What Happened
A travel nurse employed at Raleigh General Hospital in Beckley, West Virginia, pleaded guilty to unlawfully using patients' protected health information to divert hydromorphone for her own use.
Using her personal biometric login, she would begin a checkout transaction on an automated dispensing cabinet for hydromorphone purportedly needed for a patient. Once the drawer opened, she siphoned off a portion of the vial's contents, diluted the remainder with another substance so the vial appeared full, recapped it, and returned it to the drawer. She then canceled the transaction, leaving no record that the drug had been dispensed at all.
She carried out the scheme repeatedly over roughly five months of employment at the hospital, relying on patients' identifiable health information to make each attempted withdrawal look legitimate. She pleaded guilty to one count of obtaining a controlled substance by fraud and one count of wrongful disclosure of individually identifiable health information, and faces up to 14 years in prison at an April 2025 sentencing.
What Went Wrong
- A canceled dispensing-cabinet transaction was not flagged for review even though the drawer had already been opened and a vial handled.
- Diluted vials returned to the cabinet passed as full on visual inspection, with no chemical or volumetric verification in place.
- A travel nurse's access to patient health information was not limited to only the patients she was actually assigned to treat.
How It Could Have Been Prevented
- Flag and independently review every canceled controlled-substance transaction where the cabinet drawer was actually opened.
- Periodically test returned or partially used vials for potency rather than relying on visual fill-level checks alone.
- Restrict staff access to patient records to those patients within their current assignment, with audit logging of out-of-assignment lookups.
- Cross-reference dispensing-cabinet activity against actual nurse-to-patient assignments for each shift.
Related Guidance
- Hospital Diversion Prevention Checklist — Self-assessment covering dispensing-cabinet and access controls.
- 15 Red Flags of Drug Diversion — Behavioral and transactional indicators including canceled transactions.
- Diversion Case Registry — More documented cases involving traveling and contract nursing staff.
- Employee Screening & Fitness for Duty — DEA screening requirements for staff with controlled substance access.