What Happened
The North Dakota Board of Nursing accepted a Stipulation for Settlement on July 25, 2024 for Sherry Fjestad, an RN/LPN employed at North Dakota Surgery Center in Grand Forks from August 2021 until she was terminated in May 2024 amid allegations of suspected diversion of controlled medications. The Board suspended her license indefinitely and assessed a $2,000 penalty plus costs.
Board minutes show North Dakota Surgery Center in Grand Forks submitted a Peer Review Report on April 10, 2024, covering a nurse employed there from August 2, 2021 to May 17, 2024, when she was terminated amid allegations related to suspected diversion of controlled medications. At its July 25, 2024 meeting, the North Dakota Board of Nursing accepted a Stipulation for Settlement suspending her license for an indefinite period until terms were met, and assessed a $2,000 penalty plus costs and disbursements.
What Went Wrong
- A licensed nurse with nearly three years of tenure at a single surgery center was able to trigger diversion suspicion only after an extended employment period, suggesting detection lagged actual conduct.
- The board record does not identify the specific controlled substance involved, which limits the surgery center's ability to publicly benchmark its own detection gap against similar facilities.
- As with many state board actions, the case reached the public record only after employment termination — a lagging indicator of when the diversion was actually occurring.
How It Could Have Been Prevented
- Surgery centers should pair automated dispensing cabinet analytics with anesthesia and procedure records so that access outside expected case patterns is flagged in near real time.
- Route peer-review reports on suspected diversion to the state board promptly, and pair them with a waste-witnessing audit covering the employee's full tenure, not just the final incident.
- Publish drug-specific detail in board settlement records where consistent with investigation confidentiality rules, so peer facilities can calibrate their own surveillance thresholds.