What Happened
A registered nurse at Community Medical Center in Missoula, Montana diverted fentanyl and hydromorphone for her own use, and was caught only after coworkers reported repeated suspicious behavior.
From July 2020 to February 2021, she diverted fentanyl and hydromorphone while working as a nurse at the hospital. In January 2021, a coworker noticed her acting suspiciously — filling syringes with her back to a patient, then putting something in her jacket pocket and stepping behind a curtain before wiping her arm with an alcohol pad. Shortly after, she asked the coworker to witness her disposing of Dilaudid and fentanyl, using the coworker's presence to make the waste appear properly documented. In February 2021, another coworker saw her placing a vial in her scrub pocket while acting anxiously, and reported it.
When supervisors confronted her, she admitted to stealing narcotics and using them. A search of her bag turned up unmarked syringes — some used, some containing liquid — along with used alcohol-swab wrappers, and a urine sample tested positive for fentanyl. She pleaded guilty in January 2022 to unlawfully obtaining controlled substances by fraud, deception, and subterfuge, and was sentenced to two years of probation and a $2,000 fine.
What Went Wrong
- Waste witnessing was a formality, not a control. She was able to recruit a coworker to "witness" disposal of drugs she had already diverted, turning a safeguard into cover.
- Detection relied entirely on coworker vigilance. Two separate employees independently noticed and reported unusual behavior before any system or audit flagged the diversion.
- Physical behavior patterns went unaddressed until reported. Turning away from a patient while handling controlled substances and visibly manipulating clothing/skin are recognizable diversion behaviors that only surfaced through informal peer observation.
How It Could Have Been Prevented
- Require two-person independent verification for controlled-substance waste, with both parties observing the actual wasting event rather than being told it occurred.
- Train staff to recognize and immediately report behavioral red flags — turning away from patients during medication handling, unexplained trips to bathrooms or private areas after handling narcotics — as an affirmative duty, not optional courtesy.
- Establish an anonymous, low-friction reporting channel so coworkers who notice suspicious patterns can flag concerns before a second incident is needed to trigger action.
- Pair behavioral concerns with a for-cause drug screen policy that can be invoked promptly once a credible report is received.
Related Guidance
- 15 Red Flags of Drug Diversion — Behavioral indicators including waste-process manipulation and body language patterns.
- Hospital Diversion Prevention Checklist — Controls for controlled-substance wasting and witness verification.
- Employee Screening & Fitness for Duty — For-cause testing and reporting protocols.
- More Diversion Case Studies — Additional hospital nurse diversion cases.