Do no harm: Staunton pharmacy still on probation after board investigation in 2023
All the details in our Health Safety stories come from publicly available Final Orders, Consent Orders, Orders of Suspension and other documents from the Virginia Department of Health Professionals. Unless otherwise noted, direct quotes are taken from those documents. For more information, see the Editor’s note below the story.
STAUNTON–Incorrectly dispensed medications, untrained staff, and a 700-prescription long production queue — this is just a sample of the issues found in a Virginia Department of Health Professions order against Kroger Pharmacy #343 on 850 Statler Boulevard in Staunton.
On November 2, 2022, a physician made a phone call to the pharmacy, giving staff the necessary documents and information for their patient to get the medication they prescribed.
The patient came the next day. They waited while staff tried to find the prescription, but ultimately left empty-handed.
The next day, the patient tried again. They got the same result. Fed up, the patient made a few phone calls and picked up the medication from another pharmacy.
The patient finally got a call letting them know the medication was ready for pick up.
It was Nov. 24.
When an inspector arrived on Dec. 8, she found the script. According to the label, it was filled on Nov. 4. However, the pharmacy manager told the inspector the prescription was filled on Nov. 25.
The Kroger pharmacy continued to work on its production queue. The inspector found over 700 medications in the queue. Over 600 were beyond the promise date, the day a patient should be able to pick up their prescription.
The Virginia Board of Pharmacy published a consent order against the Kroger pharmacy in August 2023. The order has a list of errors that could emerge when rushing through a queue of medications – dispensing the wrong medication, dispensing the same medication twice, and incorrectly transcribing doctor’s instructions for the medication on the package. The order states:
Between June 29 and Aug. 21, the pharmacy had “unexplained losses” of controlled substances, including gabapentin, tramadol, and promethazine with codeine syrup.
One prescription, prednisone, was dispensed twice, once on July 1 and again on August 11.
Around July 8, 2022, the Kroger Pharmacy dispensed “90 tablets of oxycodone IR 20 mg (C-II) rather than the prescribed 90 tablets of oxycodone IR 15 mg, and failed to report the error, when discovered, to the patient or the prescriber.”
On July 20, the pharmacy dispensed “triamcinolone 0.025% cream #80g” but the prescription was for triamcinolone 0.25% cream #30g.
The order points to a reason for the long production queue – lack of staffing.
“The pharmacy failed to employ sufficient pharmacists and/or pharmacy technicians to address the volume of prescriptions in a timely manner,” reads the order. “Further, several pharmacy technicians and pharmacy technician trainees resigned or were terminated in July 2022 after complaining about working conditions.”
In interviews with an inspector, one pharmacist said they were pressured to begin serving as a pharmacist-in-charge before completing training. The prior pharmacist-in-charge had to train the incoming manager “on all of the managerial duties when they overlapped four shifts before she was transferred to a different store in July 2022.”
A pharmacy technician trainee told the inspector they were required to work shifts before finishing the required training modules. The consent order explains, “She resigned after telling the human resources representative that she had no time to train and felt uncomfortable handling patients’ medications without further training." She returned to the job after “being promised adequate time to finish her training,” but this did not happen. She resigned.
The pharmacy took the medical board’s equivalent to a no contest plea in criminal court – the location “neither admits nor denies” the allegations in the order, “but waives its right to contest” the allegations and accepts “any sanction imposed hereunder.”
Those sanctions include:
A monetary penalty of $10,000.
The pharmacy’s permit was placed on “indefinite probation” for “not less than one year.”
The pharmacy will submit quarterly reports to the board outlining its weekly staffing schedules and its weekly volume of prescriptions for the previous quarter.
Before the August order, another consent order was entered in Sept. 2022. According to the order, the pharmacy failed to complete an inventory of controlled substances before a new pharmacist-in-charge took over in September 2021. The order required Kroger to pay the board $1,000.
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To file a formal complaint against a health professional, click here. For links to the public information informing this story, see below.
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EDITOR’S NOTE: When citizens are a danger to the public safety, law enforcement arrests them and charges them with crimes; they have the opportunity to face a jury of their peers; if convicted, they serve time and/or probation that can often ensnare them in the system for years.
When a medical professional is an alleged danger to the public safety, the Virginia Department of Health Professionals handles all facets of the inquiry, including the investigation and penalties. And sometimes, even when a medical professional is found liable of doing harm to patients, they may face a reprimand, pay a fine and continue to practice, without missing a day of work and with little chance for the public to see what they’ve done.
The Health Safety stories in this series tell the facts of cases where medical professionals endanger our public health safety. They also bring you into the world of the medical board’s consent orders and public final orders, so you can see exactly how the VDHP’s self-policing system works.
About the 'Do No Harm' series: Local doctors and medical professionals get in trouble. Here's how to find out who and how.
Lyra Bordelon (she/her) is the public transparency and justice reporter at The News Leader. Do you have a story tip or feedback? It’s welcome through email to lbordelon@gannett.com. Subscribe to us at newsleader.com.
This article originally appeared on Staunton News Leader: Kroger Pharmacy dispensed wrong medications, failed inspection
