Diversion Case Studies

VA Nurse Diverted Narcotics from Dying Veterans at West Haven VA

West Haven, Connecticut

Tara Severino, an RN at the West Haven VA Medical Center, diverted narcotics from sick and dying veterans in the ICU between January and July 2023, in one case keeping part of a patient's dose for herself. She falsified disposal records and was sentenced to two years of probation with home confinement.

Savannah-Area Weight-Loss Clinic Physician Pays $100,000 Over Controlled-Substance Recordkeeping Failures

Savannah, Georgia

Dr. Donald Lyle Gates, who operates Scale Solutions weight-loss clinics in the Savannah, Georgia area, agreed to pay a $100,000 civil penalty to resolve allegations that he violated the Controlled Substances Act's recordkeeping requirements. A DEA inspection found that Gates's offices lacked complete and accurate records of the controlled substances he was responsible for, including inventories and documentation of receipt, distribution, and dispensing of the weight-loss drugs phentermine and phendimetrazine. Investigators also alleged Gates repeatedly removed controlled substances from his DEA-registered office locations and stored them at his home. Gates agreed to a two-year term of increased DEA oversight while retaining his registrations to dispense controlled substances.

Hawaii nurse alleged to have swapped a patient's Adderall tablets for Seroquel

Hawaii's Regulated Industries Complaints Office alleged that a nurse was terminated by her employer, a treatment center operating as Nova Luna Center and ʻAi Pono Hawaii, after she allegedly removed four Adderall tablets from a patient's medication pill packet and replaced them with four Seroquel tablets. RICO further alleged she had no authorization to possess, obtain, furnish or administer the Adderall herself, in potential violation of the state nursing statute and Board of Nursing rules. The matter was resolved through a Board-approved settlement agreement, which is a compromise of claims and not a finding of liability. The action was included in the DCCA disciplinary summary covering actions through August 2024.

Former nurse accused of replacing fentanyl with tap water in IV drips at Oregon hospital

Medford, OR

Attorneys representing living and deceased patients filed a $303 million wrongful death and medical malpractice lawsuit against an Oregon hospital after a former nurse was accused of replacing prescribed fentanyl with nonsterile tap water in intravenous drips. The complaint accuses the hospital of negligence and failing to monitor medication administration and prevent drug diversion by employees. Police began investigating after hospital officials noticed a spike in central line infections and said they believed an employee had been diverting fentanyl; the former nurse was arrested in June and charged with 44 counts of second-degree assault and has pleaded not guilty.

Pharmacy technician charged with diverting controlled substances on multiple occasions

Cowlitz County, Washington

In September 2024, the Pharmacy Quality Assurance Commission charged a pharmacy technician with unprofessional conduct. The charges state the technician admitted to diverting controlled substances on multiple occasions while employed as a pharmacy technician in 2023. The case was listed under Cowlitz County in the state disciplinary summary.

Home care aide accused of failing to administer and account for residents' narcotic medications

In September 2023, a home care aide allegedly failed to document and potentially failed to administer required narcotic medications to multiple residents she was caring for. She also allegedly failed to complete required narcotic counts and did not respond to the Department of Health's attempts to investigate. The Home Care Aide Program charged her with unprofessional conduct in September 2024.

Gate City Pharmacist Tampered with Oxycodone and Hydromorphone Tablets

Gate City, Virginia

A pharmacist in Gate City, Virginia, was sentenced to 24 months in federal prison after pleading guilty to tampering with oxycodone and hydromorphone at the pharmacy where he worked. He swapped oxycodone tablets with prednisone, a steroid, and hydromorphone tablets with leflunomide, a rheumatoid arthritis drug, then dispensed the substituted pills to patients. He also shorted some patients' prescriptions and kept the withheld pills for himself. Investigators warned the tampering created a risk that a pharmacist filling a later prescription could unknowingly dispense the wrong drug to a customer, endangering patients relying on legitimate pain or inflammation control.

Tennessee Board of Nursing accepts surrender of practical nurse over Gallatin diversion

Gallatin, Tennessee

The Tennessee Board of Nursing disciplined a licensed practical nurse in Gallatin over controlled-substance diversion, according to the August 2024 disciplinary action report. The order records that the licensee diverted controlled substances from their employer, and the board accepted a voluntary surrender of the license. A board order is an administrative finding on the board's own investigation, not a criminal conviction, and the report states no quantity.

Tennessee Board of Nursing suspends registered nurse over Riceville diversion

Riceville, Tennessee

The Tennessee Board of Nursing disciplined a registered nurse in Riceville over controlled-substance diversion, according to the August 2024 disciplinary action report. The order records that the licensee diverted controlled substances from their employer, and the board suspended the license with terms. A board order is an administrative finding on the board's own investigation, not a criminal conviction, and the report states no quantity.

Tennessee Board of Nursing accepts surrender of advanced practice nurse over Hendersonville diversion

Hendersonville, Tennessee

The Tennessee Board of Nursing disciplined a advanced practice nurse in Hendersonville over controlled-substance diversion, according to the August 2024 disciplinary action report. The order records that the licensee diverted controlled substances from their employer, and the board accepted a voluntary surrender of the license. A board order is an administrative finding on the board's own investigation, not a criminal conviction, and the report states no quantity.

Tennessee Board of Nursing suspends registered nurse over Memphis diversion

Memphis, Tennessee

The Tennessee Board of Nursing disciplined a registered nurse in Memphis over controlled-substance diversion, according to the August 2024 disciplinary action report. The order records that the licensee diverted controlled substances from their employer, and the board suspended the license. A board order is an administrative finding on the board's own investigation, not a criminal conviction, and the report states no quantity.

Tennessee Board of Pharmacy accepts surrender of pharmacy technician over Knoxville diversion

Knoxville, Tennessee

The Tennessee Board of Pharmacy disciplined a pharmacy technician in Knoxville over controlled-substance diversion, according to the August 2024 disciplinary action report. The order records that the licensee diverted controlled substances from their employer, and the board accepted a voluntary surrender of the license. A board order is an administrative finding on the board's own investigation, not a criminal conviction, and the report states no quantity.

Tennessee Board of Pharmacy revokes pharmacy technician over Dayton diversion

Dayton, Tennessee

The Tennessee Board of Pharmacy disciplined a pharmacy technician in Dayton over controlled-substance diversion, according to the August 2024 disciplinary action report. The order records that the licensee diverted controlled substances from their employer, and the board revoked the license. A board order is an administrative finding on the board's own investigation, not a criminal conviction, and the report states no quantity.

Tennessee Board of Nursing disciplines registered nurse over Soddy Daisy diversion

Soddy Daisy, Tennessee

The Tennessee Board of Nursing disciplined a registered nurse in Soddy Daisy over controlled-substance diversion, according to the August 2024 disciplinary action report. The order records that the licensee diverted controlled substances from their employer, and the board imposed discipline. A board order is an administrative finding on the board's own investigation, not a criminal conviction, and the report states no quantity.

Pharmacist-in-charge convicted of conspiring to dispense oxycodone through a co-owned pharmacy to individuals with illegitimate prescriptions

A pharmacist pleaded guilty in the U.S. District Court for the Southern District of Florida to one count of conspiracy to distribute and dispense a controlled substance. In the plea agreement, the pharmacist admitted that he and co-conspirators, through a pharmacy he co-owned and operated as the pharmacist-in-charge, dispensed oxycodone 30 mg pills to individuals with obviously illegitimate prescriptions for cash. The pharmacist was responsible for unlawfully dispensing and distributing at least 12,494 oxycodone 30 mg pills to five individuals for approximately $96,600 in cash. The Maryland Board of Pharmacy revoked the pharmacist's license based on the conviction.

Maui nurse sanctioned after alleged diversion of Adderall from patient medication packet

The Hawaii State Board of Nursing sanctioned a Maui nurse with a $5,000 fine on Aug. 1, 2024, in a board-approved settlement agreement. The state alleged the nurse was terminated by Nova Luna Inc., dba Nova Luna Center and 'Ai Pono Hawaii, because she diverted four Adderall tablets from a patient's medication pill packet, replaced them with four Seroquel tablets, and had no authorization to possess, obtain, furnish, or administer the Adderall herself.

Hospital certified nursing assistant and registered medical assistant charged with diverting oxycodone from a patient

Spokane County, Washington

In August 2024, the secretary of health charged a certified nursing assistant and registered medical assistant with unprofessional conduct. The alleged facts state that from November to December 2021, the aide falsely identified herself as a patient's sister at the hospital where she was employed and diverted oxycodone from that patient. She also allegedly provided the patient Adderall and Remeron without a prescription, and in January 2022 her urinalysis was positive for alprazolam without a prescription. The case was charged and is subject to the disciplinary process.

Hospital Pharmacy Manager Stole 35,000+ Opioid Vials from Secure Vault

Muncie, Indiana

Christopher Knoth, pharmacy manager at IU Health Ball Memorial Hospital, was arrested in July 2024 after an audit and search warrant revealed he had taken hydromorphone, methadone, and morphine vials from the hospital's secure vault over roughly five years. Felony charges were filed in August 2025.

Grand Forks Surgery Center Nurse Suspended Over Suspected Medication Diversion

Grand Forks, North Dakota

The North Dakota Board of Nursing accepted a Stipulation for Settlement on July 25, 2024 for Sherry Fjestad, an RN/LPN employed at North Dakota Surgery Center in Grand Forks from August 2021 until she was terminated in May 2024 amid allegations of suspected diversion of controlled medications. The Board suspended her license indefinitely and assessed a $2,000 penalty plus costs.

Oklahoma City Anesthesiologist Convicted of Diverting Hospital Opioids

Oklahoma City, Oklahoma

A federal jury convicted a contract anesthesiologist on 18 counts of obtaining controlled substances by deceit or subterfuge after he exploited his hospital access to divert fentanyl, ketamine, hydromorphone, and midazolam. On at least six occasions in March 2022, he withdrew large quantities of controlled substances by claiming they were needed for patient surgeries he was not scheduled to perform and did not perform, then falsely reported disposing of the drugs while keeping them for himself. He was indicted in September 2023 and convicted at trial in July 2024, facing up to four years in federal prison on each of the 18 counts.

Manchester hospital agreed to pay $300,000 to resolve controlled-substance recordkeeping allegations after fentanyl diversion

Catholic Medical Center in Manchester, New Hampshire agreed to pay $300,000 to resolve allegations that it failed to keep accurate records of controlled substances, including opioids. A Drug Enforcement Administration audit found the hospital's records did not accurately reflect its inventory for seven controlled substances, including fentanyl. The allegations arose from an investigation into a nurse anesthetist who diverted leftover fentanyl and falsified disposal records. The settlement is not a finding of liability, and the hospital did not admit wrongdoing.

Catholic Medical Center Pays $300,000 Over CRNA's Fentanyl Diversion

Manchester, New Hampshire

Catholic Medical Center in Manchester, New Hampshire, agreed to pay $300,000 to resolve allegations it violated the Controlled Substances Act by failing to keep accurate records of controlled substances, after an independent certified registered nurse anesthetist stole fentanyl from the hospital for nearly a year. The nurse removed fentanyl from syringes intended for operating-room patients, replaced it with saline and hydromorphone, and falsely recorded leftover doses as wasted rather than actually discarding them, generating false wasting records. A DEA audit found the hospital's controlled-substance inventory records for seven drugs, including fentanyl, did not match the quantities actually on hand, and that it lacked effective controls to prevent theft. The nurse pleaded guilty in June 2024 to tampering with consumer products; the hospital did not admit liability but implemented new controls.

Hospital pharmacy manager diverted hydromorphone, methadone and morphine from a CII safe using unused transaction types

Muncie, IN

A proposed settlement agreement before the Indiana Board of Pharmacy states that a hospital pharmacist serving as pharmacy manager used normally-unused transaction types in the hospital's automated inventory system to remove controlled substances from the CII safe and take personal possession of them between November 2020 and July 2024, using his duty to transfer controlled substances to affiliated outpatient centers as cover. The agreement states the hospital lacked auditing and comparison procedures that would have detected the discrepancies between amounts recorded as utilized at the outpatient centers and actual patient utilization. The hospital reported the suspected loss to the DEA and the Board in July 2024 and disclosed the loss of hydromorphone, methadone and morphine on an amended DEA Form 106. Under the agreement the hospital's pharmacy license and controlled substances registration would be placed on indefinite probation for not less than three years with a $44,000 fine, and criminal charges were filed against the pharmacist in 2025.

Okanogan County nurse admitted diverting controlled substances; hydromorphone removal cited

Okanogan County, WA

In July 2024, the Board of Nursing (formerly the Nursing Commission) entered an agreed order with conditions with a registered nurse and advanced registered nurse practitioner. The nurse must continue to comply with a monitoring program. In October 2023, the nurse removed hydromorphone for multiple patients who did not have orders for hydromorphone and did not document the administration or waste of the medication. The nurse admitted to diverting controlled substances for approximately two years.

Telehealth Firm Done Global Indicted in $100M Adderall Distribution Scheme

San Francisco, California

In June 2024, DOJ indicted Done Global founder and CEO Ruthia He and clinical president David Brody for a $100 million scheme that allegedly caused the dispensing of millions of doses of Adderall and other stimulants without a legitimate medical purpose. Both were later convicted at trial.