Diversion Case Studies

Kansas long-term care pharmacy settles allegations of improper Schedule II emergency dispensing

A long-term care pharmacy in Lenexa, Kansas agreed on December 13, 2022 to pay $3 million to resolve allegations that it violated federal law in dispensing Schedule II controlled substances. The government alleged that between October 1, 2019 and March 31, 2021 the pharmacy dispensed Schedule II drugs for purported emergencies in quantities greater than adequate for the emergency period and failed to obtain the required written prescriptions. The settlement also resolved claims that Medicare and Medicaid improperly paid for controlled substances dispensed without valid prescriptions. The pharmacy self-reported the violations to the DEA, and the settlement is not a finding of liability.

Kentucky hospital agrees to $4.4 million civil penalty over recordkeeping that allowed pharmacy technician to divert 60,000 opioid doses

Federal prosecutors in Lexington announced that Pikeville Medical Center agreed to pay a $4.4 million civil penalty to resolve claims that inaccurate inventory and dispensing records allowed a pharmacy technician to divert more than 60,000 doses of oxycodone, hydrocodone and methadone from the narcotics vault and automated dispensing cabinets between January 2016 and September 2018. The settlement does not determine liability, and prosecutors noted the hospital self-reported the diversion and cooperated with the Drug Enforcement Administration. The technician and a spouse pleaded guilty in 2020 to conspiracy to distribute the drugs and received sentences of 41 and 38 months respectively.

Kentucky hospital pharmacy technician diverted over 60,000 opioid doses; hospital paid civil penalty

Federal prosecutors said a hospital system in eastern Kentucky failed to keep accurate controlled-substance inventories and dispensing records, which enabled a then pharmacy technician to divert more than 60,000 doses of oxycodone, hydrocodone and methadone from the narcotics vault and automated dispensing cabinets between January 2016 and early September 2018. The technician and her husband pleaded guilty in 2020 to a conspiracy to distribute the drugs and received prison sentences of 41 and 38 months. The hospital self-reported the diversion, cooperated with the DEA, and agreed to pay a $4.4 million civil penalty under a settlement that does not determine liability, plus a three-year memorandum of agreement with inspection, reporting and training requirements. The exact settlement announcement date is not stated in the source; the plea year is used above.

Iowa Nurse Pleads Guilty to Diverting Fentanyl From Elderly Patients' IV Pumps

Clear Lake, Iowa

A nurse diverted liquid fentanyl intended for elderly patients by withdrawing it directly from their IV pumps with a syringe for his own use. The Iowa Department of Inspections and Appeals Medicaid Fraud Control Unit investigated the diversion, which involved fentanyl meant to be administered to patients under his care. He pleaded guilty on November 21, 2022, in federal court in Sioux City, Iowa, to acquiring a controlled substance by misrepresentation, fraud, deception, and subterfuge. Sentencing was pending at the time of the plea, and he faced up to four years in prison.

Alaska registered nurse surrendered license over diversion and substance-abuse allegations

The Alaska Board of Nursing adopted a voluntary surrender of a registered nurse's license on November 1, 2022, over allegations of diversion and substance abuse. The board's disciplinary order cites violations of AS 08.68.270(3), AS 08.68.270(7), and 12 AAC 44.770(8) and (22), the state's unprofessional-conduct provisions that cover misappropriating drugs for personal or unauthorized use. The published board record does not identify the employer, setting, or specific drug involved.

Pharmacy technician admitted to theft of controlled substances from her employer; credential revoked

A pharmacy technician admitted to the theft of various controlled substances from her employer. Acting on that admission, the Louisiana Board of Pharmacy revoked her credential and further prohibited her from applying or reapplying to practice or assist in the practice of pharmacy. The Board approved the voluntary consent agreement at its regular meeting on November 16, 2022.

Vermont chain pharmacy manager diluted hydromorphone oral solution and falsified inventory records

The manager of a retail chain pharmacy in Berlin, Vermont was convicted in federal court of obtaining controlled substances by fraud and sentenced to three years of probation. According to court records, the pharmacist removed hydromorphone oral solution from a stock bottle for personal use, diluted the remainder with liquid diphenhydramine and distilled water, re-taped the tamper seal and returned the bottle to inventory where it could have been dispensed to patients. The pharmacist also obtained hydromorphone tablets and solution by making false entries in the ordering and inventory systems. Public board records cited in the release describe earlier hydromorphone thefts in 2015 and 2016 that had led to conditions on the pharmacist's license; the license was reinstated in 2020 and then suspended in September 2021 when the new allegations surfaced.

South Dakota hospital ambulance fentanyl vials found filled with saline; no suspect identified

During a daily controlled-substance count on an ambulance in August 2022, a medic noticed two fentanyl vials that looked unusual and turned them over to the hospital pharmacy, where testing the following month showed both contained normal saline. The hospital reported the suspected diversion to the state Department of Health and the Division of Criminal Investigation, which was still reviewing the matter with no suspect identified. A November 2022 state inspection found the hospital had no policies for securing ambulance medications, that a master override key for the electronic medication safes had been accessible to all ambulance staff, and that medications had been kept in a keyed cabinet while the safes' doors were away for software updates.

Le Roy pharmacy technician pleaded guilty to diverting hydrocodone and other controlled substances

A Le Roy pharmacy technician was indicted in October 2021 and pleaded guilty in November 2022 to theft of medical products and possession of a controlled substance with intent to distribute. Court documents state he stole hydrocodone, alprazolam and promethazine with codeine while employed as a technician and sold them illegally, diverting over 28,000 hydrocodone pills. He was later sentenced to 30 months in federal prison.

Colorado Nurse Sentenced Over ICU Fentanyl Drip Diversion

Denver, Colorado

A Denver hospital nurse was sentenced to five years of probation after pleading guilty to stealing most of a bag of fentanyl intended for a comatose, intubated ICU patient by lowering the IV pump's drip rate and falsifying the flow-rate record, then draining a second fentanyl bag into a cup and refilling it with saline before hospital staff intervened.

Dubuque Pharmacist Sentenced for Stealing and Tampering With Patients' Medications

Dubuque, Iowa

A pharmacist who worked at two Dubuque-area pharmacies stole more than 2,500 doses of controlled substances from pharmacy inventory between 2018 and 2020. In February and March 2020, he also tampered with medication already filled for six prescriptions belonging to five different patients, including two children, by opening the capsules, removing most or all of the drug, and putting the empty capsules back into stock bottles so they would still be dispensed to patients. He pleaded guilty to acquiring controlled substances by deception and tampering with consumer products, and was sentenced to two years in federal prison, fined $10,000, ordered to pay $9,993 in restitution, and required to forfeit his pharmacy license.

St. Louis County Hospital Nurse Pleads Guilty to Fraudulently Obtaining Fentanyl

St. Louis County, Missouri

A registered nurse at Mercy Hospital South in St. Louis County, Missouri fraudulently obtained fentanyl from an automated medication dispensing machine for her own use on multiple occasions over about two weeks in early 2020. She pleaded guilty to obtaining a controlled substance by fraud and was scheduled for sentencing.

DC nurse diverted fentanyl from two Washington hospitals

Washington, DC

Between November 3 and November 27, 2019, while employed as a registered nurse at Sibley Memorial Hospital in Washington, DC, the nurse drew controlled substances she did not administer, reported medication as wasted, and drew medication that had not been prescribed for her patients. The hospital investigated and required a drug test; on December 17, 2019 the nurse failed to provide a sample and resigned the same day. At MedStar Georgetown University Hospital, an investigation covering September 23, 2020 to January 13, 2021 found comparable handling and documentation violations involving fentanyl, including withdrawals for patients who were not assigned to her, and a drug test on January 22, 2021 returned positive for fentanyl. The nurse admitted diverting fentanyl for personal use. The Board of Nursing summarily suspended the license on July 23, 2021 and issued a final order on October 27, 2022 revoking it with the revocation stayed: the license stays suspended until January 31, 2023 and is restored only through full participation with the Committee on Impaired Nurses.

Traveling Nurse Sentenced for Diverting Opioids at Four Montana Facilities

Anaconda, Montana

A traveling nurse diverted oxycodone and hydrocodone from four different Montana facilities in 2021: Community Hospital of Anaconda, Copper Ridge Health and Rehabilitation Center, Continental Care and Rehabilitation Center, and The Ivy, all in the Butte-Anaconda-Deer Lodge area. She routinely withdrew opioids from pharmacy stock without documenting administration to patients, moving to a new facility within days each time a prior employer discovered a shortage. Staff drug screens after each incident came back negative for other nurses, and she either refused testing or produced a diluted or cold urine sample. She pleaded guilty in June 2022 to three counts of unlawfully obtaining controlled substances and was sentenced to one year and one day in prison followed by one year of supervised release.

Former Nurse Pleads Guilty to Diverting Opioids From Two Boston-Area Hospitals

Boston, Massachusetts

A former nurse pleaded guilty to unlawfully obtaining controlled substances from two separate Boston-area hospitals over several years. While working as a student nurse in 2018, she admitted to hospital investigators that she had stolen and self-injected fentanyl. In 2020, while employed at a different Boston-area hospital, she stole an infusion bag containing fentanyl that was actively being used to treat a patient, and on another occasion took multiple syringes of hydromorphone from a locked drug cabinet. She pleaded guilty to four counts of unlawfully obtaining controlled substances by fraud, deception, and subterfuge.

Pain clinic nurse practitioner convicted of diverting opioids to a family member using other patients' names

Eagle River, AK

A federal jury convicted a nurse practitioner who operated a pain management clinic on 10 felony counts tied to illegal opioid prescribing. Evidence showed she wrote opioid prescriptions under other individuals' names to divert nearly 5,000 pills to her opioid-addicted, live-in partner, and fabricated appointment records for those individuals to conceal the scheme. She also pre-signed and pre-dated prescriptions for non-medical staff to hand out to patients for cash payments when she was away from the office.

Pharmacy technician took controlled substance from pharmacy for personal use

An agreed Texas Board of Pharmacy order states that a pharmacy technician took a controlled substance from the pharmacy for personal use. The order suspended the technician until cleared by a mental health professional and imposed five years of rehabilitation probation. The order also noted an incapacity preventing practice as a pharmacy technician or technician trainee with reasonable skill, competence, and safety.

Missouri nurse diverted fentanyl at two hospitals after being fired for the first diversion

A registered nurse from Cape Girardeau pleaded guilty in federal court in the Eastern District of Missouri to obtaining a controlled substance by fraud, admitting she fraudulently obtained fentanyl for personal use. Prosecutors said pharmacy staff at a St. Louis-area hospital flagged her in early 2020 for withdrawing two to three times more fentanyl than her peers, and she was fired after a positive drug test. She later took a job in another hospital's intensive care unit and was fired again in January 2022 over her fentanyl handling. She was sentenced to four years of probation.

Registered nurse diverted oxycodone, hydrocodone/acetaminophen, and hydromorphone from patients at a Madison medical center

Madison, WI

A registered nurse at a medical center in Madison, Wisconsin, admitted diverting pain medications from patients for personal use over about 1.5 years, totaling approximately 100 patients and 200 dosages. The nurse admitted diverting oxycodone, hydrocodone/acetaminophen, and liquid hydromorphone on June 12 and 13, 2021, and had charted that a patient had already received pain medication when the patient asked for it. The nurse later pled guilty to federal charges of acquiring hydrocodone/acetaminophen, oxycodone, and hydromorphone by misrepresentation/fraud/deception by entering patient information into the automated dispensing cabinet and removing controlled substances for personal use. The Board accepted the voluntary surrender of the nurse's license and imposed costs and reinstatement restrictions; the nurse received three years of probation and a $3,500 fine.

Hilo Hospital Nurse Charged With Stealing Fentanyl

Hilo, Hawaii

A former Hilo Medical Center nurse was charged in September 2022 with second- and third-degree promotion of a dangerous drug and two counts of obtaining a controlled substance through fraud, deceit, misrepresentation or theft, following an investigation by Hawaii's State Narcotics Enforcement Division and the Hawaii Police Department into alleged fentanyl theft tied to incidents at the hospital. She pleaded not guilty at arraignment and was released on $55,000 bail pending further proceedings.

Connecticut Outpatient Clinic Nurse Sentenced for Tampering With Fentanyl Vials

Hartford, Connecticut

A nurse employed by The Vascular Experts, a Connecticut outpatient medical practice, used his access to the facility's sedation supplies to withdraw fentanyl from vials meant for patient anesthesia and refill the vials with saline so the theft would go unnoticed. Another nurse at the practice noticed the tampered vials, and when company officials questioned him he admitted stealing the fentanyl to treat a medical condition of his own. He pleaded guilty to tampering with a consumer product and was sentenced to 24 months in prison, three years of supervised release, and a $5,000 fine.

Butte Hospital Nurse Sentenced for Diverting Hydromorphone Cartridges

Butte, Montana

A registered nurse working the post-operation floor at a Butte hospital diverted hydromorphone cartridges beginning in September 2020, generating an abnormally high number of oxycodone and hydromorphone transactions compared to other nurses on her floor. She recorded doses as 'wasted' or administered them and then cancelled the orders in the system to cover the theft. The hospital terminated her after she tested positive for hydromorphone and oxycodone/oxymorphone. She pleaded guilty in May 2022 to unlawfully obtaining a controlled substance and was sentenced to five years of probation.

Oklahoma nursing home LPN pleaded guilty to larceny of a patient's Schedule II medication

According to the Oklahoma Board of Nursing complaint, an LPN was terminated from a nursing home in February 2022 after admitting to a substance-abuse problem, diverting a patient's Schedule II medication for personal use and destroying the patient's narcotic record. The nurse was charged with felony larceny of a controlled dangerous substance in March 2022 and pleaded guilty in September 2022, receiving a five-year deferred sentence with supervised probation. The Board proposed a temporary suspension pending a hearing on the merits, which is an interim step rather than a final finding.

Detroit Hospital Nurse Pleads Guilty to Tampering With Critical Care Patients' Hydromorphone

Detroit, Michigan

A registered nurse in the critical care unit of a Detroit hospital removed vials and syringes of injectable hydromorphone from the unit's automated medication dispensing machines and replaced the drug with saline before returning the containers to the machines. The tampering occurred over roughly five months in 2020 and exposed critical care patients to inadequate pain relief without their knowledge. She pleaded guilty to tampering with a consumer product.

Massachusetts Paramedic Pleads Guilty to Tampering With Ambulance Fentanyl Vials

Needham, Massachusetts

A licensed EMT paramedic working part-time for a Massachusetts ambulance service tampered with three fentanyl citrate vials while on a shift in Needham in September 2020, removing most of the fentanyl and replacing it with saline; lab testing found the vials retained only 4.4%, 6.8%, and 24.2% of their declared fentanyl concentration. She was charged in June 2022 and pleaded guilty on August 30, 2022, to tampering with a consumer product, facing up to 10 years in prison at a sentencing later that year.