Diversion Case Studies

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.

UC San Diego anesthesiologist's license revoked after alleged sedative diversion and saline substitution

According to a law-firm blog summarizing news reports and Medical Board of California records, an anesthesiologist at UC San Diego Medical Center had his license revoked in April 2018 following an interim suspension in September 2017. The blog reports that the physician acknowledged a long-term addiction to sedative drugs diverted from hospital supplies and patients, and that he was accused of administering anesthesia while impaired and substituting saline for drugs such as morphine and fentanyl in roughly 800 patient cases. The board accusation reportedly cited dangerous drug use and falsified medical records. The blog cautions that its case facts may be inaccurate.

Meridian nurse practitioner pleaded guilty to swapping hydrocodone in clinic cabinets for muscle relaxants and forging prescriptions

A nurse practitioner employed by a medical organization with multiple facilities in Idaho pleaded guilty in federal court to obtaining controlled substances by fraud, identity theft and misbranding a drug held for sale. According to court records, on at least seven occasions the practitioner accessed locked medication cabinets without authorization, removed bottles of hydrocodone, replaced the pills with a muscle relaxant, resealed the bottles and returned them to the back of the cabinet. The practitioner also forged two prescriptions for hydrocodone using another provider's information. Sentencing was set for June 5, 2018.

Delaware nurse who impersonated a doctor to obtain Xanax lost bid to regain license after permanent revocation

In 2008, a Delaware nurse impersonated a doctor to obtain Xanax for personal use and pleaded guilty to obtaining a controlled substance by misrepresentation or fraud, with the conviction taking effect after the terms of a court diversion program were not met. The Board of Nursing suspended the nurse's licenses in 2011, and after the nurse continued to practice for eight months during the suspension, the Board permanently revoked the licenses. A 2015 gubernatorial pardon of the conviction did not restore eligibility, and the Delaware Supreme Court affirmed the Board's denial of new license applications in February 2018.

Delaware nurse who obtained Xanax by impersonating a doctor loses bid to regain license

A Delaware nurse pled guilty to obtaining a controlled substance by misrepresentation or fraud after impersonating a doctor in 2008 to obtain Xanax for personal use. The Board of Nursing suspended her licenses in 2011, and after she worked as a nurse for eight months while the suspension was in effect, the Board permanently revoked them. Following a 2015 gubernatorial pardon of the criminal conviction, she applied for licensure again; the Board denied the applications, and in February 2018 the Delaware Supreme Court affirmed, reasoning that the permanent revocation rested on practicing without a license rather than on the pardoned conviction.

Home-Infusion Pharmacy Tech Diluted Hospice Patients' IV Opioids

Birmingham, Alabama

The lead pharmacy technician at ContinuumRx of Central Alabama prepared the vast majority of the company's IV bags of morphine and hydromorphone for terminally ill hospice and homecare patients in debilitating pain. Between December 2014 and September 2016, he removed the opioids from vials with a syringe, replaced the withdrawn amount with saline or sterile water, and returned the diluted vials to inventory undetected, later using them to compound IV bags that were distributed to hospice patients. He pleaded guilty to tampering with a consumer product and was sentenced on February 21, 2018, to five years in federal prison.

Wyoming hospital nurse sentenced for diluting hydromorphone and meperidine vials

A former registered nurse at a hospital in Douglas, Wyoming, was sentenced in federal court in February 2018 to eight months of imprisonment after pleading guilty to one count of tampering with a consumer product and one count of acquiring a controlled substance by misrepresentation, deception or subterfuge. A September 2017 grand jury indictment alleged that 58 vials of hydromorphone and a container of meperidine were tampered with by removing some or all of the drug and replacing it with saline solution. The sentence also imposed three years of supervised release with home confinement and substance abuse treatment requirements.

Former registered nurse at Memorial Hospital of Converse County sentenced for stealing hydromorphone and meperidine and replacing them with saline

Douglas, WY

A former registered nurse at Memorial Hospital of Converse County in Douglas, Wyoming, was sentenced in federal court in February 2018 for stealing narcotics and diluting patients' narcotics. The former nurse had pleaded guilty in November to one count of tampering with a consumer product and one count of acquiring a controlled substance by misrepresentation, deception or subterfuge. An indictment alleged tampering with 58 vials of hydromorphone (Dilaudid) and one container of meperidine (Demerol) by removing some or all of the drug and replacing it with saline solution. The sentence was two concurrent eight-month prison terms and two concurrent three-year supervised release terms, and the state nursing board suspended the nurse's license.

Former pharmacy-tech trainee at Little Rock VA hospital sentenced to prison for role in opioid theft and sales

A former pharmacy-technician trainee at the Veterans Affairs hospital in Little Rock was sentenced in mid-February 2018 to two and a half years in federal prison. The sentence was for her role in a conspiracy to distribute opioids that a co-worker had stolen from a hospital supplier.

Arizona Pharmacist Sentenced in Opioid Diversion Case (2018)

Arizona

Peoria, Arizona pharmacist Vilawoe Aku Boadu, owner of Scottsdale Health Pharmacy and V-Estrella Pharmacy, was sentenced to 120 months in prison for diverting more than 200,000 oxycodone and hydrocodone tablets.

Kentucky Pharmacist Convicted in Opioid Diversion Case (2018)

Kentucky

Pharmacist and pharmacy owner in Ashland, KY pleaded guilty on or about Aug. 21, 2018 to a conspiracy to misbrand oxycodone and hydrocodone, announced by the U.S. Attorney in Charleston, WV.

New Mexico Nurse Sentenced in Opioid Diversion Case (2018)

New Mexico

Albuquerque hospice nurse was sentenced to three years in prison on a conspiracy to distribute oxycodone and to acquire it by fraud and deceit.

North Carolina Nurse Charged in Opioid Diversion Case (2018)

North Carolina

The NC SBI arrested Mission Hospital nurse Meg Elizabeth Eisenhower on three counts of felonious embezzlement of a controlled substance for allegedly diverting liquid fentanyl in April-June 2017 from the hospital's Neuro-Trauma ICU in Asheville.