Diversion Case Studies

Boise hospital nurse diverted fentanyl vials by falsifying dispensing-system records

Boise, ID

A registered nurse at a Boise hospital had access to a system that monitored the distribution and management of prescription medications, including controlled substances. On at least 28 occasions, the nurse accessed the machine and removed fentanyl 100 mcg/2 mL vials by falsifying and manipulating information in the system, according to court records cited by the U.S. Attorney's office. The nurse pleaded guilty on Oct. 25, 2018, and was sentenced to three years of probation; the case was investigated by a DEA-led Tactical Diversion Squad.

Hilo clinic physician and employees accused of unlawfully distributing opioids

Hilo, HI

At a medical clinic in Hilo, a physician and four employees were arrested and accused of prescribing and unlawfully distributing powerful narcotics, sedatives and opioids, including hydrocodone, oxycodone, fentanyl and morphine. They are scheduled to stand trial in U.S. District Court in June.

Army hospital pharmacy technician admitted stealing and distributing hydrocodone and oxycodone

Oahu, Hawaii

A pharmacy technician at Tripler Army Medical Center was charged with and later admitted stealing and distributing 8,505 pills containing five milligrams of either hydrocodone or oxycodone from the hospital's pharmacy vault. The technician is serving a one-year sentence in a federal correctional institution in California.

KU Hospital Pharmacy Tech Stole 483 Bags of Fentanyl

Kansas City, Kansas

A pharmacy technician at the University of Kansas Hospital stole fentanyl from the hospital where his duties included stocking automated dispensing cabinets, taking 483 bags of the drug over time. He was sentenced in 2018 to three years of probation, and his pharmacy license was revoked.

Tribal pharmacy in St. Ignatius paid civil penalty after about 2,500 oxycodone pills went missing

Approximately 2,500 oxycodone pills were stolen or unaccounted for at the Confederated Salish and Kootenai Tribes' pharmacy in St. Ignatius, prompting a Drug Enforcement Administration inspection covering March 2017 to March 2018. The DEA alleged the pharmacy failed to adequately track controlled-substance records and failed to report the missing oxycodone. The pharmacy resolved the alleged violations through a civil settlement with the U.S. Attorney's Office, agreeing to pay a $95,520 penalty and to conduct annual compliance evaluations for three years; the settlement is not a finding of liability.

Arizona pharmacist and technician sentenced for diverting over 200,000 opioid tablets through two Phoenix-area pharmacies

A pharmacist who owned two Phoenix-area pharmacies and a pharmacy technician who worked for her were convicted in federal court of conspiring to distribute controlled substances and to launder drug proceeds. According to the U.S. Attorney's Office, from September 2014 until their arrest in July 2017 the pharmacies processed fraudulent prescriptions and distributed more than 200,000 oxycodone and hydrocodone tablets, thousands of alprazolam tablets, and more than 13 gallons of promethazine with codeine into the community. The pharmacist was sentenced on November 28, 2018 to 120 months in prison; the technician had earlier been sentenced to 48 months. Two coconspirators who created fraudulent prescriptions and distributed the drugs to street-level dealers were also convicted.

Confederated Salish and Kootenai Tribes' Pharmacy Settles Over Missing Oxycodone

St. Ignatius, Montana

The Confederated Salish and Kootenai Tribes' Pharmacy on the Flathead Indian Reservation agreed to pay a $95,520 civil penalty after a DEA inspection, prompted by roughly 2,500 oxycodone pills that were stolen or unaccounted for, found the pharmacy had failed to adequately track controlled-substance records and failed to report the missing pills to DEA. The pharmacy also agreed to certify compliance annually for three years or face a judgment of up to $240,640. The settlement was announced November 20, 2018.

Montana reservation pharmacy settled over 2,500 unaccounted-for oxycodone tablets

A pharmacy on Montana's Flathead Indian Reservation agreed to a $95,000 settlement after it could not account for about 2,500 oxycodone tablets over a one-year period ending March 2018. A Drug Enforcement Administration inspection found that staff were not adequately tracking controlled substances and that the pharmacy had not reported the missing oxycodone to the agency. The settlement, reached with the tribal government that operates the pharmacy, requires compliance with federal controlled-substance recordkeeping rules and exposes the pharmacy to a $240,000 fine for any future violations. A settlement is a negotiated resolution and not a finding of liability.

Registered nurse alleged to have diverted a controlled substance from a nursing facility in Mukwonago

Mukwonago, WI

A registered nurse was alleged to have diverted a controlled substance from a nursing facility in Mukwonago, Wisconsin, on or around November 7, 2018. The Wisconsin Board of Nursing accepted a stipulation and entered a final decision and order on September 10, 2020, accepting surrender of the nurse's license, barring reinstatement for at least one year, and imposing $632 in costs.

Physician charged with health care fraud and distributing Suboxone without medical necessity through a clinic

Dublin, OH

A federal grand jury charged a Central Ohio physician practicing in Dublin with charges related to a health care fraud scheme and with prescribing and distributing Suboxone without medical necessity. The scheme allegedly included marketing prescription creams in Sav-a-Lot and low-income neighborhoods and persistently mailing those creams to Medicaid customers. The physician was charged in a seven-count indictment and was scheduled for an initial appearance in federal court. The Board of Pharmacy collaborated on the investigation with the Ohio Attorney General's Medicaid Fraud Control Unit, HHS Office of Inspector General, DEA and FBI.

Two South Denver pharmacists pleaded guilty to felony opioid distribution charges

Two pharmacists practicing in south Denver pleaded guilty in federal court to felony charges related to the illegal dispensing and distribution of controlled substances, including opioids. The pleas were announced by the U.S. Attorney's Office for the District of Colorado and the DEA Denver Division in October 2018. The release does not describe the sentences imposed.

Hospital pharmacy technician diverted hydrocodone and oxycodone from a pharmacy vault through fraudulent automated dispensing transactions

A former pharmacy technician at Tripler Army Medical Center was sentenced to 12 months in jail and six years of court supervision after pleading guilty to one count each of possessing with intent to distribute hydrocodone and oxycodone. According to the report, she stole 8,505 pills, each containing 5 milligrams of either painkiller, from the hospital's pharmacy vault between February 2017 and March 2018, using her fingerprint and unique login to conduct 82 fraudulent transactions in the hospital's automated medication distribution and tracking system, which did not require a valid prescription for patients being discharged. The report states she supplied pills to her boyfriend and used some herself, and that she repaid the hospital $1,033 before sentencing.

Las Vegas nurse practitioner and surgical technician pleaded guilty to distributing hydrocodone and oxycodone prescriptions for cash

An advanced practice registered nurse and a surgical technician pleaded guilty in federal court in Las Vegas in October 2018 to unlawfully distributing prescription opioids, the U.S. Attorney for the District of Nevada announced. Investigators said that from about January to May 2018 the two conspired to distribute hydrocodone and oxycodone to people without a legitimate medical purpose in exchange for cash, with the technician meeting buyers in parking lots and handing out prescriptions from the nurse practitioner's pad bearing a physician's pre-signed DEA number. The nurse practitioner also pleaded guilty to health care fraud tied to prescriptions written without a legitimate medical purpose, which the government said cost Medicare and Medicaid approximately $3.7 million.

Arkansas nurse surrenders license after record reviews found controlled-substance diversion at two facilities

Reviews of medical records at an academic medical center in Little Rock and at a second facility uncovered diversion of controlled substances by a nurse, with the diversion dated to around September 2018. The nurse voluntarily surrendered the nursing license, and the matter was reported to the state licensure board.

University of Michigan Health System Pays $4.3M in Record Drug Diversion Settlement

Ann Arbor, Michigan

The University of Michigan Health System (UMHS) agreed to pay the United States $4.3 million, the nation's largest settlement of its kind at the time, to resolve allegations that it violated the Controlled Substances Act. DEA opened its investigation after two UMHS employees — a nurse and an anesthesiology resident — overdosed on opioids, including fentanyl, at a UMHS facility in December 2013, one fatally. The investigation found UMHS failed to secure DEA registrations for 15 off-site ambulatory care locations that received and dispensed narcotics from the main hospital pharmacy, and found significant recordkeeping violations including failing to timely notify DEA of thefts or significant losses of controlled substances. The settlement was announced August 30, 2018.

Pharmacy Technician Diverts Fentanyl at Iowa Methodist Medical Center

Des Moines, Iowa

Between August and October 2016, Victor Van Cleave, a pharmacy technician at Iowa Methodist Medical Center, diverted about 252 vials of fentanyl and 18 vials of hydromorphone meant for patients. He replaced the drugs with sterile water and was sentenced in 2018 to 30 months in federal prison.

Long Island pharmacy chain settled claims it failed to timely report controlled substance losses and thefts

A national retail pharmacy chain agreed to pay $1.5 million to resolve a federal investigation alleging that certain of its Long Island stores failed to timely report the loss or theft of controlled substances, including hydrocodone, as required by the Controlled Substances Act. The government said timely reporting is required so the DEA can promptly investigate possible diversion. The settlement resolved civil penalty claims and is not a finding of liability.

Pain clinic physician indicted for prescribing fentanyl, oxycodone and other controlled substances without patient examinations

Hamilton, OH

A federal grand jury charged a physician who owned and operated a pain clinic in Hamilton, Ohio, in a 114-count indictment arising from an alleged pill-mill operation. According to the indictment, patients were prescribed fentanyl, oxycodone, methadone, morphine and other controlled substances on many occasions without actually being seen by the doctor, and the practice allegedly billed Medicare, Medicaid and the Bureau of Workers' Compensation for medically unnecessary prescriptions. At least one patient allegedly died as a result of using the prescribed controlled substances. The physician is also alleged to have received more than $103,000 from a pharmaceutical company for purported speaking engagements about a fentanyl spray that were allegedly sham programs, and the state Board of Pharmacy had opened a joint investigation in October 2016 over concerns about prescribing that did not meet minimum standards of patient care.

ED Nurse Transmits Hepatitis C to Patients at Good Samaritan Hospital

Puyallup, Washington

A CDC investigation linked an August 2017-March 2018 hepatitis C outbreak of at least 12 patients to Cora Weberg, an ED nurse who admitted diverting injectable fentanyl and hydromorphone and replacing them with saline. Her contaminated syringes exposed patients to her blood, and she lost her nursing license.

Health system settles alleged opioid diversion case over tens of thousands of missing oxycodone 30 mg tablets

Springfield, GA

A Springfield, Georgia health system agreed to pay $4.1 million to settle alleged large-scale opioid diversion claims, according to the DEA. An investigation reportedly found tens of thousands of missing oxycodone 30 mg tablets spanning more than four years, and the system allegedly failed to notify authorities of the suspected diversion within the time required by federal law. The system said it has since overhauled its pharmacy recordkeeping and reporting and implemented electronic inventory systems.

Georgia hospital settles allegations over unaccounted 30 mg oxycodone tablets believed diverted

The U.S. Attorney’s Office for the Southern District of Georgia announced a $4.1 million civil settlement with a Georgia hospital over drug diversion allegations. The government alleged the hospital failed to provide effective controls and procedures to guard against theft and loss of controlled substances, leaving tens of thousands of 30 mg oxycodone tablets unaccounted for and believed diverted over four years, and failed to notify DEA of suspected diversion timely. The hospital agreed to a DEA performance improvement plan including quarterly internal accountability audits and controlled-substance tracking requirements.

North Colorado Medical Center Nurse Stole Opioids from Locked Dispensing System

Greeley, Colorado

Marlene Gilmore, a nurse at North Colorado Medical Center, stole fentanyl, morphine, and hydromorphone from the hospital's locked automated medication management system in 2016, with evidence showing she used the drugs while on duty. She pleaded guilty to theft of a controlled substance by deception and was sentenced on April 26, 2018, to four months in federal prison, in a case announced alongside a second Colorado nurse sentenced the same week for a similar scheme at a Denver VA hospital and ER.

Denver VA and ER Nurse Tampered with Fentanyl Vials, Resealed with Skin Glue

Denver, Colorado

Lisa Marie Jones, a nurse at the Veterans Affairs Medical Center in Denver and a free-standing UCHealth emergency room, stole hydromorphone, morphine, and fentanyl from both facilities in 2016 for personal use, primarily taking "waste" medication left over after administering doses to patients. She also tampered with two vials of fentanyl at the emergency facility, removing the drug, replacing it with saline, resealing the vials with skin glue, and returning them to the automated medication management machine for potential use on future patients; the tampered vials were discovered before reaching any patient. She pleaded guilty to theft of a controlled substance by deception and tampering with a consumer product, and was sentenced on April 19, 2018, to fourteen months in federal prison.

Springfield chain pharmacy technician admitted stealing thousands of hydrocodone tablets over nine months

A Springfield pharmacy technician entered a federal plea agreement admitting to stealing hydrocodone tablets over roughly nine months, from late July 2014 to mid-May 2015, while working at a chain pharmacy. According to the plea agreement described in news coverage, the technician exploited a flaw in the pharmacy's prescription tracking system to dispense hydrocodone prescriptions twice and route the duplicate pills out through the drive-through. The number of tablets was disputed: the plea agreement cited 20,676, state regulators cited approximately 38,000, and defense counsel said a later federal review put the figure closer to 6,000. Sentencing was scheduled for July 2018; the state licensing agency had placed the technician's expired license in refuse-to-renew status in July 2017.

UT Southwestern Pays $4.5M Over Staff Fentanyl Diversion and Two Nurse Overdose Deaths

Dallas, Texas

Two UTSW nurses were found dead in Clements University Hospital bathrooms after overdosing on diverted fentanyl — one on Dec. 15, 2016, and another on April 16, 2018. Investigators found the hospital failed to maintain effective controls, and in 2021 UT Southwestern paid a $4.5 million civil penalty.