What Happened

A nurse at Mercy Hospital South in St. Louis County, Missouri repeatedly obtained fentanyl from the hospital's automated dispensing system for her own use.

Lindsay J. Maupin, a registered nurse, admitted that from January 18, 2020 to February 2, 2020, while working at Mercy Hospital South, she fraudulently obtained fentanyl from an automated medication dispensing machine on multiple occasions for personal use.

Maupin pleaded guilty to one count of obtaining a controlled substance by fraud, a charge punishable by up to four years in prison, and was scheduled to be sentenced in February.

What Went Wrong

  • Repeated fraudulent withdrawals over roughly two weeks weren't caught in real time. Multiple occasions of fentanyl access without a corresponding legitimate patient need went undetected until the case was already referred for investigation.
  • The case record does not describe an internal audit catching the pattern. As reported, the matter was investigated by DEA rather than surfaced through a hospital-led dispensing audit, suggesting a gap in routine internal reconciliation.

How It Could Have Been Prevented

  • Run automated, frequent reconciliation of dispensing-machine withdrawals against actual patient administration records rather than relying on periodic manual audits.
  • Flag any nurse whose fentanyl withdrawal frequency for a given patient exceeds the ordered dosing schedule for supervisor review.
  • Require a documented clinical justification tied to a specific active order for every controlled-substance withdrawal, checked against the patient's chart before access is granted.
  • Train charge nurses and pharmacy staff to review dispensing-machine exception reports on a daily basis rather than only when prompted by an outside complaint.

Related Guidance

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