Diversion Case Studies

Emergency room nurse suspended indefinitely for diverting controlled substances from an automated medication administration machine

A registered nurse working in a hospital emergency room repeatedly withdrew controlled substances from an automated medication administration machine and failed to document that they were administered to patients. A drug screen showed three controlled substances in the nurse's system. The Court found the conduct violated laws governing nursing practice and upheld the Georgia Board of Nursing's sanction suspending the nurse until twelve months of continued sobriety, followed by probation.

Hospital emergency room nurse diverted controlled substances from an automated medication administration machine

A registered nurse working in a hospital emergency room repeatedly withdrew controlled substances from an automated medication administration machine and failed to document that the substances were administered to patients. A drug screen indicated three controlled substances in the nurse's system. The court found the conduct violated nursing laws and upheld the Georgia Board of Nursing's proposed sanction of suspension until twelve months of continued sobriety, followed by probation.

Nurse diverted hydromorphone from an automated dispensing cabinet system at place of employment

The Mississippi Board of Nursing revoked a nurse's license after finding the nurse misappropriated drugs, supplies or equipment by diverting hydromorphone from an automated dispensing cabinet system at the nurse's place of employment. The action was taken at hearings held April 5-8, 2016.

Nevada nursing board found a licensed practical nurse withdrew morphine from patient dispensers at a rural hospital without documenting it

Caliente, NV

At a March 24 hearing in Reno, the State Board of Nursing found a licensed practical nurse guilty of withdrawing morphine from the medication dispensers of two patients at a rural hospital in Caliente without documenting what happened to the controlled substance. The board stripped the nurse's license and barred reapplication for five years.

Emory Hospital Pharmacy Technicians Diverted More Than 1 Million Doses of Controlled Substances

Atlanta, GA

Two pharmacy technicians at Emory University Hospital Midtown in Atlanta illegally ordered and received more than one million doses of controlled substances, including alprazolam, hydrocodone, and codeine products, over nearly five years by misusing buyer credentials and bypassing receiving and inventory checks. The scheme, which ran from October 2008 until hospital staff flagged a suspicious purchase in July 2013, was detailed in a Georgia Board of Pharmacy consent order finalized in February 2016. The Board placed the hospital's pharmacy license on probation for three years, fined the hospital $200,000, and barred technicians from approving controlled-substance orders going forward. Both technicians were fired and the matter was referred to the Georgia Drugs and Narcotics Agency and the DEA.

University hospital employees fired for diverting controlled substances including alprazolam and hydrocodone

Two employees at a Georgia university hospital were fired for illegally diverting more than a million doses of controlled substances in a scheme that lasted nearly five years, according to the article. The diverted drugs reportedly included the anti-anxiety medication alprazolam, sold as Xanax, and the pain medications codeine and hydrocodone. A consent order with the Georgia Board of Pharmacy fined the hospital $200,000 and placed its pharmacy license on probation for three years, and the matter was reported to the DEA.

Wayne County LPN Sentenced to Jail for Diverting Oxycodone from Nursing Home Patients

Newark, NY

Ashly Erb, a licensed practical nurse at DeMay Living Center in Newark, New York, falsified medication administration records for fourteen nursing home residents to cover up her theft of 493 narcotic pills, including 94 oxycodone pills taken from a single patient. An investigation by the New York Attorney General's Medicaid Fraud Control Unit and the state Bureau of Narcotics Enforcement led to a June 2015 guilty plea to petit larceny, with a promised conditional discharge contingent on completing treatment and avoiding rearrest. Erb violated those conditions, and on January 6, 2016, a Wayne County judge sentenced her to 99 days in jail.

Worcester Nurse Pleads Guilty to Stealing Oxycodone from Nursing Home Patients

Worcester, Massachusetts

Joanna Dacri, a nurse at a nursing care facility in Worcester, Massachusetts, stole numerous oxycodone tablets prescribed to three patients between February and June 2014. She surreptitiously substituted similar-looking antihistamine and antidepressant tablets in place of the stolen oxycodone so the theft would go undetected. Dacri pleaded guilty on November 5, 2015, to acquiring and obtaining a controlled substance by deception, facing up to four years in prison at sentencing.

Mississippi registered nurse placed on 24-month restricted license over misappropriation ground

The Mississippi Board of Nursing's October 2015 disciplinary summary lists a registered nurse placed on restricted licensure for 24 months. The cited grounds were unprofessional conduct as identified in the Board's rules and misappropriation of drugs, supplies or equipment. The summary does not identify the drug, the workplace, or whether the action followed a hearing or an agreed order.

Mississippi licensed practical nurse's license revoked over misappropriation ground

The Mississippi Board of Nursing's October 2015 disciplinary summary lists a licensed practical nurse whose license was revoked. The cited grounds were unprofessional conduct as identified in the Board's rules and misappropriation of drugs, supplies or equipment. The summary does not name a drug or workplace and does not describe how the matter was detected.

Mississippi registered nurse voluntarily surrendered license amid record falsification and misappropriation grounds

The Mississippi Board of Nursing's October 2015 disciplinary summary records a registered nurse's voluntary surrender of license. The cited grounds were falsifying or failing to make essential entries on records, unprofessional conduct, and misappropriation of drugs, supplies or equipment. A voluntary surrender is not a finding after hearing, and the summary does not identify the drug or the workplace.

Mississippi registered nurse voluntarily surrendered license amid self-administration of drugs ground

The Mississippi Board of Nursing's October 2015 disciplinary summary records a registered nurse's voluntary surrender of license. The cited grounds were unprofessional conduct, deficiencies in essential record entries, and possessing, obtaining, furnishing or administering drugs to herself except as legally directed. A voluntary surrender is not a finding after hearing, and the summary does not name a drug or workplace.

Mississippi registered nurse voluntarily surrendered license amid misappropriation and record-entry grounds

The Mississippi Board of Nursing's October 2015 disciplinary summary records a registered nurse's voluntary surrender of license. The cited grounds were unprofessional conduct, deficiencies in essential record entries, and misappropriation of drugs, supplies or equipment. A voluntary surrender is not a finding after hearing, and the summary does not identify the drug or workplace.

Massachusetts General Hospital Pays $2.3M in Drug Diversion Settlement

Boston, Massachusetts

Massachusetts General Hospital agreed to pay the United States $2.3 million, at the time the largest settlement of its kind, to resolve allegations tied to lax controls that allowed employees to divert controlled substances. DEA opened its investigation in 2013 after MGH disclosed that two nurses had stolen nearly 16,000 pills, mostly oxycodone, from an automated dispensing machine; a subsequent DEA audit found pill-count discrepancies totaling more than 20,000 missing or incomplete medication records. As part of the settlement, MGH adopted a corrective action plan including enhanced diversion monitoring, annual external audits, and fingerprint-based access controls on automated dispensing machines, announced September 28, 2015.

Madison hospital nurse stole fentanyl vials

Madison, WI

A nurse was caught stealing vials of fentanyl from a Madison hospital in 2015. The nurse said she had wanted to get help long before she was caught diverting and had not reported herself to the state. Her nursing license was later fully reinstated.

Southern Tier LPN Pleads Guilty to Diverting Percocet from Nursing Home Patients

Horseheads, NY

Lisa Rumsmoke Clark, a licensed practical nurse at Elcor Nursing and Rehabilitation Center in Horseheads, New York, diverted nearly 200 Percocet pills from eight elderly residents over about a month by completing records that falsely showed the narcotics had been administered. The scheme was uncovered by an investigation from the New York Attorney General's Medicaid Fraud Control Unit and the state Department of Health's Bureau of Narcotics Enforcement. Clark was arraigned in May 2015 on charges including falsifying business records, petit larceny, and criminal possession of a controlled substance, and the Attorney General announced her guilty plea on August 12, 2015.

Dallas pharmacy dispensed controlled substances pursuant to invalid prescriptions; agreed order

Dallas, TX

The Board alleged that a Dallas pharmacy dispensed controlled substances pursuant to invalid prescription orders. The pharmacy accepted an Agreed Board Order, which placed the license on 2-year probation with conditions and imposed a $2500 fine.

Pharmacist-in-charge at a Dallas pharmacy dispensed controlled substances pursuant to invalid prescriptions; agreed order

Dallas, TX

The Board alleged that a pharmacist-in-charge at a Dallas pharmacy dispensed controlled substances pursuant to invalid prescription orders. The licensee accepted an Agreed Board Order, which placed the license on 2-year probation with conditions and imposed a $2500 fine.

Houston pharmacy dispensed controlled substances and dangerous drugs pursuant to invalid prescriptions; agreed order

Houston, TX

The Board alleged that a Houston pharmacy dispensed controlled substances and dangerous drugs pursuant to invalid prescription orders. The pharmacy accepted an Agreed Board Order, which placed the license on 2-year probation with conditions, imposed a $5000 fine, and required policies and procedures to ensure therapeutic dispensing of prescription drugs.

Pharmacist-in-charge and corporate president at a Cleveland pharmacy dispensed controlled substances pursuant to invalid prescriptions; agreed order

Cleveland, TX

The Board alleged that a pharmacist-in-charge and corporate president at Tristar-Cleveland in Cleveland dispensed controlled substances pursuant to invalid prescription orders. The licensee accepted an Agreed Board Order, which placed the license on 3-year probation with conditions, imposed a $7500 fine, and required successful passage of the pharmacy law exam.

Cleveland pharmacy dispensed controlled substances pursuant to invalid prescriptions; agreed order

Cleveland, TX

The Board alleged that Tristar-Cleveland in Cleveland dispensed controlled substances pursuant to invalid prescription orders. The pharmacy accepted an Agreed Board Order, which placed the license on 3-year probation with conditions and imposed a $7500 fine.

Nurse at a medical center in Caliente investigated for unaccounted morphine; license revoked

Caliente, NV

A nurse at a medical center in Caliente, Nevada, was investigated by the state for two 2015 incidents involving unaccounted morphine. The investigation indicated the nurse obtained morphine syringes for patients but failed to document whether the drug was administered, a protocol violation. The Nevada State Board of Nursing revoked the nurse's license for five years for unprofessional conduct in April, after the nurse was notified and summoned but did not appear at a March hearing.

Pharmacy technician diverted over 216,000 Norco tablets from a retail pharmacy while the pharmacist-in-charge failed to detect the theft

West Hills, CA

A pharmacy technician at a retail pharmacy diverted at least 216,630 tablets of Norco over roughly two years by ordering excess quantities on days she worked, hiding and unpacking them away from pharmacist oversight, destroying invoices, and carrying the drugs out in her purse. The pharmacist-in-charge who supervised the pharmacy was found to have failed to maintain accurate inventory records, secure the ordering system, and implement audit procedures that could have prevented or earlier detected the theft. The Board of Pharmacy revoked his license, stayed the revocation, and imposed three years' probation, a decision upheld on judicial review and affirmed by the Court of Appeal.

Minnesota Paramedic Stole Ambulance Morphine, Replaced It with Saline

Minneapolis, Minnesota

Matthew Richard Peterson, a paramedic employed by Allina Health, stole morphine and hydromorphone intended for ambulance patients between August and November 2013, extracting the drugs with a syringe and replacing the liquid with saline to cover his tracks. His tampering left more than 100 patients at greater risk of infection and untreated pain; he only came forward after co-workers discovered the scheme. He pleaded guilty to fraudulently acquiring controlled substances and was sentenced on July 16, 2015, to three years of probation.

Houston pharmacy pharmacist-in-charge dispensed controlled substances pursuant to invalid prescriptions; temporary suspension

Houston, TX

The Board found a continuing threat and entered a temporary suspension order against Rx Max Pharmacy in Houston. The pharmacist-in-charge had dispensed controlled substances pursuant to invalid prescription orders. The license was suspended until further order of the Board.