What Happened
A traveling nurse diverted opioids from four different healthcare facilities in the Anaconda-Butte-Deer Lodge area of Montana over the course of 2021, moving on to a new employer within days each time a prior one caught the shortage.
The nurse worked at Community Hospital of Anaconda, where a manager discovered in June 2021 that 392 oxycodone pills were unaccounted for after she routinely pulled the drug from the pharmacy without documenting administration to patients. When confronted, she denied diverting drugs and quit. Eleven days later she began working at Copper Ridge Health and Rehabilitation Center in Butte, which subsequently discovered hydrocodone diversions matching her shifts. A third diversion occurred in October 2021 at Continental Care and Rehabilitation Center in Butte, where dozens of hydrocodone and oxycodone tablets went missing and patient log sheets were manipulated or destroyed; a fourth occurred in November 2021 at The Ivy in Deer Lodge, where oxycodone and morphine counts came up short.
At each facility, staff urine screens came back negative for every nurse except her, and she either refused to test, left before providing a sample, or produced a sample that was too cold to be valid. She pleaded guilty in June 2022 to three counts of unlawfully obtaining controlled substances and was sentenced in October 2022 to one year and one day in prison followed by one year of supervised release.
What Went Wrong
A nurse was able to divert opioids at four separate facilities over roughly six months before any of them shared information with each other or with licensing authorities in time to stop her. Key failures included:
- No mechanism existed for facilities to flag a recently terminated nurse's diversion concerns to the next employer hiring her days later.
- Administration records for controlled substances were not reconciled against actual patient doses in real time, allowing undocumented withdrawals to accumulate before detection.
- Paper medication logs could be torn out or altered after the fact, and destroyed entries were not immediately flagged as a control failure.
- A refused or invalid (out-of-temperature) drug screen was not treated as an automatic trigger for suspension pending investigation at every facility.
How It Could Have Been Prevented
- Reconcile controlled-substance withdrawals against actual patient administration on every shift, not on a delayed or periodic basis.
- Treat a refused drug test or an invalid sample as grounds for immediate suspension from medication access, not a data point to be argued over.
- Verify professional references and any pending investigations before granting a newly hired nurse access to controlled-substance storage.
- Audit paper medication logs for missing pages, tears, or unexplained alterations as part of routine controlled-substance recordkeeping review.
Related Guidance
- Diversion prevention checklist — Self-assessment covering rehabilitation and skilled-nursing controlled-substance controls.
- 15 Red Flags of Drug Diversion — Behavioral and recordkeeping indicators of diversion by clinical staff.
- Why Controlled Substance Count Reconciliation Stops Diversion — Closing the gap between dispensed and administered doses.
- More Diversion Case Studies — Additional documented cases of healthcare drug diversion.