What Happened
Lisa Marie Jones, a nurse working at the Veterans Affairs Medical Center in Denver and at a free-standing UCHealth emergency room, stole opioids from both facilities and tampered with fentanyl vials, resealing them with skin glue before returning them to circulation.
In 2016, Jones stole hydromorphone, morphine, and fentanyl from the two facilities for personal use, primarily taking "waste" medication left over after she administered controlled substances to patients. More seriously, she tampered with two vials of fentanyl at the emergency facility: she removed all of the drug, replaced it with saline, and resealed the vials with skin glue before placing them back into the facility's automated medication management machine for potential use on a future patient. The tampered vials were discovered before they could reach any patient.
Jones pleaded guilty to one count of theft of a controlled substance by deception and one count of tampering with a consumer product. On April 19, 2018, she was sentenced to fourteen months in federal prison and three years of supervised release on each count, to run concurrently. The case was investigated by the FDA Office of Criminal Investigations and the Department of Veterans Affairs Office of Inspector General, and was announced alongside a second Colorado nurse sentenced the same week for a similar scheme at North Colorado Medical Center.
What Went Wrong
Jones was able to steal "waste" medication and tamper with fentanyl vials at two different facilities before detection. Key failures included:
- Wasted controlled-substance doses left over after patient administration were not consistently witnessed and verified by a second staff member, creating an opening for theft.
- Vials that had been removed from the automated dispensing machine and later returned were not inspected for tamper evidence — such as reglued seals — before re-entering usable stock.
- No visual or chemical check caught fentanyl vials that had been emptied and refilled with saline before they could be loaded back into the dispensing system.
- The scheme spanned two separate facilities, suggesting that access controls and monitoring were not coordinated across the nurse's work sites.
How It Could Have Been Prevented
- Require a second clinician to witness and document wasting of any unused controlled-substance dose at the bedside, with electronic sign-off.
- Inspect any vial returned to an automated dispensing machine for tamper evidence — cap or seal irregularities — before it becomes available for the next patient.
- Use weight- or volume-based verification for high-diversion-risk drugs like fentanyl to catch vials that have been emptied and refilled with a substitute liquid.
- Coordinate diversion-monitoring data across all facilities where a clinician holds credentials or shifts, since a single employee's risk profile can span multiple work sites.
Related Guidance
- Tough Issues — High-risk scenarios with annotated SQL for analyzing waste-witnessing and dispensing-return gaps.
- 15 Red Flags of Drug Diversion — Behavioral and transactional indicators including excessive wasting and tampered vials.
- Hospital Diversion Prevention Checklist — Hospital self-assessment, 8 sections 63 items, including waste-witnessing and dispensing-cabinet controls.