News Leader Investigation Reveals: State often does not release details you need to avoid doing business with troubled Pharmacies or pharmacists.
Seventeen area pharmacies have violated the law since 2010, with mistakes ranging from keeping sloppy records to not having the proper environment for compounding life-sustaining medicine, a News Leader investigation of state records shows.
If you walked into one of those pharmacies in the months after they failed inspection, you had no way of knowing your pharmacy or pharmacist had been cited, even though the state’s Board of Pharmacy knew.
That’s because the information is not made public when you need it, and it’s not available where you most often come into contact with the world of medicine — at your local pharmacy itself.
The News Leader spent four months examining hundreds of pages of public state inspection orders published from January 2010 to November 2016, focusing on ones involving Staunton, Waynesboro and Augusta County. We also reviewed all orders from 2016 across Virginia, in order to inform our reporting with context and understand how the state handles discipline.
A third of the local violations cited against pharmacies were against a single offender, Augusta Health’s on-site hospital pharmacy, leading to $21,750 worth of fines stemming from a November 2015 inspection.
Pharmacists were also investigated.
A News Leader review of orders of the Board of Pharmacy revealed: a Western State pharmacy tech who diverted 240 opioid tablets for her personal use in the summer of 2014, and a Waynesboro pharmacist at the West Main Street CVS who in 2009 mistakenly dispensed an anti-seizure drug to a child instead of the prescribed ADHD drug, resulting in “negative behavioral symptoms.” That error began with a CVS pharmacy tech incorrectly entering the drug data into the computer system.
The Western State pharmacy tech’s license was suspended weeks before her license expired. The other two pharmacy workers above still retain their unrestricted license to practice pharmacy in the state.
The News Leader also discovered a single pharmacist who, despite admitting to four dozen violations since 1987 across seven pharmacies from Richmond to Weyers Cave, has not lost her license for a single day.
Over 40 violations in 27 years, and no suspension
The trail of official documents in the case of Patricia Roper starts in the winter of 1987.
It covers violations committed across 30 years, and includes two periods of probation.
From Richmond to Culpeper to Elkton and Weyers Cave, Patricia Roper racked up violations dispensing the wrong medication to patients, dispensing medicines at double the prescribed strength and at half the strength, at double the instructed dosage and at half the instructed dosage, according to state findings. She dispensed the wrong number of pills, to the wrong customer, with the wrong refill information.
While working at Culpeper Memorial Hospital early on in her career, she neglected to give some in-hospital patients their medicine at all.
After years of continued run-ins with the Board of Pharmacy, she owned and operated her own pharmacy in Elkton, and later in Weyers Cave. In both cases she failed to give customers proper notice before closing.
Her license, which is still current, expires at the end of 2016.
Roper’s entire history with the Board bears a full examination for a number of reasons.
In the six years and 11 months of Pharmacy Board orders with a local connection researched by The News Leader, Roper’s record is by far the longest of any pharmacist who practiced in this area and was disciplined by the board. The board has power to summarily suspend the license of a pharmacist, yet they never suspended Roper’s license.
Her record shows what a pharmacist can do decade after decade without the board halting her work.
The same mistakes in dispensing medicines were repeated month after month, year after year, sometimes within a month after the pharmacist was placed on probation, sometimes while she was petitioning to have probation lifted.
We may not know if the board’s public orders about Roper represent the entirety of the pharmacist’s mistakes. The itemized mistakes in the orders represent only the mistakes that produced complaints to the board, investigations and final consideration for discipline.
Trail of trouble
Patricia Roper’s history of board orders starts innocuously enough.
On Jan. 29, 1987 she was disciplined for “failing to enclose the drug storage area in such a manner as to prevent unauthorized access and to prevent the diversion of drugs stored in the area,” while she was pharmacist-in-charge of Hudgins Drug Store in Richmond in 1985 and 1986.
Roper was fined $100. It was a decade before she would face the board again.
In April 1995, while a pharmacist at Culpeper Memorial Hospital, Roper dispensed the wrong type of diabetes medicine to a patient, according to state findings. She also failed to dispense morning medications to five patients in a timely manner, and bagged afternoon medications for four other patients instead of placing them in the patients’ boxes.
In the same month, she dispensed a medication for congestive heart failure and atrial fibrillation at half the prescribed strength.
Later that year in August, she was counseled for dispensing the antibiotic Zithromax at twice the strength prescribed, along with inaccurate instructions for taking the medicine. In September she dispensed the wrong number of tablets of an appetite suppressor.
In January 1996, she dispensed atenolol, a beta blocker commonly used to treat high blood pressure and chest pain, to the wrong member of a family. This type of error is probably more likely to generate a complaint from the public because the patient can easily discover it.
So Roper, employed at Revco Discount Drug Center in Locust Grove, was counseled by her employer for these mistakes, as well as for behavioral issues, records show.
For three months she received inpatient treatment at The William J. Farley Center in Williamsburg for alcohol dependence and depression, a 1997 board document shows. She also signed a four-year contract with Virginia Pharmacists Aiding Pharmacists Program.
In September, according to the document, by her own admission she relapsed into alcohol dependence and she returned to the Farley Center for evaluation.
Taking all this into account, the committee placed her on probation. She was still allowed to practice under the terms, which included self-reports, continued therapy and involvement with Virginia Pharmacists Aiding Pharmacists Program, and written notification to the pharmacist-in-charge at Revco of her probationary status. She was not fined.
Roper was a person who’d chosen a professional path that is healing in its very nature; a person whose lifestyle choices had affected her career in ways potentially dangerous for those she served; but a person who’d been caught in time and was seeking help.
So in June 1997, the Board gave her a second chance by placing her on probation.
But before the end of the next month her behavior was already breaking the terms of probation, and she was committing additional violations.
According to a May 5, 1998, “Notice of Informal Conference,” Roper had failed to comply with numerous conditions of her probation, including “Paragraphs #2, #3, #5, #7, #8, #9 and #11…” of the consent order she had signed. There are 12 numbered paragraphs in the order.
Roper failed to provide required reports including self-reports. She failed to provide written notice to her boss at Revco of her probationary status. After transfer of ownership of the pharmacy from Revco to CVS, she failed to provide notice to the incoming lead pharmacist of her probationary status, documents state.
Reports of breathalyzer tests were not received by the board, nor were reports of compliance with her continued participation with the Virginia Pharmacists Aiding Pharmacist Program. Additional reporting required by the probation was not received by the board.
Meanwhile, she continued to dispense medicine at the wrong strength, according to state findings.
In December 1997, she dispensed the cholesterol drug Lipitor to a patient at half strength.
In January of 1998 she again incorrectly dispensed the high blood pressure pill altenolol — at twice the strength and twice the dosage.
She made a similar mistake only days after being placed on probation, in fact, when she directed a patient to take two Coumadin tablets twice daily instead of one tablet daily. Coumadin is a blood thinner used to help prevent stroke and heart attacks. For patients who’ve had heart surgery, maintaining the proper levels in their blood so it gets neither too thick nor too thin is critical to survival.
During this time Roper was counseled for tardiness and for not reporting several improperly filled prescriptions.
In the hearing of May 1998 Roper told the committee that she’d had difficulty attending meetings because of her own and her daughter’s medical problems.
While this did not address the numerous other violations, the committee chose to keep Roper on “continued probation” with additional conditions of a chemical dependency evaluation, a psychological evaluation and a physical evaluation by “specialists approved by the Board.”
Roper was not fined, nor was her license suspended, though both orders’ language stated that her inability to satisfy requirements of the probation conditions constituted “grounds for suspension or revocation of her license.”
After a year and a half, although still not meeting probation terms, Roper had the restrictions lifted.
Not much appeared in the public record for the next few years of Roper’s career, at least not at the time.
The story of this local pharmacist, and her decades of public work overseen by a state board, continues in the new century, in May 2003, when Roper was again contacted by the Board of Pharmacy.
This time it was about 14 violations during her tenure at CVS Pharmacy as well as two violations at her own business, Elkton Pharmacy.
Roper now owned and was the pharmacist-in-charge of her own place. But the new trouble brewing with the state was about prior issues, a cascade of them.
The notice sent to her documents issues dating back to her time at CVS in Locust Grove. Schedule II controlled substances, including oxycodone, had been left out on the counter after the prescription department closed, according to the documents.
Even more serious, she dispensed 100 tablets of a narcotic opioid instead of a simple diuretic.
She directed a patient to take a seizure medicine used to treat epilepsy and migraines at twice the amount daily, the record claimed. She dispensed a major antidepressant at twice the prescribed dosage. Instead of giving a patient an opioid for severe pain, Ultram, she dispensed a medicine designed to improve food digestion, Ultrase.
She also lied in documentation asserting she had fulfilled continuing education hours for 1998 and 1999, according to state records.
All these allegations were for the year 2000, barely a year after her probation was lifted without restriction.
She closed out the year 2000, now at her own business, Elkton Pharmacy, by dispensing an antibiotic with a risk of fatal liver failure, Trovan, to a patient needing medicine for bacterial conjunctivitis, i.e. pink-eye, called Tequin.
Ultram, Ultrase. Trovan, Tequin. Hydrocodone, hydrochlorothiazide. These words may look very similar. It’s the pharmacist’s job to know the difference. Not knowing the difference can be deadly.
For reasons unexplained in the final order, Roper did not appear before the board June 12, 2003, to discuss these violations.
The Board’s Special Conference Committee did not meet with Roper and her counsel until Jan. 15, 2004 — more than seven months after the notice.
Roper was then reprimanded and placed on probation.
This time she was fined $2,600 and required to “report all prescription errors within (10) days of notification of error,” as well as required to do more classes.
Within two years, with clients being served daily in Elkton, new problems would arise.
These included, according to board findings, dispensing a prescription to the wrong person in a family; mislabeling the number of refills; mislabeling the quantity of capsules; dispensing a blood pressure medication at double the strength; dispensing a medicine to treat fungal yeast infections instead of an antibiotic; dispensing the wrong dosage of an opioid; dispensing the wrong diabetes medicine; dispensing 90 pills of a common cholesterol medicine instead of 30, while the same day dispensing 30 pills of a medicine to control seizures instead of the prescribed 90 pills; and mixing up multiple prescriptions to two customers of the same name.
The Board ordered that Roper remain on probation. She again was ordered to report all prescription errors to the Board within 10 days of notification of the error.
She was given the additional requirement of enrolling and successfully completing a 12-hour course titled “Basic Error Prevention Techniques” given by the University of Florida College of Pharmacy.
Roper closed Elkton Pharmacy in 2011.
The last order of public record involving her is dated June 25, 2014.
Roper, having apparently opened the new Weyers Cave Pharmacy as the pharmacist-in-charge, was fined $1,000. “[I]n May 2013, unlicensed individuals opened the pharmacy and pharmacy department and had access to the pharmacy department when the pharmacist was not in the pharmacy,” the order states.
Then, in an encore of her time at Elkton Pharmacy, she failed to give the public and the Board proper notice that Weyers Cave Pharmacy was closing.
Through her lawyers, Roper has declined to be interviewed or to comment on her career as a pharmacist.
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