June 4 – State councils recently suspended the licenses of Cheshire Medical Center’s head nurse and two other staff after gallons of fentanyl solution disappeared from Keene Hospital, according to the NH Office of Professional Licensure and Certification.
The state medical licensing authority, which oversees the New Hampshire Boards of Pharmacy and Nursing, issued Chief Nurse Amy Matthews’ emergency suspension on May 26. She issued the emergency suspensions of chief pharmacist and pharmacy manager Melissa Siciliano and pharmacist Richard Crowe on March 30.
The documents ordering the suspensions indicate that hundreds of bags of fentanyl solution were stolen by a nurse. But according to the OPLC, neither Matthews nor Siciliano, whose license has since been reinstated, were involved in the theft.
Rather, the documents note the supervisory nature of their roles at the hospital and their responsibilities for safeguarding the controlled substances used there.
The document ordering the suspension of Matthews’ license states: “The loss of such a significant amount of fentanyl under its direction, even after the implementation of corrective measures, indicates that the licensee is negligent and/or negligent. in their work, so that they constitute an imminent threat to public health, safety or well-being”.
The document ordering Crowe’s license suspension says the OPLC investigation implicated him “as having played an essential role in the diversion and/or failure to report the diversion” of the fentanyl solution. He notes that he was responsible for reconciling controlled substance reports at Cheshire Medical between September and February.
A spokeswoman for the Federal Drug Enforcement Agency confirmed an ongoing criminal investigation into the lost fentanyl on Thursday. She declined to comment further on the investigation.
A Cheshire Medical Center spokesperson declined to answer emailed questions about the situation and only responded with a brief statement.
Fentanyl is a synthetic opioid used in the medical field for sedation and pain relief. It is 50 to 100 times more potent than morphine and highly addictive and dangerous when used illicitly, according to the National Institute on Drug Abuse.
Since September, more than 7 1/2 gallons of fentanyl solution from Cheshire Medical’s intensive care unit have gone missing, much of it stolen by the nurse, according to suspension documents. But not all of the fentanyl lost can be attributed to that theft, according to the documents, which indicate that hospital staff said a winter surge of COVID-19 also impacted record keeping related to the fentanyl and other drugs.
Around February 4, Alexandra Towle, a nurse in the hospital’s intensive care unit, said she stole fentanyl from Cheshire Medical Center, according to OPLC documents. Towle died in March.
A preliminary agreement not to practice that she signed on February 9 indicates that she stole 12 bags of fentanyl in October, 50 to 100 bags in November, approximately 100 bags in December and 200 bags in January.
She said in an email to an OPLC investigator that the drugs were for her own use to deal with work stress during the pandemic, but that representation differs from what she provided to the hospital in a separate email, according to an OPLC document. In that email, she said she gave 12 bags of fentanyl to a friend, the document says.
Between Jan. 31 and Feb. 4, the OPLC received complaints about the theft of fentanyl from the ICU, according to documents from that office.
On February 2, the OPLC received a controlled substance loss form and letter from the hospital, indicating that there were 23 bags, or 1,150 milliliters, of fentanyl solution that had been stolen, but that he expected those numbers to rise due to an ongoing internal investigation, the documents say.
In response to emailed questions to Siciliano, her attorney, Rick Fradette, said she became aware of the theft of fentanyl on Feb. 1 and reported it to the pharmacy board the next day.
Over the following months, the hospital submitted at least three updated lost controlled substance forms which, as of April 14, showed a cumulative amount of lost/unaccounted fentanyl solution totaling 583 bags, or 7.7 gallons. , all attributable to the period between September and January, according to OPLC documents.
OPLC investigators held a meeting with hospital staff on March 8, during which staff explained that the spike in critically ill COVID-19 patients during the winter surge resulted in the non- application of controlled substance procedures, according to the OPLC document restoring Siciliano’s license. .
Siciliano said she worked 50 to 60 hours a week before the flare-up, but more than 80 hours during it, the document says. She oversaw multiple machines dispensing a fentanyl solution that hundreds of professionals had access to, and some of the discrepancies in record keeping are also due to software changes made by the hospital, the document said.
Hospital reports from the time the fentanyl was stolen indicate that patients treated with the drug were still receiving their prescriptions, this document states.
In February and March, the hospital responded to the loss and theft of fentanyl by implementing corrective measures, including permanently locking down the medication room, training nursing and pharmacy staff in prevention and detecting theft and implementing a daily count of controlled substances, according to OPLC documents. .
After implementing those measures, the hospital submitted another controlled drug loss form showing that an additional 553 milliliters — or about 11 bags — of fentanyl solution had gone missing between April 10 and May 7, according to the documents, which indicate the hospital did not believe this fentanyl was stolen.
“Cheshire Medical Center continues to work closely with government agencies on the ongoing investigation into this matter, even as we review and refine our policies and protocols regarding the safe handling of pharmaceuticals,” the hospital said. in a statement emailed to The Sentinel. “Patient and employee safety is always our first priority, and we have a zero-tolerance policy regarding the diversion of any controlled substance.”
Citing an inability to comment on staffing issues, Cheshire Medical Center spokesman Matthew Barone declined to answer emailed questions that included whether Matthews, Siciliano or Crowe remained employed at the hospital. He also did not address questions about the medical uses of fentanyl solution at the hospital, the most recent total of fentanyl wasted, or how much of the drug the hospital had in stock at any given time.
The pharmacy board reinstated Siciliano’s license on April 20, according to the OPLC. But she has resigned from her duties at Cheshire Medical Center, as stated in a letter she sent to the Pharmacy Board dated May 25. She will remain employed at Dartmouth-Hitchcock, which is affiliated with the Cheshire Medical Center, as the clinical lead for the pharmacy services system, the letter says.
Matthews could not be reached for comment. An email sent to her Cheshire Medical Center address returned an out of office reply and attempts to reach her by phone were unsuccessful. Crowe also could not be reached for comment by phone or email.
The OPLC did not return multiple requests for comment on whether Matthews or Crowe appealed their license suspensions.
Ryan Spencer can be reached at 352-1234 ext. 1412 or [email protected] Follow him on Twitter at