MARION — A Grant County hospice facility has been cited by the state for reusing and relabeling medications from dead patients, according to a recently released inspection report.
The Indiana State Department of Health conducted a survey at Heart to Heart Hospice of Central Indiana, located at 1385 N. Baldwin Avenue in Marion, in the fall of 2021.
While at the Marion facility, the state found a cabinet of medications including controlled substances of both existing patients and deceased patients.
“Medications were found to be relabeled and reused by the hospice,” read the report.
The state found Heart to Heart Hospice failed to ensure patients received medications only from a pharmacy, failed to ensure medications were labeled correctly, and failed to ensure medications were disposed of properly, according to the report.
During a visit on Oct. 22, the state found in the cabinet a clear bag with about 20 doses of Ondansetron, a medication to prevent vomiting, with a laser label made for a patient.
“Upon peeling back the laser label, a blacked out name can be observed but not the full name of the prior patient,” read the report.
The state asked why anyone in the agency had ever relabeled medications or improperly labeled them.
Former Administrator A indicated, "I have not relabeled them, but the count is right," and Former Patient Care Manager B told the state, "The meds were needing to be destroyed. Some families bring them in (sic)."
On Oct. 22, the state found multiple medications with deceased patients’ names on them including a brand new, sealed bottle of liquid morphine.
The state found it was given to an existing patient with leukemia, records show.
In a review of patient charts, the state found more than 20 patients where the facility failed to indicate the “type, strength, and quantity of the narcotics disposed.”
Dr. Veronica Vernon, an assistant professor of pharmacy practice at Butler University’s College of Pharmacy and Health Sciences, said health care facilities are required by law to properly dispose of medications.
“Per Indiana law, relabeling medications is not permitted,” Vernon said. “There’s only a few small exceptions to this rule.”
Dr. Vernon said the first reason it’s a bad idea to reuse medications is because it can result in errors.
“You may think you’re reading the label properly and that it’s saying it’s morphine 10 milligrams, but then during the relabeling process it could get relabeled as morphine 5 milligrams and that could lead to an error,” Vernon said. “Another error that can occur is the drugs could expire and that could be missed. And so an expired medication could be used for a different patient, which is of grave concern.”
Heart to Heart Hospice agreed to a plan of correction which included additional educational for staff members about proper storage and disposal of medications, looking for any improperly stored medications, and drug tests for staff.
All staff were cleared as a result of the drug tests, but one staff member walked off the job following a urine drug screen and did not follow up with additional laboratory testing, according to the report.
On Oct. 28, both Patient Care Managers at Heart to Heart Hospice in Marion resigned their positions effective immediately.
The Executive Director’s employment was terminated on Nov. 11 after completion of the internal investigation, records show.
“Investigations of hospice agencies are referred to the Centers for Medicare & Medicaid Services for appropriate enforcement regarding the violation of any federal regulations,” the Indiana State Department of Health said in a statement to WRTV, “The Indiana Department of Health can also issue additional fines regarding the violations of state regulations.”
This case is currently under review by IDOH, according to the agency.
On Dec. 6, the executive director and two patient care managers were reported to the State Attorney General in accordance with the Indiana State Board of Nursing.
WRTV Investigates reached out to both the Attorney General and the Indiana State Board of Nursing to find out if they have filed complaints against any former Heart to Heart Hospice employees.
The Indiana Attorney General declined to provide any information to WRTV about the case.
“I would call this a close call where a medication error could have occurred, or something very bad could have happened,” Vernon said. “Hopefully the patients were not hurt by this. Seven thousand to 8,000 patients die every year from medication errors across the country.”
WRTV Investigates called and emailed the Marion facility several times, but a worker who answered the phone directed WRTV to their office in Texas.
WRTV Investigates also called and emailed Heart to Heart Hospice in Plano Texas, but we have not yet heard back.
It does not appear any criminal charges have been filed.
The Grant County Prosecutor told WRTV he has not received any complaints about the facility, and the Marion County Police Department says it does not have any investigations — active or closed — in regards to the facility.
As part of the plan of correction, an area executive director or area clinic manager will audit 100% of all death discharges, medication transportation logs and all medication incidents monthly for three months until 100% compliance is met.
What To Do With Unwanted and Expired Medicine
There are several options for Hoosiers to properly dispose of unwanted and expired medications according to the state of Indiana:
- Unwanted medications may be taken to your local unwanted medicine take back collection site. Additional locations may also be found from the Drug Enforcement Administration’s Controlled Substance Public Disposal Locations Search Utility.
- Many of Indiana's local household hazardous waste collection programs accept unwanted medicine. Some counties hold household hazardous waste collection days, where prescription and over-the-counter drugs are accepted at a central location for proper disposal.
- Some pharmacies offer for sale postage-paid envelopes that are used to mail in non-controlled substances for disposal.
- Most take back sites do not accept syringes for destruction. Information on proper needle disposal is available on the Household Needles and Sharps page.
- Preferred disposal methods vary based on the given medication(s).
- School nurses who are in possession of leftover and unclaimed medications should seek assistance from the school-based law enforcement officer (such as the school resource officer) and the school contact for waste disposal. Additional information is available on the Disposal of Unused Medication in Schools fact sheet (available on the IDEM Fact Sheets page).