What Happened

An emergency room nurse at Providence Hospital in Washington, DC was identified through an internal audit of controlled-substance records as having removed narcotics for patients she was not assigned to, without orders, after discharge, and for fictitious patients. The Board of Nursing revoked her license on January 14, 2022.

Providence Hospital complained to the Board on or about January 8, 2019. The hospital had conducted an internal investigation after discrepancies appeared in its controlled substance tracking records during a routine pharmaceutical audit. That investigation identified discrepancies in 17 patient accounts, with a total of 32 drug removals, and concluded the emergency room nurse was the clinician who withdrew the medication in those cases. The withdrawals were made for patients she was not assigned to or associated with, without a physician's order, after patients had been discharged and left the hospital, or for fictitious patients. Separately, over the eleven days from December 15 to December 26, 2018, she removed 16 narcotics ostensibly for patients when no physician's prescription or order existed, and recorded removing narcotics on behalf of patients 11 times after those patients had been discharged. She resigned from Providence on January 28, 2019.

She then worked as an emergency department nurse at United Medical Center. On February 26, 2019 a routine medication audit by the center's director of pharmacy revealed unauthorized removal of controlled substances by the nurse — again for fictitious patients, patients already discharged, or without a physician's order. The center terminated her on March 15, 2019.

In an investigative interview, the nurse admitted to a DC Health investigator that she had become addicted to oxycodone and tramadol because of past health conditions, and that she had diverted narcotics from the hospitals for her own use. Both hospitals referred her to the Committee on Impaired Nurses. She was contacted to attend a July 19, 2019 meeting and failed to appear, and COIN expelled her from the program on September 17, 2019. Invited to a January 17, 2020 meeting, she was instructed to apply to COIN and register with a monitoring agency and did not do so.

DC Health summarily suspended her license on January 2, 2020, and the Board issued its Notice of Intent to Take Disciplinary Action on January 17, 2020, charging addiction to or habitual use of a controlled substance, providing professional services while using one, and dispensing or administering drugs without authorization. She did not appear at the hearing held on November 3, 2021. The Board found her liable on all three charges and revoked the registered nursing license effective on service of the January 14, 2022 order.

What Went Wrong

  • Withdrawals were made against patient accounts that could not support them — patients not assigned to the nurse, patients already discharged, and patients who did not exist — and the audit trail did not stop any of them in real time.
  • Recording removals after discharge went undetected across an eleven-day window until a routine audit, meaning reconciliation lagged the diversion by weeks or months.
  • The pattern repeated at a second employer within weeks, where a routine pharmacy audit found the same unauthorized removals — the first hospital's finding did not prevent the second episode.
  • Two referrals to the impaired-nurse program produced a missed meeting, an expulsion for non-attendance, and an uncompleted enrollment, leaving no monitoring in place while the license suspension proceeded.

How It Could Have Been Prevented

  • Reconcile automated dispensing cabinet records against the assignment sheet, discharge list, and physician orders every shift or at least daily, so withdrawals for non-assigned, discharged, or fictitious patients surface before a routine audit finds them.
  • Alert automatically on withdrawals keyed to discharged patients or to accounts with no active order — both are unambiguous diversion signatures rather than ambiguous usage patterns.
  • Act on the first audit finding with a referral that includes the dispensing record, and verify the receiving program's follow-up, since a referral that ends in a no-show leaves the same risk in the next facility.
  • Reconcile pharmacy audit findings and human-resources actions across the facilities a nurse has worked in during the credentialing window, so a termination for diversion is visible to the next employer.

Related Guidance

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