Healthcare Crime Investigating Abuse, Fraud, and Homicide by Caregivers Healthcare Crime Investigating Abuse, Fraud, and Homicide by Caregivers Kelly M. Pyrek Boca Raton London New York CRC Press is an imprint of the Taylor & Francis Group, an informa business CRC Press Taylor & Francis Group 6000 Broken Sound Parkway NW, Suite 300 Boca Raton, FL 33487-2742 © 2011 by Taylor and Francis Group, LLC CRC Press is an imprint of Taylor & Francis Group, an Informa business No claim to original U.S. Government works Printed in the United States of America on acid-free paper 10 9 8 7 6 5 4 3 2 1 International Standard Book Number: 978-1-4398-2033-9 (Hardback) This book contains information obtained from authentic and highly regarded sources. Reasonable efforts have been made to publish reliable data and information, but the author and publisher cannot assume responsibility for the validity of all materials or the consequences of their use. 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Table of Contents Acknowledgments xi Introduction xiii 1 Healthcare Trends, Stressors, and Workplace Violence 1 Stressors of Healthcare and Workplace Violence 6 When Healthcare Professionals Are the Abused 8 When Healthcare Professionals Are the Abusers 13 Breaking Professional Boundaries 18 References 22 2 Patient Privacy and Exploitation 25 Exploitation via Photography 34 Exploitation via Cell Phone Photos 34 Exploitation via Internet Improprieties 38 Exploitation via Medical Records Snooping 39 The Impact of Patient Privacy Breaches 41 Is Patient Privacy a Fallacy? 42 References 44 3 Abuse and Assault 47 How Patients Are Abused by Healthcare Providers 47 Who Is Abused: Victimized Patient Populations 50 Disabled Patients 50 Psychiatric Patients 54 Elderly Patients 59 Who Are the Abusers: The Victimizers 62 Physicians 62 Psychiatrists 64 Dentists 66 Pediatricians 68 Nursing Assistants and Aides 70 Reporting, Regulating, and Prosecuting Abuse 73 References 75 vii viii Table of Contents 4 Fraud and Theft 81 Extent and Impact of Medical Fraud 81 Healthcare’s Complexity Encourages Fraud 83 Perpetrators of Fraud 88 Individuals 88 Organized Criminal Groups 91 Victims of Fraud 92 Investigations and Antifraud Programs 94 Crime and Punishment, Deterrence and Prosecution 98 The Future and Recommendations for Fighting Fraud 101 Four Faces of Fraud 106 Fraud 1: White-Coat Crime: The Medical Criminals 107 Fraud 2: Financial Abuse of Vulnerable Populations 110 A Word about Home Healthcare 115 Fraud 3: Medical Identity Theft 116 Fraud 4: Substance Abuse and Drug Diversion 122 Physicians 123 Nurses 124 Substitution 128 Forgery 129 Partial Administration 130 References 137 5 Suspicious Death and Homicide 141 Healthcare Serial Killers: An Overview 141 The Medical Murder Hall of Shame 144 Physicians 144 Harold Shipman 144 Michael Swango 145 Nurses 145 Beverly Allitt 145 Richard Angelo 145 Charles Cullen 145 Robert Diaz 145 Vickie Dawn Jackson 146 Kristen Gilbert 146 Gwendolyn Graham and Catherine Wood 146 Genene Jones 146 Orville Lynn Majors 146 Filipina Narciso and Leonora Perez 146 Terri Rachals 146 Table of Contents ix Mary Rose Robaczynski 147 Kimberly Saenz 147 Richard Williams 147 Allied Healthcare Providers 148 Donald Harvey 148 Efren Saldivar 148 The Mechanics of Medical Murder 148 The Victims: Why They Are Marked for Murder 148 The Methods of Their Madness: How They Kill 149 The Methods of Their Madness: When They Kill 153 The Methods of Their Madness: Where They Kill 154 The Methods of Their Madness: Why They Kill 155 Factitious Disorders and Healthcare Professionals 163 Detection of Medical Murder: Suspicious Deaths and Mortality Patterns 168 The Importance of the Index of Suspicion 180 Red Flags Associated with Medical Murder 183 References 186 6 Investigations, Sanctions, and Discipline 189 Healthcare Crime Investigations in the Digital Age 199 Obstacles to Investigations 204 Prosecution of Medical Malfeasance: Moving from Criminal to Civil 206 Evasion of Detection by Health Professionals 213 Elder Justice Act 223 Nursing Home Transparency and Improvement Act 226 Patient Safety and Abuse Prevention Act 227 Discipline of Problematic Healthcare Professionals 228 Physician Discipline 230 Nurse Discipline 233 The Role of the Medical Boards 235 Sanctions and Legal Action 241 The Role of Healthcare Security 245 The Role of Healthcare Human Resources 248 What Is Happening with Medical Murder Now? 262 References 264 7 Prevention Strategies and the Future of Healthcare Crime 267 Strategy 1: Admit Healthcare System Failures 267 x Table of Contents Strategy 2: Address the Shortcomings in the Healthcare System 273 Strategy 3: Investigate Problems in Healthcare Working Conditions 276 Strategy 4: Establish Accountability 277 Pressure from Within for Accountability 278 Pressure from Outside for Accountability 280 Strategy 5: Embrace Quality Improvement 282 Strategy 6: Reduce Risk for Intentional Harm 286 Strategy 7: Educate Healthcare Providers 287 Strategy 8: Address Healthcare Professionals’ Stressors 295 Strategy 9: Legislate Change 296 Strategy 10: Address Major Anomalies 298 Strategy 11: Remove Barriers to Reform 300 Strategy 12: Create New Opportunities for Dialogue 301 References 304 Index 307 Acknowledgments Successful journalism requires an interviewer who knows how to get to the heart of an issue and an interviewee who is not afraid of the hard questions. I am fortunate to have had the opportunity to interview experts in the fields of forensic science investigation, forensic nursing, and forensic psychology, as well as healthcare administration and public policy, healthcare human rela- tions, and healthcare law. The following individuals have graciously given of their time to share their expertise with me to augment that research and perspective that I bring to this book: • Janet Barber, RN, MS, FAAFS • Norman Bates, JD • Joseph Bellino • Marshall Kapp, JD • Kenneth W. Kizer, MD • Jeffery Payne • Katherine Ramsland, PhD • Louis Saccacio • Bruce Sackman • Beatrice Crofts Yorker, JD, MS, RN xi Introduction Justice will not come … until those who are not injured are as indignant as those who are. Thucydides At the time of writing, the U.S. Congress had just passed sweeping reform for the nation’s healthcare system, but the proposed legislation does little to ameliorate or even address an aspect of healthcare that is increasingly perva- sive—crime perpetrated by healthcare professionals. For the purposes of this book, these crimes will be divided into four broad categories—(1) exploita- tion, (2) fraud, (3) abuse, and (4) murder—each of which encompass a wide range of criminal behaviors against patients, coworkers, and employers. Can an entire book be dedicated to the concept of crime committed by healthcare practitioners? I was initially skeptical until I started digging deeper into the medical and legal literature, perusing reports in the main- stream media and talking to experts in the fields of healthcare, medicine, law, economics, social sciences, and human resources. Although not entirely pervasive, there is sufficient evidence that crime may be on the upswing in U.S. healthcare institutions. It may not be as high profile as medical errors and adverse events, but it is occurring, and it is certainly not on every facil- ity’s radar—as the cases of healthcare serial killers Michael Swango, Kristen Gilbert, and Charles Cullen clearly demonstrate. Healthcare institutions are intended to be places of healing, not houses of horror. So, why are so many individuals being harmed by or dying at the hands of healthcare professionals? That is the journey of discovery in this book that I hope you will take with me. There are five thoughts about crime perpetrated by healthcare professionals that I endeavor to express in this book: It is perturbing. 1. The breach of trust that occurs every time that a patient is exploited, defrauded, abused, or murdered is horrifying to con- template. Healthcare practitioners take oaths to heal, not harm, yet some of the most prolific serial killers have been healthcare professionals. Their motives vary, but their malfeasance results in morbidity and mortality that creates fear among healthcare consumers, erodes confidence in the healthcare system, and adds xiii