What Happened
Jolie King, a registered nurse at the VA Medical Center Urgent Care Clinic in Pineville, Louisiana, used her access to the clinic's narcotics supply cabinet to divert hydromorphone for personal use.
King used her position as a registered nurse to access the clinic's narcotics supply cabinet and retrieve vials of controlled substances intended for patient treatment. Rather than withdrawing drugs for patients actually under her care, King logged into the cabinet, randomly selected a patient's name from the system, and withdrew hydromorphone without any physician's order tied to that withdrawal. In at least one instance, in an attempt to avoid detection, she refilled two emptied vials with saline before returning them to the cabinet.
King admitted she used the diverted drugs for her own personal use. She pleaded guilty on May 28, 2020, to fraudulently obtaining hydromorphone, a Schedule II controlled substance.
What Went Wrong
A dispensing cabinet's patient-selection requirement did not stop an employee from using it as cover for withdrawals unconnected to any real order. Key failures included:
- The narcotics cabinet allowed withdrawal under any patient's name in the system without verifying an active physician's order for that specific patient.
- No routine audit matched cabinet withdrawals against the treating clinician's orders and the patient's actual visit record.
- Refilled vials returned to the cabinet were not inspected or tested for tampering before being made available for other patients.
How It Could Have Been Prevented
- Require the dispensing cabinet to validate an active, matching physician order before releasing a controlled substance under a patient's name.
- Run recurring audits that cross-reference cabinet withdrawals against clinician orders and confirmed patient encounters, flagging mismatches.
- Inspect and test any vial returned to a cabinet as partially used or refilled before it re-enters circulation.
- Restrict and log which staff can select patient profiles unrelated to their assigned caseload when accessing narcotics cabinets.
Related Guidance
- Tough Issues — High-risk scenarios with annotated SQL for analyzing order-fraud patterns.
- 15 Red Flags of Drug Diversion — Behavioral and transactional indicators including withdrawals unmatched to orders.
- Diversion prevention checklist — Clinic self-assessment covering dispensing cabinet controls.
- Employee Screening & Fitness for Duty — DEA screening requirements (21 C.F.R. §1301.90) for staff with controlled substance access.