Diversion Case Studies

Montgomery County Pharmacy Reaches Consent Decree Over Fraudulent Opioid Dispensing

Germantown, Maryland

The United States reached a consent decree with Upton Care Pharmacy, Inc. and its pharmacist, Abtin Youssefi-Rashti, resolving civil allegations that they violated the Controlled Substances Act between 2018 and when the pharmacy closed in 2022. The government alleged the pharmacy dispensed controlled substances to more than 300 patients who traveled over 180 miles to fill prescriptions, regularly filled concurrent opioid-and-stimulant combinations, accepted cash payment despite available insurance, and dispensed doses up to 1,800 morphine milligram equivalents per day. Under the decree, Youssefi-Rashti agreed to pay a $100,000 civil penalty, surrender his pharmacist's license for at least three years, and Upton Care surrendered its DEA registration.

Raleigh-Area Nurse Sentenced for Tampering with Surgical Patients' Painkillers

Fuquay-Varina, North Carolina

Melissa Elizabeth Chacona, a nurse at a Raleigh-area surgical practice, began extracting fentanyl, morphine, and meperidine from vials in early 2019 and replacing the medication with saline, compromising at least 78 vials intended for surgical patients. Testing found some vials held less than 15% of the labeled drug. She pleaded guilty and was sentenced in May 2023 to 48 months in federal prison.

Cape Girardeau Nurse Admits Taking Leftover Fentanyl from Hospital

Cape Girardeau, Missouri

Lindsey M. Francis, a registered nurse at Saint Francis Medical Center in Cape Girardeau, Missouri, admitted taking and injecting leftover fentanyl from tampered vials on multiple occasions beginning in mid-2021, a practice discovered in January 2022 after a colleague found a used syringe in a locker room. She pleaded guilty in May 2023 to unlawfully acquiring a controlled substance.

Surgical practice nurse sentenced for tampering with fentanyl, morphine, and meperidine and replacing them with saline

Raleigh, NC

A nurse at a Raleigh-area surgical practice pleaded guilty to tampering with painkillers intended for surgery patients. According to court documents, beginning in early 2019 and over several months, the nurse extracted fentanyl, morphine, and meperidine from vials and replaced it with saline, compromising at least 78 vials. The nurse was sentenced to 48 months in prison and three years of supervised release, and the plea agreement requires permanent surrender of the nursing license.

Pharmacy technician's credential revoked for theft of oxycodone tablets from a patient's prescription

A pharmacy technician's credential was revoked by the Louisiana Board of Pharmacy for the theft of eight oxycodone tablets from a patient's prescription. The Board also prohibited the individual from applying or reapplying to practice or assist in the practice of pharmacy. The action was taken at the Board's May 24, 2023 meeting.

Denver Paramedic Supervisor Sentenced for Stealing 1,900 Vials of Fentanyl

Denver, Colorado

Christopher Robert Pattinson, a paramedic field lieutenant supervisor at a Denver-area hospital, stole approximately 1,900 vials of fentanyl from the paramedic department over four years, altering narcotics logs to conceal the theft and, in his final months, replacing fentanyl in ambulance kits with a clear liquid believed to be saline. He was sentenced in April 2023 to three years in federal prison.

Chicago-Area Rehab Center Nursing Director Pleads Guilty to Diluting Patients' Morphine

Chicago, Illinois

Sarah Diamond, Assistant Director of Nursing at a Chicago-area medical rehabilitation center responsible for dispensing patient medications, removed liquid morphine from bottles prescribed to at least five patients in July and August 2021 and replaced it with another liquid so the volume would appear unchanged. Two diluted bottles were later found to contain only about 26 percent and 53 percent of their declared morphine content. Diamond then administered the diluted doses to patients being treated for pain while keeping the withheld morphine for her own use. She pleaded guilty in April 2023 to tampering with a consumer product.

Hospital nurse accused of diverting fentanyl from CHI Health St. Elizabeth

Lincoln, NE

A former registered nurse at CHI Health St. Elizabeth in Lincoln, Nebraska, is accused of taking fentanyl from the hospital and improperly accounting for fentanyl waste in medical records. According to court documents, an audit found numerous fentanyl checkouts with discrepancies in May and June 2022, and a urine test was positive for fentanyl. The nurse denied taking the medication and resigned in July 2022. The nurse has been charged with acquiring a controlled substance by fraud; an arrest warrant was issued and she had not yet been arrested.

Nursing home director of nursing used pre-signed prescription pads to divert hydrocodone

Montgomery, AL

A director of nursing at a Montgomery-area nursing home used prescription pads pre-signed by the facility's medical director to fax fraudulent prescriptions to the pharmacy between November 2022 and April 2023. She then took the hydrocodone delivered by the pharmacy's courier for herself rather than the patients. She pleaded guilty to second-degree theft, was sentenced to 18 months in community corrections, and surrendered her nursing license.

Missoula Hospital Nurse Sentenced for Diverting Opioids Flagged by Distribution Audit

Missoula, Montana

Caitlin Ashley Evans, a nurse at St. Patrick Hospital in Missoula, was caught after a hospital official reviewing drug distribution data in October 2021 noticed she was ordering oxycodone, hydromorphone, hydrocodone, and fentanyl at far higher rates than her peers; a coworker separately reported suspicious activity by Evans. When confronted by hospital administrators, Evans admitted she had been diverting drugs since the fall of 2020 by taking waste amounts of hydromorphone and morphine two to three times a week, substituting saline before disposal. She pleaded guilty in November 2022 to obtaining controlled substances by fraud, deception, and subterfuge, and was sentenced in March 2023 to three years of probation.

Kansas Nurse Sentenced for Tampering with Fentanyl and Hydromorphone Vials

Overland Park, Kansas

Alec Ramirez, a nurse at Menorah Medical Center in Overland Park, Kansas, removed vials of fentanyl and hydromorphone from an automated dispensing cabinet in March 2021 and replaced the drugs with another liquid before returning the vials to the cabinet. He pleaded guilty to tampering with a consumer product and possession of fentanyl by deception, and was sentenced in March 2023 to 18 months in prison.

Kansas hospital nurse sentenced for tampering with fentanyl and hydromorphone vials

A former registered nurse at an Overland Park, Kansas hospital was sentenced to 18 months in federal prison and forfeited his nursing license after stealing controlled substances from his employer. According to court documents, in March 2021 he removed vials of fentanyl and hydromorphone from an automated dispensing cabinet, replaced the contents with an alternate liquid, and returned the vials to the cabinet. A federal grand jury had indicted him in November 2021 on two counts of tampering with a consumer product and two counts of obtaining controlled substances by deception and subterfuge.

Licensed practical nurse removed controlled substances from workplace while also working under a suspended license and submitting a fraudulent Board letter

The Georgia Board of Nursing revoked a licensed practical nurse's license after finding she removed controlled substances from her workplace, continued working as an LPN while her license was suspended, and drafted a fraudulent letter purportedly from the Nursing Board. The Court upheld the Board's revocation decision.

Virginia Nurse License Suspended Over Roanoke-Area Hospital Opioid Diversion

Roanoke and Blacksburg, Virginia

A Virginia nurse who worked at Carilion Roanoke Memorial Hospital and LewisGale Hospital had a nursing license suspended after a local TV investigation and Virginia Board of Nursing action found she took pain medication meant for patients in severe pain, falsely documented that it had been given, and used the diverted opioids herself while on duty.

Vermont registered nurse's license conditioned after attempted diversion of medications from a facility medication cart

The State charged a registered nurse in June 2022 with attempting to divert medications at the facility where she worked; according to the charges, she changed her mind before removing the medications and left them in the top drawer of the medication cart. Her employment at the facility was terminated as a result of the attempted diversion. A Stipulation and Final Order entered February 27, 2023 conditioned her license, including provisions applying if she attends a nursing program with a clinical component.

Michigan Pharmacist Sentenced for Selling 25,000+ Opioid Pills from His Own Pharmacy

Madison Heights, Michigan

A pharmacist who owned and operated Great Health Pharmacy in Madison Heights, Michigan used the pharmacy to unlawfully dispense controlled substances outside the course of legitimate pharmacy practice. He filled prescriptions brought to him by a patient recruiter for cash, sometimes dispensing in the names of people who never came to the pharmacy, and at other times sold entire stock bottles of controlled substances directly to the recruiter with no prescription at all. He pleaded guilty to unlawfully dispensing more than 25,000 dosage units of oxycodone, oxymorphone, and other Schedule II drugs, plus over 200,000 milliliters of promethazine with codeine, and to money laundering. He was sentenced in February 2023 to 84 months in federal prison and ordered to forfeit approximately $1.2 million in cash seized during the investigation; a co-defendant patient recruiter was separately sentenced to 72 months.

Missouri Methadone Clinic Owner Admits Diluting Methadone to Conceal a Shortage from the DEA

Leadington, Missouri

A physician who owned Best Medical LLC, a family medicine practice in Leadington, Missouri, opened a DEA-registered methadone clinic in 2021 to treat patients with narcotic use disorders. Days after the clinic received its first shipment of methadone oral concentrate, the doctor discovered a shortage but instead of reporting it to the DEA within the required one business day, he waited and then had the clinic's clinical director file a report understating the missing amount. He then came into the closed clinic on a Sunday and added saline and water to the remaining methadone supply to mask the shortfall. He pleaded guilty in February 2023 in federal court in St. Louis to adulterating a drug with intent to defraud or mislead and agreed to surrender his DEA registration.

Pharmacy technician diverted a customer's oxycodone prescription at a Hagerstown pharmacy

Hagerstown, MD

The Maryland State Board of Pharmacy found that a pharmacy technician employed at a pharmacy in Hagerstown, Maryland diverted 45 pills of oxycodone 5 mg/325 mg from a customer's prescription on January 4, 2022. According to the pharmacy's investigative report, the technician removed the prescription from the bag in the customer waiting area, placed the pills in her pocket, and deleted the prescription on hold. The technician admitted to the pharmacy's asset protection manager and in a written statement that she took the patient's medication to self-medicate a back injury. The Board revoked her pharmacy technician registration.

Pharmacy technician admitted to stealing controlled substances from employer pharmacy

A certified pharmacy technician admitted to stealing controlled substances from the pharmacy where they were employed. The Louisiana Board of Pharmacy revoked the credential and barred the individual from applying or reapplying to practice or assist in the practice of pharmacy.

Pharmacy technician accused of forging controlled substance prescriptions from employer pharmacy

A certified pharmacy technician was alleged to have forged controlled substance prescriptions from the pharmacy where they were employed. The Louisiana Board of Pharmacy revoked the credential and barred the individual from applying or reapplying to practice or assist in the practice of pharmacy.

Registrant's registration revoked for diversion of controlled substance from pharmacy

A registrant's registration was revoked by default board order. The order cited diversion of a controlled substance from a pharmacy, with a violation date of February 2023.

Massachusetts Nursing Home Nurse Sentenced for Diluting a Dementia Patient's Morphine

Northborough, Massachusetts

A registered nurse employed at a Worcester County, Massachusetts nursing home was working an overnight shift in a dementia care unit in November 2020 when she tampered with a bottle of morphine sulfate prescribed to a resident in her care, removing some of the drug and replacing it with water. A nurse on a later shift administered the diluted dose to the patient before the tampering was discovered. She pleaded guilty in March 2022 to tampering with a consumer product and to obtaining a controlled substance by fraud and deception, and was sentenced in January 2023 in federal court in Worcester to 52 months in prison and three years of supervised release.

Massachusetts Nurse Sentenced for Tampering With Fentanyl at Hospital and Surgery Center

Massachusetts

Hugo Vieira, a nurse who worked at a Massachusetts hospital's post-surgery recovery unit and an outpatient vascular surgery center, removed fentanyl from vials intended for surgical patients between 2017 and January 2019 and replaced it with saline to conceal the theft. When the tampering was discovered, law enforcement recovered 60 tampered vials at the surgery center and two more at the hospital recovery unit; testing showed the vials contained only 1.3 to 7 percent of their declared fentanyl concentration. Vieira pleaded guilty in May 2022 to tampering with a consumer product and was sentenced in January 2023 to five years of probation, including one year of home detention, and a $20,000 fine.

Pain clinic nurse practitioner conspired to dispense fentanyl by forging a physician's signature on prescriptions

A nurse practitioner at a pain management clinic was convicted of conspiring to dispense fentanyl products outside the usual course of professional practice and without a legitimate medical purpose. She admitted to seeing patients unsupervised while impaired by her own drug use and to having a co-defendant forge a physician's signature on controlled-substance prescriptions. She was sentenced to 20 months in federal prison after cooperating with prosecutors.

Central Pennsylvania hospital nurse charged with diverting morphine from an emergency department

State prosecutors filed a criminal complaint in December 2022 accusing a former emergency department registered nurse of using subterfuge and falsified records to obtain morphine that investigators say was never given to the patients it was drawn for. The complaint alleges three episodes in June and July, including the use of saline syringes to simulate witnessed waste. These are allegations that had not been resolved at the time of the report. State licensing records showed the nurse's license was indefinitely suspended in September of that year, and the hospital confirmed the person no longer worked there.