Diversion Case Studies

Kansas City, Kansas grocery pharmacy settles allegations of dispensing before receiving prescriptions

A Kansas City, Kansas company entered into a civil settlement agreement with the federal government to pay $250,000 to resolve allegations that a retail pharmacy it owns violated civil provisions of the Controlled Substances Act. The government alleged that between February 2019 and June 10, 2022 the Price Chopper Pharmacy dispensed controlled substances before receiving prescriptions, improperly partially filled prescriptions, and failed to maintain controlled substance inventory records. A settlement is not a finding of liability.

Central Illinois pharmacy technician sentenced to 30 months for diverting hydrocodone and other controlled substances

A Le Roy, Illinois pharmacy technician was sentenced on September 7, 2023 to 30 months in federal prison for theft of medical products and possession of a controlled substance with intent to distribute. According to court documents cited by the DEA, the technician stole hydrocodone, alprazolam and promethazine with codeine while employed at a pharmacy and sold them illegally. At sentencing, the court found the technician responsible for diverting more than 28,000 hydrocodone pills to the illicit market.

Louisiana registered nurse placed on stayed suspension and probation on a charge of diverting non-narcotic medication

At its September 13, 2023 hearing, the Louisiana State Board of Nursing listed action against a registered nurse on a charge of diversion of non-narcotic medication. The license was suspended, with the suspension stayed, and probated for a minimum of one year with stipulations. The board's listing marks the matter as resolved by consent order and does not describe the underlying facts or the setting.

Out-of-state compact nurse ordered to stop practicing in Louisiana on charges including diversion of a controlled substance and a drug screening violation

The Louisiana State Board of Nursing's September 13, 2023 action list includes a nurse who had been practicing in Louisiana under a Nurse Licensure Compact privilege. The nurse was charged with a drug screening violation, inappropriate acquisition or diversion of a controlled substance, and failure to cooperate with the board's investigation. The board ordered the nurse to cease and desist from practicing registered nursing in Louisiana on compact privileges. The listing does not describe the drug, the setting, or the underlying facts, and the charges are allegations as listed by the board.

Louisiana nurse ordered probated on any reinstatement after charges of controlled-substance diversion, falsified records and a criminal conviction

The Louisiana State Board of Nursing's September 13, 2023 action list includes a registered nurse charged with inappropriate acquisition or diversion of a controlled substance, misappropriation of patient or other property, filing false reports or falsifying records, conduct evidencing ethical or moral unfitness, and a criminal conviction. The published entry states that upon reinstatement the license shall be probated to run concurrently with a monitoring agreement. The portion of the entry describing the immediate action on the license is not included in the available excerpt, and the listing does not describe the drug or the setting.

Out-of-state compact nurse ordered to stop practicing in Louisiana on charges of controlled-substance diversion and failure to cooperate

A second compact-privilege nurse on the Louisiana State Board of Nursing's September 13, 2023 action list was charged with failure to cooperate with a board investigation and inappropriate acquisition or diversion of a controlled substance. The board ordered the nurse to cease and desist from practicing registered nursing in Louisiana under compact privileges. The listing does not identify the drug, the setting, or the underlying facts, and the charges are allegations as listed by the board.

ICU nurse at Mercy Hospital in Ardmore pleaded guilty to stealing fentanyl and hydromorphone and swapping pain medication with tap water

Ardmore, OK

An ICU nurse pleaded guilty to tampering with pain medications, including fentanyl. According to the U.S. Attorney’s Office, the nurse admitted to stealing fentanyl and hydromorphone intended for patients in the intensive care unit at Mercy Hospital in Ardmore. The nurse also confessed to swapping pain medication with tap water in March and April 2022.

Registered nurse convicted of tampering with fentanyl citrate vials and obtaining controlled substance by fraud at Chamberlain hospital

Chamberlain, SD

A registered nurse at a hospital in Chamberlain, South Dakota, was convicted of obtaining a controlled substance by misrepresentation, fraud, forgery, deception, and subterfuge. According to the text, between June 19 and September 11, 2021, the nurse removed fentanyl citrate for injection from a vial, replaced most of it with saline solution, and returned the tampered vial to storage knowing the diluted fentanyl could be dispensed to surgical patients. The nurse was sentenced in September 2023 to two years of probation and a $100 special assessment to the Federal Crime Victims Fund. The text also states the nurse was indicted in October 2022 on charges including tampering with consumer products and obtaining a controlled substance by fraud; those counts were alleged.

Hospital nurse tampered with fentanyl vial, replacing drug with saline

Pierre, SD

A registered nurse working at a Chamberlain hospital was sentenced for obtaining a controlled substance. Between June 19 and September 11, 2021, the nurse tampered with a vial of fentanyl citrate stored by the hospital, removed the fentanyl for injection and replaced most of it with saline solution. The nurse returned the tampered vial to storage knowing the diluted fentanyl could be dispensed to surgical patients to treat severe pain. The nurse was sentenced to two years of probation on September 11, 2023.

Admission of taking controlled substances from a pharmacy for personal use

The individual admitted to taking drugs without authorization from the pharmacy for personal use (2 counts). A felony theft of controlled substance under $150,000 was deferred. The sanction was 90 days suspension and 5 year probation.

Pharmacist charged with diverting hydrocodone/APAP tablets from a West Virginia pharmacy

Stonewood, WV

A Vermont-licensed pharmacist was charged by the Vermont Board of Pharmacy with diverting controlled substances from a pharmacy in Stonewood, West Virginia. The specification alleged that the pharmacist took 25 to 50 hydrocodone/APAP tablets per day from the pharmacy for 3 to 5 years without a prescription, including while filling legitimate prescriptions for himself and/or family and accessing non-public areas to remove bottles. The pharmacy reported losses of 7,000 hydrocodone/APAP 10/325 mg tablets to the United States Drug Enforcement Administration, and the losses were attributed to the pharmacist. The requested relief includes license revocation, suspension, reprimand, conditions, or other discipline.

Ardmore ICU Nurse Pleads Guilty to Replacing Patients' Pain Medication With Tap Water

Ardmore, Oklahoma

Rebecca Elaine Holloway, a nurse in the intensive care unit at Mercy Hospital in Ardmore, Oklahoma, admitted to stealing fentanyl and hydromorphone intended for ICU patients in acute pain between March and April 2022. She removed the pain medication from its vials, refilled the empty vials with tap water, and returned the tampered vials to the hospital's controlled storage locker so they would be administered to unsuspecting patients. She admitted she knew this deprived critically ill patients of pain relief and placed them at risk of death or bodily injury. Holloway pleaded guilty in August 2023 to tampering with consumer products following an investigation by the FDA and the Oklahoma Bureau of Narcotics.

Sioux City Nurse Pleads Guilty to Stealing Opioids from Hospital Employer

Sioux City, Iowa

A nurse at a Sioux City, Iowa hospital stole fentanyl, morphine, hydromorphone, and hydrocodone that were meant to be dispensed to patients, diverting the drugs for her own use. She concealed the theft by falsifying documentation, including omitting required information from controlled-substance disbursement log entries. She pleaded guilty on August 30, 2023 in federal court in Sioux City to acquiring a controlled substance by fraud and to making false statements relating to health care matters. The case was investigated jointly by Iowa's Medicaid Fraud Control Unit, the Department of Health and Human Services, and the DEA.

Nebraska Practical Nurse License Revoked Over Narcotic Count Discrepancies

Nebraska

The Nebraska Board of Nursing revoked a licensed practical nurse's ability to practice after alleging she failed to complete required narcotic medication counts at one care facility and, at a second facility, documented giving narcotic pain medication to patients who denied receiving it and signed out narcotics more often than physicians had ordered.

Pharmacy technician's credential revoked for theft of controlled substances from employer pharmacy

A pharmacy technician's credential was revoked for theft of controlled substances from the employer pharmacy. The Board also prohibited the individual from applying or reapplying to practice or assist in the practice of pharmacy. The action was taken by consent agreement accepted during the August 2023 Board meeting.

Cumberland, Maryland Pharmacy Reaches Consent Decree Over Fraudulent Opioid Prescriptions

Cumberland, Maryland

A federal judge approved a consent decree between the United States and Beckman's Greene Street Pharmacy in Cumberland, Maryland, and its pharmacist, John A. Beckman, resolving civil allegations that they violated the Controlled Substances Act. The government alleged that since at least 2017 the pharmacy filled fraudulent prescriptions while ignoring red flags — including dangerous drug combinations such as an opioid, a benzodiazepine, and carisoprodol (the "holy trinity"), opioid-and-buprenorphine pairings, cash payments despite available insurance, and daily doses up to 1,000 morphine milligram equivalents. The government further alleged the pharmacy dispensed opioids to more than ten patients who died within ten days of filling those prescriptions. Under the decree, the pharmacy agreed to pay a $120,000 civil penalty and adopt a red-flag documentation and prescription-refusal protocol going forward.

Pharmacist-in-charge diverted hydrocodone and tramadol powder from a pharmacy controlled-substance safe; Maryland license revoked

The Maryland Board of Pharmacy found that a pharmacist who was pharmacist-in-charge at a pharmacy in Virginia diverted controlled substances. A camera in the pharmacy area captured him removing medication from the controlled substance safe and placing it in his pocket, and on several occasions into a cup; a subsequent inventory showed 847 mg of tramadol powder and 2,947 mg of hydrocodone powder missing. The pharmacy's president stated in writing that the pharmacist admitted taking controlled substances, including hydrocodone powder, and using them in his coffee and other beverages while working, and the pharmacist admitted to Virginia Board investigators that he diverted controlled substances for personal use between August 13 and October 13, 2021, after which he was terminated. The Board revoked his Maryland license by order dated July 2023.

Minnesota home hospice nurse diverted controlled substances from 24 patients

The Minnesota Department of Health investigated an allegation that a hospice registered nurse diverted controlled substance medications belonging to patients receiving hospice care in their homes. The department determined that financial exploitation was substantiated and that the nurse was responsible for diverting 24 patients' controlled substance medications. The agency was issued a correction order, the nurse is no longer employed there, and the report was referred to the Board of Nursing, the Drug Enforcement Administration and local prosecutors for possible further action.

Surgery Center RN Sentenced for Swapping Fentanyl for Saline in ~450 Vials

Jensen Beach, Florida

From February 28 to April 18, 2022, circulating nurse Catherine Shannon Dunton took fentanyl from nearly 450 vials at a Jensen Beach outpatient surgery center and refilled them with saline before returning the vials to stock. She was sentenced to 48 months in federal prison.

Wilmington family-medicine physician paid $170,000 to resolve allegations of unlawful opioid prescribing

A physician practicing at a Wilmington family-medicine clinic agreed to pay $170,000 to resolve alleged Controlled Substances Act violations. The government contended that from about 2009 to 2018 the physician issued opioid and other controlled-substance prescriptions outside the usual course of professional practice, including the opioid, benzodiazepine, and muscle-relaxer combination on nearly 400 occasions and nearly 9,000 Schedule II prescriptions over a two-year period. The physician had previously surrendered his DEA registration and agreed not to reapply for Schedule II prescribing authority until April 30, 2024. The settlement is not an admission of liability, and the government's assertions are allegations only.

Cheshire Medical Center Pays $2 Million After Nurse Stole Fentanyl IV Bags

Keene, New Hampshire

Cheshire Medical Center in Keene, New Hampshire agreed to pay $2 million after a nurse stole 23 intravenous fentanyl bags from a dispensing machine, with 634 more bags later unaccounted for; the nurse died in March 2022. A follow-up DEA audit found 17,961 additional missing controlled-substance units and recordkeeping failures. The settlement was announced June 22, 2023.

New Hampshire hospital paid $2 million to settle DEA record-keeping allegations after fentanyl diversion

Federal drug enforcement authorities announced a $2 million settlement with a New Hampshire regional medical center over alleged record-keeping violations under the Controlled Substances Act. The settlement followed the hospital's discovery that an employed nurse had been diverting bags of fentanyl beginning in October 2021; the hospital's own investigation counted 283 diverted bags and could not account for an additional 163. A settlement resolves allegations and is not a finding of liability. The state Office of Professional Licensure and Certification also disciplined the hospital's chief nursing officer, director of pharmacy and a pharmacist.

New Hampshire hospital agreed to pay $2 million to settle allegations that poor drug records allowed theft

Cheshire Medical Center in New Hampshire agreed to pay $2 million in a settlement announced in June 2023. According to the U.S. Attorney's office, the settlement followed the hospital's failure to keep accurate records of its drugs, which allowed the drugs to be stolen. Reporting referenced state licensing documentation in which a nurse in the hospital's intensive care unit self-reported. A settlement is not a finding of liability.

CVS pharmacy manager diverted hydromorphone tablets and liquid solution for personal use; license revoked

Berlin, VT

A pharmacist and pharmacy manager at a CVS pharmacy in Berlin, Vermont admitted to diverting hydromorphone 8 mg tablets, approximately 100 over several months in 2021, and an unknown amount of liquid hydromorphone 1 mg/mL solution for personal use. The pharmacist also documented the expected tablet count as in stock even though he knew the count was off because of the diversion, and told investigators he replaced the diverted liquid volume with distilled water to make it appear full; testing later showed diphenhydramine in the solution. The Vermont Board of Pharmacy found the pharmacist in default, treated the allegations in the Specification of Charges as proven, and revoked his license.

National chain pharmacy manager disciplined after oxycodone reported lost/stolen as employee pilferage

Waldorf, MD

A Maryland Board of Pharmacy consent order resolved charges against a pharmacist and pharmacy manager at a national chain pharmacy in Waldorf, Maryland. The pharmacy reported a controlled substance theft/loss and classified it as employee pilferage; a DEA report listed oxycodone HCL 10 mg and 15 mg tablets lost or stolen. The Board found the pharmacist violated patient safety and standard-of-care rules for filling questionable CII prescriptions without validation and for refusing-to-dispense requirements, while fraud and false-record charges were dismissed as unsubstantiated. The order reprimanded the license, placed it on probation for at least one year, required continuing education, and imposed a $1,000 fine.