What Happened

A registered nurse working in Washington, DC was found to have repeatedly handled and documented fentanyl and other controlled substances improperly at two hospitals, tested positive for fentanyl, and had her license revoked with the revocation stayed in an order dated October 27, 2022.

The first report came from Sibley Memorial Hospital, which referred the nurse to the Board of Nursing on December 22, 2019 after she resigned during an ongoing investigation into suspected diversion. The hospital's own review, covering November 3 to November 27, 2019, found unusual instances of drug waste, delayed manual recording of drug administration, the use of one vial of narcotics for multiple administrations, and medications being held. Questioned during the investigation, the nurse admitted violating hospital policy but denied diversion for personal use. The hospital required a drug test; on December 17, 2019 she did not provide a sample and resigned that day.

The nurse then worked at MedStar Georgetown University Hospital. On January 28, 2021 that hospital notified the Board that she had been removed from duty after a positive drug test and several instances of suspicious and unsupported withdrawal of fentanyl. The drug test was positive for fentanyl. The findings of fact cover September 23, 2020 to January 13, 2021: on some occasions the nurse drew controlled substances purportedly for patients who were not assigned to her, and on others she drew medication that was never administered to patients. She admitted diverting fentanyl for personal use, and described how a tramadol prescription after a dental appointment began her use of controlled substances.

DC Health summarily suspended the license effective July 23, 2021, and the license remained suspended. The Board issued its final order on October 27, 2022: the registered nursing license was revoked, the revocation was stayed, and the license was to remain suspended until January 31, 2023. The suspension and the revocation would be lifted if the nurse entered into full participation with the Committee on Impaired Nurses by that date; if she did not, the revocation would take effect on January 31, 2023.

What Went Wrong

  • Medication was drawn in volumes and combinations that did not match the patients being cared for, including withdrawals for patients who were not assigned to the nurse and medication that was never administered.
  • Documentation was manipulated or delayed: unusual drug-waste entries, delayed manual recording of administration, and medications held rather than wasted or administered.
  • The nurse failed to provide a required drug-test sample at the first hospital, resigned the same day, and moved to a second hospital, where a drug test was positive for fentanyl.
  • Two separate hospitals each identified the pattern independently; the earlier departure did not surface in a way that prevented the second episode.

How It Could Have Been Prevented

  • Reconcile dispensing-cabinet withdrawals against the census and physician orders daily, so withdrawals for non-assigned patients, patients already discharged, or patients never treated are flagged within hours rather than after an internal investigation concludes.
  • Treat unusual waste patterns and delayed manual documentation as reportable red flags with an escalation path to the diversion committee, not only as policy violations to be discussed with the individual.
  • Make a drug test a mandatory, non-withdrawable condition of continued employment and of any board referral, since an incomplete test after a suspected diversion attempt is itself a strong indicator.
  • Share the outcome of a diversion investigation with the board referral record so that the next employer's credentialing review can see a documented pattern, not just an unexplained resignation.

Related Guidance

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