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The search warrant served on Bradford Regional Medical Center in early March has been unsealed by McKean County Judge John Pavlock — and it details allegations of a nurse anesthetist allegedly misappropriating medication, fabricating patient records and practicing while impaired.
The nurse, Joan Carl, was employed by Gulfstream Anesthesia and working within BRMC during the times mentioned in the affidavit of probable cause for the search warrant. Carl has not been charged with any crimes.
She is still listed on BRMC’s website as a certified registered nurse specializing in anesthesiology.
Gulfstream Anesthesia did not return a message seeking comment; neither did a spokesman for state Attorney General Josh Shapiro, whose office conducted the search. BRMC spokesman Dennis McCarthy said hospital officials have not heard from the attorney general’s office since the search took place.
“Bradford Regional Medical Center has just seen the full version of the warrant and affidavits relative to the search warrant executed by the Pennsylvania state attorney general’s office at BRMC March 8,” McCarthy said. “We will not publically discuss allegations, legal documents, internal operations of the hospital or oversight visits by third-party organizations, particularly in the absence of any formal findings.”
According to the affidavit, an agent with the attorney general’s office met with a drug diversion investigator of the federal Drug Enforcement Agency, along with an investigator from the Pennsylvania Department of State professional conduct section regarding a complaint about Carl.
The DEA investigator said Carl has a “prior record of discipline regarding her nurse license in the state of North Carolina involving the drug Toradol” (an anti-inflammatory drug), the affidavit reads.
The investigators met with the director of the pharmacy at BRMC, Tom Kreiner, who said he had reported numerous incidents of suspected impairment and controlled substance record discrepancies involving Carl to operating room supervisor Shannon Weikart, the affidavit reads.
He reported to investigators that a technician had found a syringe labeled fentanyl with the initials JC on it in the locker room. The syringe was taken to Kreiner, who sealed it in an envelope and gave it to an administrative secretary at the instruction of Dr. William Mills, chief medical officer, the affidavit reads.
When Kreiner asked about it later, he was told it wasn’t any of his business, he told investigators. He said Carl was suspended in November 2016, but “remains on the job and continues in her duties” as of Jan. 31. He provided to investigators an email from a nurse that said she was in the operating room with another nurse anesthetist when Carl entered, put a vial of medication in her pocket and left the room. When the nurse asked about it, the other anesthetist said it was Toradol and Carl had taken it to make the “counts right,” the affidavit reads.
A chart of alleged medication errors by Carl was created by Kreiner, showing 30 instances from November 2015 to January 2017 in which discrepancies existed. According to the affidavit, the alleged errors included dispensing more medication than necessary for a patient and not recording disposal of the excess, using fentanyl on the wrong patient and dispensing pain medication for one patient and using it on another.
During the same time frame, the three other anesthetists had a total of 14 discrepancies, the affidavit reads.
Kreiner said monthly dispensing reports went to Weikart, and noted “that Joan Carl was the highest dispenser each month,” the affidavit alleges. He said Jeff Zewe, chief operating officer of the hospital, knew about the allegations and had been the one who suspended Carl in November 2016.
Several witnesses told investigators they saw Carl appearing to be impaired while in the operating room, “wrapped in a blanket, swaying from side to side, stumbled and could barely keep her eyes open,” the affidavit reads.
This was reported to Weikart, who, one witness said, “did not move or seem interested,” told them to go and did not go to the operating room to see what was happening, the affidavit reads.
A witness reported that staff had approached Mills and Zewe to talk about Carl’s behavior and to air their suspicions that she might be under the influence, but were told it was “not in the contract with Gulfstream to drug test Joan Carl,” the court records read.
A nurse who spoke with the investigators said she had seen an anesthesiologist give a vial of epinephrine to Carl after a surgery, and saw her take lidocaine as well. She also reported she had seen Carl “fabricating patient vital signs” during an operation, filling out the paperwork in its entirety before checking to see what the vital signs actually were, the affidavit reads. The nurse said she had provided the information to Tim McNamara, senior vice president of human resources for BRMC.
One witness explained an anesthesia monitor used during procedures would keep records during a procedure, but Carl’s handwritten records didn’t match. She added that Carl had been deleting the records on the machine as soon as the procedures were completed, court records read.
A nurse interviewed by investigators said she noticed during a surgical procedure that the blood pressure monitor was not working. She and another nurse noticed the monitor was not connected to the cuff, and the cuff was not properly placed. However, Carl’s patient anesthesia record had recorded numbers on it. A printout from the machine and Carl’s record were both given to Weikart, the affidavit alleges.
A nurse in the recovery room at BRMC reported Carl’s patients often had the need for additional care, and lacked adequate care while being treated by Carl. She reported seeing Carl’s patients “climbing off carts and crying in pain” when Carl had allegedly just administered fentanyl to them. Another case she reported was of a patient who had no respiration, and that Carl hadn’t noticed, although she was sitting next to the patient, the record reads.
The investigators reported the need to seal the search warrant, saying the witnesses interviewed feared retaliation from BRMC and Gulfstream officials.
While officials with BRMC did not comment on specifics of the allegations, they did provide information on accolades from various agencies for its efforts in quality, safety and best practices.
“Patient quality and safety at BRMC is the first priority and the hospital takes great pride in its efforts to ensure that each and every patient receives safe, effective care and has consistently performed at a high level relative to reviews by The Joint Commission (which accredits hospitals) and other third-party organizations,” McCarthy said. “Robust process improvement initiatives and audits involve physicians and staff at every level of the organization and in every department. These efforts include monthly quality and safety internal reviews, daily internal audits of departments and inspections by multiple agencies including The Joint Commission, Department of Health, Centers Medicare and Medicaid Services (CMS), DEA and Office of Pharmacy Affairs (a division of Health Resources and Services Administration).”
McCarthy continued, “BRMC is performing at the 94th percentile nationally according to an independent organization which measures quality, safety and best practices. The hospital’s efforts to put in processes, audits and improvement initiatives to safeguard patients is ahead of many other hospitals in the region. Quality and safety is regularly reviewed by the Quality Committee of the BRMC board of directors as well as at the monthly board of directors meetings.”
He recounted further accolades for safety as well.
“In 2016, for the second consecutive year Bradford Regional Medical Center received the ‘Safety Across the Board’ Excellence Award from The Hospital Association of Pennsylvania,” McCarthy said. “This award recognizes the hospital’s exceptional performance relative to reducing preventable patient harm. Of 109 eligible Pennsylvania hospitals, BRMC was one of only 33 hospitals to earn this award.”
Another honor in 2016 was given by Highmark Blue Cross Blue Shield, which announced that BRMC was designated as one of the first hospitals to receive the Blue Distinction® Center+ for Maternity Care designation. Hospitals that receive a Blue Distinction® Center+ for Maternity Care designation agree to meet requirements that align with principles that support evidence-based practices of care, McCarthy said.
He concluded, “The hospital is focused on delivering high quality, safe care, to the Bradford community and we are proud of the skilled clinicians, physicians and support staff who provide great care to our patients every day.”