by Alice Benjamin, MSN, ACNS-BC, FNP-C
HARTFORD, Conn. – A former nurse at the West Haven VA Medical Center has been sentenced to two years of probation, including six months of home confinement, for diverting narcotics intended for veterans in her care. Tara Severino, 58, pleaded guilty to obtaining controlled substances by fraud or subterfuge after a federal investigation uncovered disturbing misconduct in the facility’s Intensive Care Unit (ICU).
The case, prosecuted by Assistant U.S. Attorney Christopher Lembo, sheds light on the vulnerabilities in controlled substance management in healthcare settings and underscores the importance of safeguarding patient care.
A Pattern of Abuse
Severino, who worked as a registered nurse in the ICU for critically ill or dying patients, was found to have ingested fentanyl, hydromorphone, and oxycodone meant for her patients. According to court documents, she repeatedly misappropriated narcotics over a six-month period, from January to July 2023.
In one particularly egregious instance, Severino administered fentanyl to a brain-dead patient 19 times over nine days, claiming she observed signs of pain and seizures. Investigators revealed that her primary motive was to divert portions of the narcotics for personal use.
Severino also consumed “waste” from partially administered doses, falsified medical records to conceal her actions, and in some cases, volunteered to care for patients not assigned to her in order to access their medications. This misconduct not only violated ethical and legal standards but also compromised patient care, as other medical staff unknowingly made treatment decisions based on the false assumption that patients had received prescribed doses.
Impact on Patients and Families
The ripple effects of Severino’s actions are profound. Pain management for dying veterans was compromised, with some patients likely left under-medicated in their final moments. Medical staff made decisions based on falsified records, which could have affected overall care plans. Families, trusting that their loved ones were receiving compassionate and adequate care, were left betrayed.
“This case is a stark reminder of the critical need for transparency, accountability, and robust systems to prevent diversion in healthcare settings,” said Vanessa Roberts Avery, U.S. Attorney for the District of Connecticut, in a statement.
Investigative Efforts
The misconduct came to light through the efforts of the Department of Veterans Affairs Office of Inspector General, with assistance from the DEA New Haven’s Tactical Diversion Squad and the West Haven Police Department. Severino’s actions, which included falsifying documentation and tracking systems, highlighted significant gaps in the monitoring of controlled substances.
Systemic Lessons from the Case
The case raises important questions about how controlled substances are managed and monitored in healthcare facilities, particularly those serving vulnerable populations like veterans. While the West Haven VA Medical Center is now under heightened scrutiny, similar vulnerabilities could exist in other facilities.
Healthcare organizations must implement strict safeguards to prevent drug diversion, including:
- Automated Systems: Utilizing advanced medication dispensing systems that track narcotics in real time, flagging irregularities immediately.
- Regular Audits: Conducting frequent, unannounced audits of controlled substances to identify discrepancies.
- Mandatory Reporting: Establishing clear protocols for reporting suspected diversion without fear of reprisal.
- Staff Education: Training all staff to recognize the signs of substance misuse among colleagues.
- Support Systems: Providing resources for healthcare workers struggling with addiction, as untreated substance use disorders can lead to incidents like this.
What Families and Patients Can Do
While families often assume healthcare providers will adhere to the highest ethical standards, there are steps they can take to ensure their loved ones are receiving appropriate care:
- Ask Questions: Stay informed about the medications your loved one is prescribed. Don’t hesitate to ask why a specific drug is being administered or request clarification about dosages.
- Monitor Behavior: Pay attention to changes in your loved one’s pain levels, sedation, or alertness. If something feels off, voice your concerns to the care team.
- Request Oversight: If a nurse frequently volunteers to care for your loved one, it’s okay to ask for more information or to have additional oversight from other staff members.
- Keep Records: Maintain a personal log of medications administered, especially in long-term or critical care situations. This can help identify discrepancies if something seems amiss.
- Report Concerns: If you suspect unethical behavior, report it immediately to the hospital administration or patient advocacy office.
A Broader Call to Action
This case serves as a wake-up call for both healthcare providers and policymakers. With rising rates of substance misuse among healthcare professionals, systemic changes are urgently needed to protect patients while addressing the root causes of addiction in the workforce.
For veterans and their families, the betrayal of trust in this case is immeasurable. Yet it also shines a light on the critical importance of vigilance and accountability within healthcare systems. As more facilities adopt stricter protocols and as families become more empowered advocates for their loved ones, the hope is that such incidents become a thing of the past.
If you or someone you know suspects drug diversion in a healthcare setting, it’s important to act. Contact the facility’s patient advocacy office, risk management department, or compliance hotline to report your concerns. Additionally, local authorities and regulatory bodies, such as state health departments or boards of nursing, can assist in ensuring accountability and patient safety. Patients and families can also seek support from organizations dedicated to patient advocacy to protect their loved ones and promote ethical care practices.
