What Happened
Catholic Medical Center in Manchester, New Hampshire, agreed to pay $300,000 to resolve allegations it violated the Controlled Substances Act by failing to keep accurate records of controlled substances, after an independent certified registered nurse anesthetist (CRNA) stole fentanyl from the hospital for nearly a year.
The nurse removed fentanyl from syringes intended for operating-room patients, replaced it with a combination of saline and hydromorphone, and diverted the fentanyl for her own use. Rather than properly discarding leftover medication after procedures, she falsely recorded it as wasted, generating false wasting records that concealed the theft. The DEA's investigation found she was able to steal controlled substances approximately once every day she worked over the course of a year.
A DEA audit of the hospital's records found that its inventory for seven controlled substances, including fentanyl, did not accurately reflect the quantities actually on hand, and that the hospital lacked effective controls and procedures to guard against theft and diversion. Catholic Medical Center did not admit liability but agreed to pay $300,000 and has since taken steps to improve its controls. The nurse pleaded guilty in June 2024 to tampering with consumer products.
What Went Wrong
- Wasting of unused controlled substances after procedures was recorded without independent witnessing or verification.
- Inventory records for multiple controlled substances, including fentanyl, did not match actual on-hand quantities for an extended period.
- A single independent contractor's near-daily pattern of access went undetected for nearly a year despite regulatory recordkeeping requirements.
How It Could Have Been Prevented
- Require a second clinician to witness and document destruction of any wasted controlled substance at the point of care.
- Reconcile controlled-substance inventory against dispensing and wasting records on a regular, audited schedule rather than relying on self-reported figures.
- Apply the same oversight and audit frequency to independent contractors and locum staff as to directly employed personnel.
- Investigate discrepancies between physical inventory counts and recorded quantities immediately, rather than allowing them to accumulate.
Related Guidance
- Hospital Diversion Prevention Checklist — Self-assessment covering waste documentation and inventory reconciliation.
- 15 Red Flags of Drug Diversion — Behavioral and transactional indicators including falsified waste records.
- Diversion Case Registry — More documented cases of hospital civil settlements over CSA recordkeeping failures.
- Regulatory Guide — CSA recordkeeping and inventory obligations for hospitals.