Diversion Case Studies

Palomar Health Pays $250,000 Over Fentanyl Diversion in Cath Lab

Escondido, California

Palomar Health, California's largest public health care district, paid $250,000 to resolve allegations that fentanyl was diverted from its Cardiac Catheterization Lab in Escondido and that the district failed to keep accurate controlled-substance records. The government's investigation, opened after Palomar Health self-disclosed that an employee may have diverted controlled substances, concluded that numerous vials of fentanyl were removed from the lab's automated medication dispensing machines over a five-month period and that unused fentanyl was not properly disposed of. In addition to the payment, Palomar Health entered a memorandum of agreement with the DEA requiring enhanced security, specialized staff training, and improved controlled-substance handling procedures.

Registered nurse charged with stealing oxycodone and hydrocodone/acetaminophen from residents at Prince George Healthcare Center

Georgetown, SC

A registered nurse employed at Prince George Healthcare Center in Georgetown, South Carolina, was arrested and charged with six counts of exploitation of a vulnerable adult and six counts of theft of a controlled substance, first offense. The charges allege that between February 19 and March 7, 2023, the nurse stole for personal use and withheld oxycodone and hydrocodone/acetaminophen prescribed to six residents. The case was reported by the facility to the Georgetown Police Department and investigated by the South Carolina Attorney General’s Vulnerable Adults and Medicaid Provider Fraud unit and the state Bureau of Drug Control.

ICU nurse accused of diverting patients' liquid fentanyl and replacing it with tap water at a Medford, Oregon hospital

Medford, OR

Police in Medford, Oregon, announced the arrest of a former intensive care unit nurse on suspicion of swapping patients' pain medication with tap water. According to a police statement, there was concern that the nurse had been diverting patients' liquid fentanyl for personal use and then replacing it with tap water, causing serious infections; the arrest followed a hospital report of a growing number of central line infections. The nurse faces 44 counts of second-degree assault, charges police said reflect the total number of patients the investigation revealed to have been affected. A lawsuit filed in March alleged that a hospitalized patient's pain medication was replaced with nonsterile tap water, introducing bacteria that led to death; the nurse also voluntarily agreed in November 2023 to a nursing license suspension pending completion of an investigation.

Registered nurse and advanced practice nurse charged after removing hydromorphone without patient orders and admitting to diverting controlled substances from the workplace

Okanogan County, Washington

The Washington State Board of Nursing charged a registered nurse and advanced registered nurse practitioner with unprofessional conduct in June 2024. Charges state that in October 2023 the nurse removed hydromorphone for multiple patients who had no orders for the drug and did not document its administration or waste. The nurse admitted to diverting controlled substances from the workplace for personal use over roughly two years. The case is pending.

Texarkana pharmacist pleads guilty to falsifying records to conceal theft of methadone and other narcotics

A former staff pharmacist at a Texarkana, Arkansas pharmacy pleaded guilty in the Western District of Arkansas to altering records to hide thefts of narcotics between April 2023 and April 2024. Court records state the pharmacist used the pharmacist-in-charge's login to conceal the thefts and allegedly took the drugs for personal use over a long period. The pharmacist was released on an unsecured appearance bond pending sentencing, and the Arkansas State Board of Pharmacy lists the license as suspended.

Madera pharmacist pleaded guilty to dispensing over 200,000 opioid pills on forged prescriptions

A Madera pharmacist pleaded guilty in federal court to conspiring to distribute and distributing oxycodone and hydrocodone. According to court records, from December 2014 through November 2018 the pharmacist dispensed more than 200,000 pills through the pharmacy he owned on prescriptions he knew were forged, delivered by two co-defendants who paid in cash. He faces a statutory maximum of 20 years in prison on each count, with the actual sentence to be set by the court.

New Hampshire hospital nurse anesthetist pleaded guilty after substituting saline for operating-room fentanyl

A nurse anesthetist at a Manchester, New Hampshire hospital pleaded guilty in June 2024 to tampering with consumer products. According to the U.S. attorney's office, the nurse admitted replacing liquid fentanyl intended for an operating-room patient with saline and another drug. Investigators said the nurse diverted leftover fentanyl instead of discarding it, falsified disposal records, and took controlled substances about once a day for roughly a year. Sentencing had not yet occurred when the plea was reported.

Physician terminated by employer for diverting fentanyl, versed and dilaudid from patients

Tampa, FL

At its June 21, 2024 meeting, the Texas Medical Board entered an agreed order publicly referring a physician to the Texas Physician Health Program. The Board found the physician suffers from impairment and was terminated by his employer based on unprofessional conduct and diverting fentanyl, versed, and dilaudid from patients.

Long Island pharmaceutical employee sentenced to six years for stealing thousands of oxycodone pills from employer

A 64-year-old Bellerose resident was sentenced to six years in prison followed by two years of post-release supervision for stealing thousands of oxycodone pills from her employer, a Suffolk County-based pharmaceutical business. The case was prosecuted by Suffolk County authorities and reported on May 31, 2024. The district attorney used the case to warn about the dangers of buying prescription medications from illegal sources.

Dodge County Hospital Nurse Diverted Oxycodone Using Automated Dispensing Cabinet Swap

Dodge County, Minnesota

Jennifer Lee Garrison, a post-anesthesia care nurse at a Minnesota hospital, pleaded guilty to obtaining a controlled substance by fraud after diverting oxycodone from an automated dispensing cabinet for her own use. Garrison withdrew two-pill oxycodone orders but gave patients only one pill, falsifying patient pain reports to conceal the shortfall. She also triggered a separate transaction for oxybutynin, a non-controlled drug, opening its drawer to mask an additional withdrawal of oxycodone from an adjacent drawer before canceling the oxybutynin transaction. The scheme ran from August 2022 to July 2023, escalating to roughly six diverted pills a day, and ended with a guilty plea in May 2024.

Barbourville Pharmacy Pays $215,000 Over Red-Flag Prescription Failures

Barbourville, Kentucky

Smith Family Pharmacy in Barbourville, Kentucky, and its pharmacist-in-charge, Stephanie Smith, agreed to pay $215,000 in civil penalties to resolve allegations that they violated the Controlled Substances Act by filling prescriptions bearing clear diversion red flags. From April 2017 to December 2021, the pharmacy filled over 500 prescriptions for oxycodone and oxymorphone that showed red flags such as dangerous drug combinations, unusually high dosages, and patients traveling out of state to see prescribers, without resolving those concerns as the CSA's corresponding-responsibility rule requires. Some of the prescriptions had been written by out-of-state physicians later convicted of illegal prescribing. As part of the settlement, the pharmacy entered a four-year Memorandum of Agreement with the DEA requiring stronger dispensing controls.

Registered nurse sentenced to probation for stealing OxyContin from a hospital narcotics cabinet and replacing it with other medications

Canton, SD

A registered nurse at Sanford Canton-Inwood Medical Center in Canton, South Dakota, removed OxyContin from blister packs in a narcotics cabinet and replaced it with melatonin and acetaminophen, then resealed the packs, according to the document. The nurse used the stolen OxyContin for personal use. The nurse pleaded guilty on March 6, 2024, to obtaining a controlled substance by misrepresentation, fraud, forgery, deception, and subterfuge, and was sentenced on May 24, 2024, to two years probation and a $100 special assessment.

Pharmacy technician charged with taking Promethazine-Codeine syrup from pharmacy

King County, Washington

A pharmacy technician was charged with unprofessional conduct by the Pharmacy Quality Assurance Commission in May 2024. The charges allege that in December 2023 the technician was seen taking two bottles of Promethazine-Codeine Syrup from the pharmacy where they worked, and that approximately 46 bottles of Promethazine-Codeine were unaccounted for during times the technician worked at pharmacies from January to December 2022.

Clinic pharmacy assistant charged with stealing OxyContin and Oxycodone prescriptions from the clinic where she worked

Whitman County, Washington

The Pharmacy Quality Assurance Commission charged a pharmacy assistant with unprofessional conduct in May 2024. Charges state that in November 2023 the assistant stole prescriptions for OxyContin and Oxycodone from the clinic where she worked. The case is pending.

Nurse at Texas Health Hurst-Euless-Bedford diverted fentanyl, morphine, and other controlled substances from an automated dispensing cabinet

Bedford, TX

A registered nurse at a Texas hospital was investigated for removing two Norco 5 mg tablets from an automated dispensing cabinet when the physician's order was for only one tablet. A facility audit found 10 mg of morphine, 100 mcg of fentanyl, 2.5 mg of diazepam, and 15 mg of temazepam unaccounted for, and indicated the nurse removed morphine without an order and failed to document wastage or return of unused controlled substances. The Arkansas State Board of Nursing placed the nurse's license on probation for two years and imposed a civil penalty and remedial education.

Hospital Pharmacy Technician Pleaded Guilty to Tampering with Hydromorphone

Norwich, Connecticut

Tiffany Moss, a pharmacy technician at Backus Hospital in Norwich, Connecticut, admitted stealing part of a hydromorphone solution meant for patients, using her badge to access secure storage and remove three bags of the drug. She replaced the missing portions with saline and pleaded guilty to tampering.

Minnesota Pharmacist in Charge Pleads Guilty to Stealing Oxycodone Bottles From Inventory

Maplewood, Minnesota

The pharmacist in charge at a pharmacy in Maplewood, Minnesota, took bottles of oxycodone from the pharmacy's inventory for personal use from March 2020 to June 2023 and falsified the pharmacy's records to conceal it. The pharmacist pleaded guilty on April 25, 2024, to one count of obtaining a controlled substance by misrepresentation. Sentencing was to be scheduled at a later time.

New Jersey drug manufacturer settles claims it failed to account for oxycodone, hydrocodone and temazepam

A pharmaceutical manufacturer, a subsidiary of a larger drug company, agreed to pay $2.25 million to resolve allegations that it violated the Controlled Substances Act by failing to account for approximately 3.1 kg of oxycodone, 7.7 kg of hydrocodone and 30 kg of temazepam between January 2019 and August 2021. DEA identified the alleged violations during on-site inspections that began in the summer of 2021. The company also entered a memorandum of agreement with DEA requiring operational improvements for three years. The claims settled are allegations only, and there has been no determination of liability.

ICU nurse sentenced for tampering with fentanyl and hydromorphone at Ardmore hospital

Ardmore, OK

A nurse employed in the intensive care unit of Mercy Hospital in Ardmore, Oklahoma, pleaded guilty to stealing fentanyl and hydromorphone intended for ICU patients, removing the pain medication from vials, refilling the vials with tap water, and returning them to controlled storage. The nurse was sentenced to 12 months in prison for one count of Tampering with Consumer Products.

Arkansas nurse self-reported diverting and consuming hydrocodone from employer

Cabot, AR

A nurse self-reported diverting and consuming hydrocodone from the employer at Cabot Health and Rehab. No disciplinary action was stated.

Arkansas rehabilitation facility nurse self-reported diverting hydrocodone

A nurse working at a health and rehabilitation facility in Cabot, Arkansas, is listed in a national drug-diversion incident database as having self-reported diverting and consuming hydrocodone from the employer. The database entry does not describe any board, court or employer outcome. The only date given is the date the entry was last updated, not the date of any charge or order.

Labor & Delivery Nurse Stole Pain Meds from 50+ New Mothers

Waterloo, Iowa

From January 2022 to March 2023, Christina Eileen Olson diverted narcotics from at least 50 new mothers at a Waterloo hospital's labor and delivery unit, falsely charting doses as administered while replacing fentanyl in a vial with saline. She was sentenced to one year and one day in federal prison.

Former Scripps Encinitas anesthesiologist placed on seven-year probation for taking and self-administering propofol and opioids

The Medical Board of California placed a former Scripps Memorial Hospital Encinitas anesthesiologist on seven years' probation through a stipulated settlement and disciplinary order, with the license revocation stayed. According to the order, the physician told board investigators she had self-administered propofol during a May 2022 shift and had taken home vials of leftover fentanyl, hydromorphone and midazolam roughly a dozen times the prior month. Probation conditions include drug testing, practice monitoring, psychotherapy, a substance abuse support group, patient notification and a bar on solo practice. The physician has not worked at a Scripps facility since May 2022.

Eastern Kentucky physician and clinic nurse sentenced for conspiracy to issue illegitimate opioid prescriptions

A physician who practiced at several Pikeville-area clinics and a nurse who worked at the same clinics were convicted at trial of conspiring to unlawfully distribute controlled substances through prescriptions written outside the usual course of professional practice. Evidence showed large monthly quantities of opioids, sometimes combined with benzodiazepines, and that the physician wrote multiple oxycodone prescriptions for the nurse, who also signed the physician's name to prescriptions. In early 2024 a federal judge sentenced the physician to 100 months and the nurse to 60 months in prison.

Oregon registered nurse accused of pulling narcotics and failing to document administration or wastage

In March 2024, the Board of Nursing charged a registered nurse with unprofessional conduct. The charge alleged that in January 2023 the nurse pulled narcotics and failed to document their administration or wastage. The case is listed under out-of-state Oregon.