Diversion Case Studies

Sentara Norfolk Pharmacy Technician Stole 50,000+ Controlled Substance Units

Norfolk, Virginia

A licensed pharmacy technician at Sentara Norfolk General Hospital was responsible for restocking the hospital's automated medication dispensing/monitoring system with controlled substances. From April 2018 to October 2019 he stole controlled substances, including thousands of opioid pills, and falsified the system's records to cover his theft. He avoided camera systems, intercepted daily audit reports that would have exposed the diversion, and swapped in reports from cabinets he had not accessed. The scheme was uncovered by the supervising pharmacist and a technician while he was on personal leave. He pleaded guilty to acquiring more than 50,000 dosage units of controlled substances through fraud, facing up to four years in prison.

South Dakota hospital nurse convicted of tampering with fentanyl vials and replacing contents with saline

Chamberlain, SD

A registered nurse at a hospital in Chamberlain, South Dakota, tampered with a vial of fentanyl citrate for injection by removing the fentanyl and replacing the majority of it with saline solution, then returned the tampered vial to storage. The nurse pleaded guilty and was convicted of obtaining a controlled substance by misrepresentation, fraud, forgery, deception, and subterfuge. The nurse was sentenced to two years of probation and a $100 special assessment. The incidents occurred between June 19, 2021, and September 11, 2021.

Registered pharmacy technician took controlled substances from a pharmacy for purposes of sale

A registered pharmacy technician took controlled substances from a pharmacy for purposes of sale, according to an agreed board order. The board imposed a 30-day suspension and 5 years probation.

Registered pharmacy technician took controlled substances from a pharmacy for use by a family member

A registered pharmacy technician took controlled substances from a pharmacy for use by a family member, according to a default board order. The board revoked the registration.

Intermountain Healthcare Nurse Tampered with Hydromorphone Syringes

Salt Lake City, Utah

A nurse on a surgical and trauma ward at an Intermountain Healthcare facility diverted hydromorphone from pre-loaded syringes for his own use, replaced it with saline, and returned the syringes — now containing greatly reduced amounts of the pain medication — to circulation for use by other hospital staff on patients. Hospital staff reported his activity to federal law enforcement, and he was also convicted of lying to an FDA special agent about his conduct during the investigation. A federal jury convicted him on three counts related to fraudulently obtaining and tampering with hydromorphone, with sentencing scheduled to follow.

Hospital nurse convicted of diverting hydromorphone from pre-loaded syringes and replacing it with saline

Sandy, UT

A former nurse at Intermountain Healthcare was convicted by a federal jury of stealing narcotics from a surgical and trauma ward and replacing painkillers with saline in syringes intended for other hospital staff. Prosecutors said the nurse diverted hydromorphone from pre-loaded syringes for personal use, replaced the pain medication with saline solution, and returned the syringes containing greatly reduced amounts of hydromorphone for medical use by other staff. The nurse was convicted of three counts related to fraudulently obtaining and tampering with hydromorphone, a Schedule II opioid, and of making false statements to an FDA special agent during the investigation.

Pain clinic physician pleaded guilty to operating a pill mill and selling oxycodone for kickbacks

Columbus, OH

A former physician pleaded guilty on July 15, 2021 to operating a pill mill out of his Columbus pain practice for more than seven years and selling oxycodone in exchange for financial kickbacks. He also staged a break-in at the practice to support a fraudulent insurance claim. He was sentenced to five years on probation, fined $5,000, ordered to forfeit more than $524,000 in proceeds, and required to surrender his medical license and DEA registration.

Massachusetts ER Nurse Tampered with Hydromorphone and Meperidine

West Boylston, Massachusetts

A nurse working in a Massachusetts hospital emergency department used his credentials to enter false 'cancel' and 'return to stock' transactions in the automated dispensing machine, allowing him to remove carpujects (syringe devices) containing hydromorphone and meperidine intended for patients in pain. He punctured the carpujects to withdraw the drugs for his own use, then refilled several with saline and returned them to the machine, where they remained available for other nurses to unknowingly administer to patients. He had previously agreed not to practice nursing after being terminated from a prior job but did not disclose that to his new employer. He pleaded guilty to tampering with a consumer product and acquiring a controlled substance by deception, and was sentenced to one year and one day in prison, with the first year in home confinement, plus three years of supervised release.

Nurse Tampered with Fentanyl Vials at Yale Fertility Clinic

Orange, Connecticut

Donna Monticone, a nurse who ordered and inventoried narcotics at the Yale fertility clinic, began stealing fentanyl for personal use in June 2020 and replaced the drug in vials with saline before returning them to stock. About 75 percent of the fentanyl given to patients that summer was found adulterated.

Nurse Arrested for Stealing 1,400+ Vials of Fentanyl from Long Island Hospital

Manhasset, New York

Melissa Frame, a nurse at North Shore University Hospital in Manhasset, New York, allegedly used her fingerprint to access a medication dispensing machine more than 50 times between October and December 2020, stealing 1,467 vials of fentanyl and 223 vials of midazolam. She falsified patient names against the withdrawals and was arrested and charged in May 2021.

Minnesota pharmacist caught on video pocketing amphetamines; suspension stayed with monitoring

Pharmacy video surveillance showed a Minnesota pharmacist placing Schedule II controlled substances into clothing pockets on four dates in June and July 2019. The pharmacist admitted removing amphetamines one to two times a week since January 2019 for personal use, about 60 to 80 tablets in total, and using them while on duty. After a chemical use assessment and a voluntary agreement to cease practice, the Board of Pharmacy in May 2021 suspended the license but stayed the suspension on conditions including monitoring through the state health professionals program and abstinence from mood-altering chemicals.

Minnesota pharmacy technician took oxycodone from filled patient prescriptions; registration surrendered

A review of pharmacy video surveillance in January 2021 showed a Minnesota pharmacy technician opening a filled prescription bag in the will-call area, pouring tablets from the vial into her hand and placing them in her pocket. When confronted by a loss prevention manager, the technician admitted stealing the pills, turned over ten oxycodone tablets, and later estimated to local law enforcement that she had taken prescription pills from patients on about ten occasions to treat her own pain. The Board of Pharmacy accepted the voluntary surrender of her registration at its May 2021 meeting.

Dothan Pharmacy Owner Sentenced for Selling Opioids Without Prescriptions

Dothan, Alabama

A licensed pharmacist owned and operated Allen's Pharmacy in Dothan, Alabama, where he personally sold Schedule II controlled substances directly to customers for cash instead of dispensing them against valid prescriptions. The Dothan Police Department opened an investigation after an anonymous tip that someone was selling prescription medications out of the pharmacy without a prescription, and DEA agents confirmed the pharmacist was selling oxycodone and hydrocodone outside any legitimate dispensing process. He was indicted by a federal grand jury in July 2020 and pleaded guilty in January 2021, specifically admitting to selling 14 hydrocodone pills to an individual for cash without a prescription. He was sentenced to 87 months in federal prison and three years of supervised release.

Fontana pharmacy technician's registration revoked over diversion of 117 tramadol tablets

The California Board of Pharmacy revoked a pharmacy technician's registration after an administrative law judge found, by a preponderance of the evidence, that the technician diverted 117 tramadol 50 mg tablets from her employer over several days in May. The pharmacist-in-charge had reported the loss to the Board as suspected employee theft. An interim suspension order issued in December 2020 was a temporary measure pending the hearing; the revocation decision was adopted on April 26, 2021 and took effect May 26, 2021.

Nursing Home Employees Sentenced for Stealing and Reselling Patients' Alprazolam

Brunswick, Georgia

Rochella Ellison, a guest services representative, and Nadia Gibson, a licensed practical nurse, worked together at a Brunswick, Georgia nursing and personal care facility to steal alprazolam from patient supplies and resell it for profit between December 2019 and early 2020. Both pleaded guilty to conspiracy to distribute the drug and were sentenced to probation in April 2021.

Lowell Nursing Home Nurse Diverted Hospice Patients' Liquid Morphine

Lowell, Massachusetts

A registered nurse at a Lowell, Massachusetts nursing home tampered with bottles of liquid morphine prescribed to two elderly hospice patients under his care, taking the morphine for his own use and replacing it with saline or Benadryl to conceal the theft. In a separate incident at a Melrose nursing home, he diverted liquid morphine from a hospice patient's bottle and falsely recorded in the patient's medical file and the Medication Administration Record that the morphine was undiluted. He pleaded guilty to tampering with a consumer product and acquiring a controlled substance by deception, and was sentenced to 42 months in prison and three years of supervised release.

Westfield Nursing Facility Nurse Diluted Hospice Patient's Morphine

Westfield, Massachusetts

A nurse at Governor's Center, a nursing facility in Westfield, Massachusetts, tampered with a bottle of morphine prescribed to a hospice patient by removing some of the morphine and diluting the remainder with another substance. The patient received diluted doses of her prescribed pain medication in the days shortly before her death. After ingesting the diverted morphine, the nurse was observed to be significantly impaired while providing patient care at the facility. She pleaded guilty to tampering with a consumer product, a charge carrying up to 10 years in prison, with sentencing scheduled for June 2021.

Roswell Park Cancer Center Nurse Tampered with Patients' Hydromorphone

Buffalo, New York

Kelsey Mulvey, a registered nurse at Roswell Park Comprehensive Cancer Center, tampered with and stole hydromorphone from medication dispensing machines between February and June 2018, canceling transactions to leave drawers open, removing the drug, and replacing it with water before returning vials to the machine. Her tampering caused a spate of waterborne bacterial infections that sickened six cancer patients between June and July 2018, with lab testing finding some vials had roughly 80 percent of their hydromorphone removed and replaced with contaminated water. She pleaded guilty in March 2021 to tampering with a consumer product.

Registered nurse accused of diverting controlled substances from Wisconsin health care facilities

Waukesha, WI

A registered nurse employed at multiple Wisconsin health care facilities was accused of diverting controlled substances for personal use and repeatedly performing improper administration and wasting of controlled substances. Complaints also alleged obtaining and ingesting steroids without a prescription, stealing saline syringes, impairment at work, and failed reasonable suspicion drug tests. The nurse neither admitted nor denied the allegations, and no Board determination on violations had been made. Under an interim order, the nurse's Wisconsin license was suspended pending investigation and final resolution, and the nurse voluntarily agreed not to practice in Wisconsin or under multistate privileges.

Connecticut fertility clinic nurse replaced fentanyl with saline, leaving patients in pain

A nurse at a Connecticut fertility clinic pleaded guilty in March 2021 to tampering with a consumer product after court records showed she had been stealing fentanyl from the clinic's supply for months in 2020. Investigators said she drained fentanyl vials for her own use, refilled them with saline, and returned them to the clinic shelves. Attorneys for patients said at least 95 fertility patients received saline instead of pain medication during procedures such as egg retrieval.

Meriden pharmacy settled after DEA audit found 2,000-tablet controlled substance shortage

A Meriden pharmacy and its owner entered into a civil settlement with the federal government to resolve allegations of Controlled Substances Act violations. A 2018 DEA audit found a shortage of more than 2,000 tablets of various controlled substances, and the government alleged failures in recordkeeping, controls against diversion, timely theft or loss reporting, biennial inventory, and order form completion. The pharmacy agreed to pay $16,800 plus interest and to hire an independent third-party pharmacy consultant under a memorandum of agreement with the DEA. The settlement is not a finding of liability.

VA Hospice Nurse Sentenced for Diluting Dying Veterans' Morphine

Bedford, Massachusetts

Kathleen Noftle, a nurse in the hospice unit at the VA Medical Center campus in Bedford, Massachusetts, used her position over three days in January 2017 to obtain morphine doses meant for veterans under her care, mixing tap water into the liquid morphine before administering the diluted medication to patients and drinking the diverted portion herself. She pleaded guilty in October 2020 to tampering with a consumer product and obtaining a controlled substance by fraud, and was sentenced in February 2021 to 40 months in federal prison.

Former pharmacist-in-charge and three others charged in Warren County oxycodone diversion scheme

State and federal authorities announced the arrests of four people, including a pharmacy's former pharmacist-in-charge, on charges they conspired to illegally obtain and distribute oxycodone and promethazine out of a Warren County pharmacy between April 2018 and October 2019. Prosecutors allege more than 30,000 high-dose oxycodone tablets were diverted using falsified prescriptions written on blanks stolen from two hospitals, and that the pharmacist agreed to fill the illegitimate prescriptions in exchange for payment. The charges are accusations only; the pharmacist had earlier entered a consent order voluntarily surrendering her license, deemed a temporary suspension pending further Board action.

Assisted living facility nurse diverted Vicodin from a resident for personal use

Sturgeon Bay, WI

The Board of Nursing found that a registered nurse diverted Vicodin from a resident at an assisted living facility in Sturgeon Bay, Wisconsin, on April 30 and May 1, 2019, for personal use. The nurse admitted having a substance abuse problem at the time of the diversion and was diagnosed with opioid and stimulant use disorders. The Board suspended the nurse’s license indefinitely, subject to possible stay upon compliance with treatment, drug testing, and practice restrictions.

Oklahoma physician, pharmacist and clinic owner sentenced over pre-signed prescription scheme

A federal grand jury indicted a physician, a pharmacist and a clinic owner in June 2018 on 103 counts related to dispensing controlled substances using invalid prescriptions and billing Medicare for them. According to the indictment, from September through December 2015 the physician supplied pre-signed blank prescription pads and the clinic owner supplied patient records, which the pharmacist allegedly used to prepare invalid refills for opioids including hydrocodone, morphine and fentanyl. All three pleaded guilty and were sentenced to probation in January and February 2021, with the physician and pharmacist agreeing to surrender their Oklahoma licenses.