Diversion Case Studies

West Hartford physician settled civil claims over prescriptions not dispensed to named patients

A West Hartford physician entered into a civil settlement with the federal government, agreeing to pay $42,500 to resolve allegations under the Controlled Substances Act. The government alleged that 11 prescriptions for Vyvanse and Subutex were written outside the normal scope of practice because they were not dispensed to the individuals named on them, and that the physician failed to account for all controlled substances purchased and dispensed from the office. The settlement resolves allegations and is not a finding of liability.

Vermont psychiatric-facility nurse accused of diverting narcotics; consent order later contested through state supreme court

An in-patient mental health facility reported to the Vermont Board of Nursing that a nurse employed there had improperly taken narcotic drugs into his possession, and the State obtained a summary suspension of his license. A consent order reached in February 2011 and approved in April 2011 continued the suspension while expressly stating it was not an admission of liability. The nurse later asked the Board to vacate the order, and the Board did so, but an appellate officer reversed that decision and the Vermont Supreme Court in 2014 held the appeal was properly brought and reinstated the reversal.

Nursing Home Nurse Sentenced for Diluting Hospice Patients' Morphine with Tap Water — Washington, 2011

Snohomish, Washington

Jolene Larsen, a licensed practical nurse and unit supervisor at Merry Haven Care Center, a nursing home providing hospice care in Snohomish, Washington, removed morphine sulfate from prescription vials over several months and replaced it with tap water so she could consume the diverted drug herself. At least one diluted dose reached a patient, whose pain went untreated until additional medication was administered. Larsen pleaded guilty to tampering with a consumer product and was sentenced in U.S. District Court to one year in prison and three years of supervised release.

California hospital lead pharmacy technician diverted over 6,000 controlled-substance tablets from dispensing system

The California Board of Pharmacy accused a lead pharmacy technician at a Loma Linda university medical center of diverting 6,540 tablets of several controlled substances from the hospital pharmacy's electronic vault and dispensing system between April 2007 and August 2008. After a two-day hearing in October 2010, the administrative law judge found the evidence established diversion of more than 6,000 tablets. The Board adopted the proposed decision on February 7, 2011, and revoked the registration outright as necessary for public protection.

Registered nurse signed out extra OxyContin, Percocet, and oxycodone not given to residents and forged a narcotic sheet

A registered nurse signed out extra doses of OxyContin, Percocet, and oxycodone that were not given to residents. The nurse also forged another registered nurse's initials on a narcotic sheet. The board approved a consent agreement with five years of probation, chemical dependency treatment, random drug screening, and employment restrictions.

Former nurse pleads guilty to stealing hydromorphone from Mayo Regional Hospital

Dover-Foxcroft, ME

A former nurse at Mayo Regional Hospital in Dover-Foxcroft, Maine, pleaded guilty Monday to Class C theft for stealing about $8,000 worth of drugs, including hydromorphone, from the hospital between 2008 and 2009. An investigation began when the hospital's pharmacy director noticed he was ordering larger quantities of certain drugs than usual and suspected diversion. The nurse took the drugs but did not administer them to patients, instead injecting them to dull pain from a previous injury, according to her attorney. Sentencing was continued; the district attorney recommended two years in prison with all but 90 days suspended and two years of probation.

New Jersey physician's license revoked for prescribing Percocet without medical justification

The New Jersey State Board of Medical Examiners revoked a physician's license for a minimum of five years and imposed monetary penalties after finding he fraudulently prescribed Percocet and falsified medical records to justify the prescriptions. The findings were based on a joint investigation in which an undercover police officer, posing as an exotic dancer who wanted the drug to relax, was given a Percocet prescription despite denying any pain. The Appellate Division affirmed the Board's decision in October 2010.

Diagnostic radiologist prescribed controlled substances in the names of others for his own use

Annapolis, MD

A physician in a diagnostic radiology practice was found by the Maryland Board of Physicians to have prescribed controlled dangerous substances and other prescription medications in the names of other people, for his own personal use. The Board imposed a stayed suspension and five years of probation subject to terms and conditions.

Surgical Technician Diverts Fentanyl, Triggers Multistate Hepatitis C Outbreak — Colorado, 2010

Denver, Colorado

Kristen Parker, a surgical technician at Rose Medical Center in Denver, stole patients' fentanyl-filled syringes for her own use and replaced them with saline-filled syringes that were then used on patients. Parker was hepatitis C-positive when she was hired, and her diversion scheme infected dozens of patients at Rose Medical Center and the Audubon Surgery Center in Colorado Springs with her strain of the virus. In February 2010, a federal judge sentenced her to 360 months (30 years) in prison — above the term contemplated in her plea agreement — followed by three years of supervised release. She was also ordered to pay more than $500,000 in restitution to the two facilities.

Tulsa hospital pharmacy operator paid civil penalty after employees stole hundreds of thousands of hydrocodone and alprazolam doses

A pharmacy management company agreed in February 2010 to pay a $1 million civil penalty to settle allegations that two Tulsa hospital pharmacies it operated violated the Controlled Substances Act by failing to account for large quantities of controlled substances. A DEA investigation found 399,500 dosage units of hydrocodone and 234,000 dosage units of alprazolam unaccounted for at one pharmacy between October 2005 and June 2007, along with 64 missing controlled-substance invoices, and smaller shortages of hydrocodone, phentermine and alprazolam plus 47 missing invoices at the second pharmacy between April 2007 and July 2008. The company fired two employees; one, who handled invoices and purchasing, pleaded guilty to illegally possessing and distributing hydrocodone. The settlement is a civil resolution, not a finding of liability, and neither hospital was alleged to be involved.

Nurse practitioner self-administered controlled substances taken from office stock

A nurse practitioner admitted that, while working in her own solo practice, she took controlled substances from her office stock and self-administered them without a prescription. The board approved a consent agreement imposing five years of probation, drug rehabilitation counseling, psychiatric or psychological therapy, random testing, and restrictions on controlled-substance access and practice.

Registered nurse had Schedule II drugs removed from an automated dispensing cabinet and unaccounted for

The board database states that an employer provided 184 incidents in which Schedule II drugs were removed from an automated dispensing cabinet by a registered nurse and were unaccounted for. The nurse had been asked to explain allegations of poor nursing practice and possible drug diversion and was diagnosed with situational anxiety disorder and chronic insomnia. A consent agreement imposed three years of probation, a public reprimand, chemical-alcohol assessment, counseling, supervision, and limits on controlled-drug access.

Respiratory care practitioner took controlled substances from a hospital's automated dispensing cabinet dispensing system without authorization

Baltimore, MD

The Maryland Board of Physicians found that a respiratory care practitioner had impairment issues and took controlled dangerous substances (CDS) from a hospital's automated dispensing cabinet system without authorization. The Board issued a reprimand and placed the practitioner on probation for a minimum of one year subject to terms and conditions.

A physician assistant was accused of unauthorized prescribing of Schedule II narcotics to family members

Annapolis, MD

The Maryland Board of Physicians summarily suspended a physician assistant's certification after determining that public health, safety, or welfare required emergency action. The basis included, among other things, an allegation of unauthorized prescribing of Schedule II narcotics to family members.

Radiation therapy technologist forged prescriptions to obtain pain medication

Eldersburg, MD

The Board determined that emergency action was required based on a radiation therapy technologist’s diagnosis of drug dependency for addiction, failure to follow up with outpatient treatment for addiction, continuing to obtain prescription pain medicine, and forgery of prescriptions in both her own name and other names. The Board summarily suspended the technologist’s certificate.

Internist fraudulently wrote prescriptions for controlled substances and misrepresented having them filled

Clinton, MD

The Board found that during 2003-2004 a physician was addicted to or habitually used controlled substances, fraudulently wrote prescriptions, made misrepresentations in having prescriptions filled, and made misrepresentations to the Board during its investigation. The Board suspended the license, immediately stayed the suspension, placed the physician on probation for a minimum of 3 years subject to terms and conditions, and imposed a $10,000 fine.

Illinois hospital bacteremia outbreak linked to nurse drug diversion

The Centers for Disease Control and Prevention lists a 2006 outbreak of nine Achromobacter xylosoxidans bloodstream infections at an Illinois hospital among U.S. outbreaks associated with drug diversion by healthcare providers. The outbreak was associated with a nurse at the hospital. The CDC source does not name the drug involved or describe any criminal or licensing outcome.

Physician assistant's certification revoked after guilty plea to illegally distributing oxycodone

Montgomery, PA

A physician assistant's certification was revoked after he pled guilty to two felony counts: distributing Oxycodone not for a legitimate medical purpose, and falsely altering a certificate of discharge from the Army.

Radiation therapy technologist's certification revoked after positive drug test for morphine

Bel Air, MD

A certified radiation therapy technologist violated a disposition agreement with the Maryland board by failing a urine screen that tested positive for morphine. The board found the violation established and revoked the technologist's certification.

Children's Wisconsin nurse diverted morphine and fentanyl for self-administration

A registered nurse at Children's Wisconsin stole morphine and fentanyl intended for pediatric patients and self-administered the drugs starting in 2000, and was caught after four years. The nurse was charged with multiple felonies, convicted of stealing drugs on the job in 2004 and 2005, spent four months in jail, and had her nursing license suspended indefinitely. The license was later fully reinstated and the nurse received a pardon.

Physician wrote prescriptions in patients' names and diverted the controlled substance for personal use

Kensington, MD

State regulators summarily suspended a physician based on investigatory facts showing the physician wrote prescriptions for controlled dangerous substances (Stadol) for patients and then used part or all of the medication for himself. Investigators also found the physician had asked a number of other physicians to write him personal prescriptions for the same drug. The action was taken as an emergency measure pending further Board proceedings.

Physician pleaded guilty to fraudulently obtaining diazepam

Brownsville, TX

A physician pleaded guilty to unlawfully possessing the controlled substance diazepam, which was obtained by fraud. Because state statute required revocation following this criminal conviction, the medical board revoked the physician's license.

Charlotte pharmacist's license suspended indefinitely for altering prescriptions and unauthorized controlled substance use

Charlotte, NC

The Board reported that a pharmacist in Charlotte altered prescriptions for controlled substances and obtained and consumed controlled substances without authorization. The pharmacist's license was suspended indefinitely.

Durham pharmacist admitted unauthorized Sufentanil use; license suspended 30 days, stayed five years

Durham, NC

A pharmacist in Durham admitted using Sufentanil without authorization. The Board accepted a recommendation to suspend the license for 30 days, stayed for five years with conditions.

Mullins pharmacist's license revoked for consuming controlled substances without authorization

Mullins, SC

The Board reported that a pharmacist in Mullins, South Carolina, consumed controlled substances without authorization. The license was revoked.