What Happened
A registered nurse at George Washington University Hospital who referred herself to the Board of Nursing after a diversion suspension later relapsed to fentanyl and oxycodone, missed required drug-sample collections, and was expelled from the District's monitoring program. Her license remains suspended under a final order dated September 1, 2021.
The hospital suspended the nurse on or about March 15, 2018 based on suspected diversion, and she resigned from the position in April 2018. She referred herself to the Board and was directed to contact the Committee on Impaired Nurses (COIN) for an alternative-to-discipline track. She applied on or about May 18, 2018 and entered a monitoring agreement the same day, to run for three years.
The findings of fact describe periods of both compliance and relapse. She relapsed in June 2018, in the early months of participation, then complied through 2019. When the COVID-19 pandemic suspended specimen collection, COIN meetings, and support-group meetings, she faltered and relapsed again in approximately March 2020, then began using controlled substances including fentanyl and oxycodone. She admitted the relapse at a COIN meeting on July 24, 2020. In the same month she did not provide a hair sample when called, and on August 4, 2020 she did not provide a sample on the scheduled collection date. Those failures and the delayed notification violated the agreement, but COIN offered her a second participation agreement effective September 19, 2020, which she did not sign until October 14, 2020.
She was called for a test sample on November 24, 2020, failed to appear, and did not contact COIN for an excuse. COIN expelled her on December 22, 2020. DC Health had summarily suspended her license on January 19, 2021, and an administrative hearing affirmed that suspension on February 19, 2021. The Board issued its Notice of Intent to Take Disciplinary Action on June 28, 2021, and the hearing panel took testimony on July 22, 2021, including expert testimony and the nurse's own account of her recovery efforts.
The panel found her liable for violating the COIN agreements and for being addicted to or habitually abusing a controlled substance, but not for professional incompetence, and recommended that her license remain suspended until she establishes sustained abstinence and full recovery — through a new COIN agreement, compliance with its terms, and discharge from the program. She may apply to reinstate at her own expense once COIN concludes she can safely resume practice and the Board determines she is competent; the Board will enter a revocation order if she does not execute a new agreement within 60 days of the order or violates its terms. The Board adopted the Recommended Decision in full by unanimous vote on September 1, 2021.
What Went Wrong
- Monitoring depended on the nurse's own attendance and sample compliance, and repeated no-shows at specimen collections — well before any positive test — went unpenalized until expulsion.
- A pandemic-era suspension of sample collection and meetings removed nearly all external checkpoints at exactly the moment relapse risk rose.
- Relapse was disclosed with delay, and a hair-sample collection was missed the same month, so the monitoring program's early-warning signals arrived nearly together with the event they were meant to precede.
- A second agreement was offered after the violations and then took almost a month to sign, leaving a gap with no active monitoring in place.
How It Could Have Been Prevented
- Treat a missed specimen collection as a reportable event with a defined consequence, rather than as a scheduling problem, because no-shows are the most reliable early indicator in a monitoring program.
- Build a continuity plan for monitoring programs — remote collection options and virtual meetings — so that an emergency never suspends the checkpoints entirely.
- Require an immediate self-report obligation with a written timeline after any relapse, and verify it against drug-testing records.
- For employers, restrict controlled-substance access as soon as a diversion suspension or board investigation begins, and confirm the board's disposition before returning the clinician to any role with access.
Related Guidance
- Hospital Diversion Prevention Checklist — includes return-to-duty and access-control items for staff under monitoring.
- 15 Red Flags of Drug Diversion — behavioral indicators, including missed or refused testing.
- All Diversion Case Studies — board actions involving monitoring agreements and relapse.