it looked just like the Roxanol. Gentz stated she usually would drink half the bottle and then replaced it with the Gatorade…. Gentz acknowledged she was aware that the diluted Roxanol was then administered to a patient.”
The investigator wrote that they asked Gentz if she “knowingly” gave diluted Roxanol to the patient and “she stated yes” but was unable to remember how many times.
“Gentz acknowledged knowing (the patient) was in poor condition with a diagnosis of cancer. Gentz also acknowledged (the patient) was experiencing pain due to her medication condition, aware she was transferred to another facility to manage her pain levels.”
In late July, the investigator reported interviewing that patient’s daughter.
She said that they knew her mother’s cancer was terminal from the beginning, described her mother’s pain as “horrific” and “described her mother’s condition as having a hole in the side of her jaw that was intensely painful.”
After returning to the facility following her hospitalization, the daughter told investigators that her mother “was crying because the pain was so severe” and reported that “a hospice nurse told her she couldn’t be in pain because of the dosage they gave her.”
The daughter reported that she took her mother out of Kinzua on January 26 and that she died the next day.