What Happened
Mid-Valley Hospital and Clinic in Omak, Washington, agreed to pay a $15,000 civil penalty under the Controlled Substances Act after admitting a nurse stole doses of hydromorphone for nearly two years.
The nurse, who had regular access to the hospital's controlled-substance supply, kept leftover medication after administering a patient's dose instead of properly wasting the remainder as required, and separately entered overrides into the hospital's automated medication dispensing system to obtain additional doses she was not authorized to withdraw. The investigation found she diverted Dilaudid (hydromorphone) almost every day she worked over roughly a two-year period, from late 2021 to October 2023.
The hospital admitted it had not enacted sufficient controls to catch the theft. Pharmacy technicians regularly printed override reports meant to flag unusual dispensing activity, but the pharmacy director routinely filed them away without reviewing them, allowing the diversion to continue undetected. In the settlement, the hospital agreed to pay $15,000 and adopt corrective pharmacy and controlled-substance procedures. The nurse separately entered agreements with the Washington Department of Health and the U.S. Attorney's Office restricting her access to controlled substances and barring her from seeking DEA registration before November 2025.
What Went Wrong
- Override reports designed to catch exactly this kind of diversion were generated but never actually reviewed by the pharmacy director for two years.
- Wasting of leftover medication after patient administration was not independently witnessed or verified.
- No secondary control caught a single nurse's pattern of near-daily overrides and leftover-medication retention over an extended period.
How It Could Have Been Prevented
- Assign clear accountability and a hard deadline for reviewing controlled-substance override reports, with escalation if reviews lapse.
- Require a second staff member to witness and sign off on wasting of leftover controlled substances at the bedside.
- Set automated alerts for individual staff members whose override frequency significantly exceeds peer norms.
- Periodically audit whether override reports generated by the pharmacy are actually being reviewed, not just produced.
Related Guidance
- Hospital Diversion Prevention Checklist — Self-assessment covering override reporting and waste-witnessing controls.
- 15 Red Flags of Drug Diversion — Behavioral and transactional indicators including override patterns.
- Diversion Case Registry — More documented cases involving hospital settlements and civil penalties.
- Regulatory Guide — CSA recordkeeping and corresponding-responsibility obligations for hospitals.