School nurse under scrutiny for mishandling student meds previously investigated

The former school nurse of Kingston Intermediate School will be asked to turn in her license, pending the conclusion of an investigation by the state’s Board of Registration in Nursing.

Earlier this month, the Board recommended that nurse M. Provenzano’s license be suspended for an “indefinite period with reinstatement requirements,” following two complaints by parents who alleged their children’s medication was either missing or improperly administered by the nurse.

25 Investigates first reported about the medication irregularities at Kingston Intermediate School (KIS) in September. Provenzano was the school nurse at KIS from August 2014 to June 2019. Now, new state documents reveal the nurse had been previously investigated for mishandling medication at a previous job.

Investigative reporter Ted Daniel reviewed more than 700 pages involving three separate cases against Provenzano. The documents were part of a public records request and date back to 2014, the year she was hired at KIS.

According to the documents, the state was actively investigating a case against Provenzano when she took the job of school nurse in August 2014.  It involved the “wasting,” or disposal of unused quantities of medication during her employment at Shriner’s Hospital for Children in Boston, where she specialized in the care of pediatric burn patients.

The Board was investigating for multiple irregularities involving the powerful opioid Morphine, according to a 207-page file reviewed by 25 Investigates.

In one instance, Provenzano gave a burn patient a prescribed 6 milligram dose of liquid Morphine from a 10-milligram cup but, “failed to document any administration or waste of the remaining 4 mgs,” reads the complaint.

In another case, involving a second patient, “the quantity of Morphine….removed from the Omnicell exceeded the amount ordered by the physician.” In a third incident, she “removed Morphine [from the Omnicell]…contrary to the physician’s order.”

Omnicell is an automated medication dispensing machine used by many hospitals to store, manage and track controlled substances, including Morphine.

“If there is a continued pattern that usually raises more questions,” said Todd Brown, vice chair of the Department of Pharmacy and Health Systems Science at Northeastern University. “But sometimes it’s a system issue. If the system doesn’t change to address the problem, there are some concerns there also.”

Provenzano left Shriners in March 2014. In a statement she tells 25 Investigates she “chose to pursue a position that could better accommodate [her] home/work/life balance.” Additionally, she points out that “in the almost six years since leaving Shriner’s Hospital [she has] continued to receive only positive and accurate references from the hospital/staff about [her] work there as a nurse.”

But the documents obtained by 25 Investigates tell a different story.

Provenzano reported to a state Nursing Board investigator that she was told “she would be terminated if she did not resign” from Shriners. The report goes on to say that a supervisor and a human resources representative advised her that “a resignation would be easier as [she] looked for new jobs, and subsequently would not tarnish her nursing record as it would it [sic] be investigated by prospective employers.”

According to Brown, the expert from Northeastern University, it is good practice for employers to ask prospective employees if they are under state investigation particularly “if they are handling controlled substances and medication that can be abused.”

25 Investigates asked the superintendent of the Silver Lake Regional School District, which Kingston Intermediate is a part of, whether she knew about the Shriner’s investigation prior to hiring Provenzano. Citing “personnel matters,” Superintendent Joy Blackwood declined to answer, but added that Provenzano was a Kingston Intermediate School (KIS) employee and not a district employee. We confirmed with the state Nursing Board that a potential employer could obtain that information with a phone call.

The Nursing Board eventually dismissed the Shriner’s complaint with a cautionary letter and no formal disciplinary action was ever taken.

In 2019, Provenzano became the target of two more state Nursing Board investigations involving suspected “Drug Violations” at KIS. The cases involved stimulants like Adderall and Ritalin.

This past summer we spoke to a KIS mother who asked to remain anonymous to protect her son’s privacy. She told us that not only did her son’s pills disappear, but they were replaced with another medication, putting him at risk. Her son was a third-grader at KIS when, she says, she discovered the discrepancy. His doctor had prescribed him two daily doses of the stimulant Adderall to treat his Attention Deficit Disorder or ADD.

“There were six other pills that did not belong in that bottle, and it was medicine that he was never prescribed. Ever!”

Instead of Adderall, she says the school nurse gave him Focalin, a different drug used to treat ADD. The tablets are very similar in color and size.

“You start losing your mind because you are like ‘there is no way I can be out already,'” said the mom. “But you know you just have to keep turning them in because they say you are out.”

Kingston Police investigated the medication discrepancies at KIS. Incident reports indicate police found “No Crime Was Involved” at the school.

In an email response to 25 Investigates’ original story back in September, Provenzano’s attorney, Mark Stern, said that “investigations were conducted by the school, the Bureau of Health Professionals Licensure, and the Police. None of those investigations determined that she had in fact done that of which she was accused.”

He added that his client was on medical leave when the most recent incident was reported at KIS in the Spring of 2019. In response to the latest story, Stern said his client was only guilty of “incomplete record-keeping.”

The state Nursing Board recently offered Provenzano “an agreement to surrender her license for an indefinite period with reinstatement requirements including a standard post-surrender probation period that may be necessary for the public health, safety and welfare.”