Diversion Case Studies

North Carolina pharmacy chain paid $100,000 to resolve claims it filled prescriptions from physician on limited license

A pharmacy operating locations in Cary and Durham agreed to pay $100,000 to resolve allegations that it violated the Controlled Substances Act in 2017-2018. The government alleged the pharmacy filled controlled-substance prescriptions written by a physician who held only a faculty limited license and was prescribing outside the scope permitted by the sponsoring university. The allegations included that the pharmacy failed to confirm the validity of the prescriber's license. The settlement resolves allegations only and is not a finding of liability.

Ready Pharmacy Pays $400K Over 26,000 Missing Controlled Substance Units

Albuquerque, New Mexico

Ready Pharmacy, a now-closed Albuquerque, New Mexico retail pharmacy, agreed to pay $400,000 to resolve civil claims that it failed to account for more than 26,000 missing dosage units of controlled substances discovered on March 15, 2016. A DEA on-site inspection also found controlled substances stored unsafeguarded. The settlement was announced February 1, 2022.

Cedar Rapids Surgery Center Nurse Sentenced for Tampering With Fentanyl Vials

Cedar Rapids, Iowa

A registered nurse at a Cedar Rapids outpatient surgery center diverted fentanyl for her own use between August 2018 and August 2019 by removing vial caps, puncturing the septum with a needle to draw out the fentanyl, refilling the vials with saline, and regluing the caps so the vials appeared unopened. She pleaded guilty in July 2021 to acquiring a controlled substance by fraud and to adulterating and misbranding a consumer product with intent to defraud. She was sentenced to five years of probation, fined $10,000, and forfeited her nursing license.

San Diego Pharmacy Pays $105K for Ignoring Opioid Prescription Red Flags

San Diego, California

Balboa Pharmacy in San Diego, California agreed to pay $105,000 to resolve allegations that it filled opioid prescriptions without resolving well-known red flags, including doses exceeding 100 morphine milligram equivalents, dangerous drug combinations, and early refills. The pharmacy also entered a Memorandum of Agreement with DEA in October 2021 to develop red-flag procedures. The settlement was announced January 20, 2022.

DC emergency nurse's diversion surfaced by automated dispensing cabinet audit

Washington, DC

On or about January 8, 2019, Providence Hospital in Washington, DC complained to the Board of Nursing of a suspected controlled substance diversion, after an internal investigation prompted by discrepancies found in the hospital's controlled substance tracking records during a routine pharmaceutical audit. The investigation identified discrepancies in 17 patient accounts, with a total of 32 drug removals, and concluded that the emergency room registered nurse was the nurse who withdrew the medication: for patients she was not assigned to or associated with, without a physician's order, after patients had been discharged and left the hospital, or for fictitious patients. A separate audit at United Medical Center, where the nurse worked later, revealed unauthorized removal of controlled substances for fictitious or already-discharged patients or without a physician's order, and she was terminated there on March 15, 2019. The nurse admitted to a DC Health investigator that she was addicted to oxycodone and tramadol and had diverted narcotics from the hospitals for her own use, and that she failed to cooperate with the Committee on Impaired Nurses. The Board revoked the registered nursing license on January 14, 2022.

Skilled nursing facility registered nurse diverted Ativan tablets from PRN supply for personal use; Vermont license warned

Gwynedd, PA

A registered nurse admitted to diverting Ativan tablets for personal use in 2015 or 2016 by taking them from the PRN supply at Foulkeways at Gwynedd Skilled Nursing Facility. The Vermont Board of Nursing found that the nurse diverted drugs for unauthorized use and failed to exercise independent professional judgment, while allegations of fraudulent or deceptive procurement and conduct likely to deceive, defraud, or harm the public were not proven. The Board warned the nurse's license and imposed no other conditions or sanctions.

Physician pleads guilty to illegally prescribing opioids and falsifying records at a Lake Milton medical office

Lake Milton, OH

A physician pleaded guilty in federal court to illegally distributing controlled substances and health care fraud. According to court documents, between March 2015 and October 2019 he prescribed opioids including oxycodone and hydrocodone, often with benzodiazepines and stimulants, outside the usual course of professional practice and without a legitimate medical purpose from a Lake Milton medical office. He admitted using false diagnoses, falsifying patient pain intensity scales, increasing dosages, and ignoring urine drug screens that suggested abuse and secondary-market sales. He also admitted unlawfully prescribing opioids to two patients who later fatally overdosed and to an individual under 21.

Vermont dental practice employee conspired to forge oxycodone prescriptions

A former employee of a St. Albans dental practice pleaded guilty in federal court to conspiring to acquire controlled substances by fraud and to theft in connection with healthcare. According to court records, between April and November 2016 the employee and a co-worker generated fake prescriptions, typically for oxycodone, forged a licensed prescriber's signature and filled them at several area pharmacies; investigators identified 46 such prescriptions. The employee also embezzled funds from the practice by falsifying billing records. In December 2021 the court imposed five years of probation and ordered restitution of $71,942.60 to the former employer.

Confluence Health Clinic Nurse Tampered with Morphine Vials

Moses Lake, Washington

A registered nurse at Confluence Health Clinic in Moses Lake, Washington used syringes to remove morphine from at least 17 vials over an eight-month period, ingesting the drug as part of her own opioid addiction. She replaced the withdrawn morphine with saline and attempted to glue the vial caps back to make them appear untampered. Before she was caught, at least one patient who was supposed to receive morphine instead got saline and had to be rushed to the emergency room in excruciating pain. She pleaded guilty to tampering with a consumer product, a charge carrying up to 10 years in prison, with sentencing scheduled for 2022.

South Jersey hospital system settles DEA allegations after 400 oxycodone tablets reported lost or stolen

A South Jersey hospital system agreed to pay $150,000 to resolve allegations that it violated the Controlled Substances Act after reporting to the DEA in July 2016 that 400 oxycodone 30 mg tablets had been lost or stolen from a hospital inpatient pharmacy. DEA diversion investigators alleged that from October 2015 through November 2016 the hospital failed to keep an accurate controlled substance inventory, failed to store controlled substances securely, and failed to properly supervise employees with access to them. The claims are allegations only, and the settlement includes no determination of liability.

Contract nurse at Winston-Salem hospital diverted hydromorphone and replaced it with saline

Winston-Salem, NC

A contract registered nurse at Novant Health Forsyth Medical Center in Winston-Salem pleaded guilty in December 2021 to one count of tampering with a consumer product. According to court documents and federal prosecutors, the nurse removed vials of injectable hydromorphone from an automated dispensing cabinet machine, injected the drug into herself, replaced it with saline, used glue to reseal the vials, and returned them to locked drawers. The nurse was sentenced to four years and six months in federal prison, a $3,000 fine, and three years of supervised release; her nursing license is suspended.

Colorado Nurse Sentenced Over Fake Research-Study Hydromorphone Diversion

Colorado

A Colorado registered nurse was sentenced to 12 months in federal prison for using her position to access patients she was not assigned to care for, falsely telling them she was conducting a study on patient-controlled analgesia pumps, then using a key to open the pump's secured hydromorphone syringe and remove a portion of the drug for herself before returning the syringe to circulation.

DC nurse diverted oxycodone from a rehabilitation hospital

Washington, DC

A registered nurse employed at MedStar National Rehabilitation Hospital in Washington, DC from 2011 until 2018 diverted oxycodone IR between July 2017 and January 2018 by withdrawing more of the medication than was prescribed for patients and entering false information into the system to conceal the diversion. The nurse told the hospital the drug was taken for an abusive partner and father of her children. A fitness-for-duty examination including a drug screening in January 2018 was negative. The hospital, after confirming the diversion through an internal investigation, placed her in a domestic violence treatment program under an agreement that she would resign on completing it; she resigned on May 29, 2018. The Board of Nursing charged willfully filing a false record in the practice of nursing and failing to conform to professional standards of conduct, and on November 23, 2021 revoked the registered nursing license.

VA Medical Center Pharmacy Chief Diverted Painkillers from Veterans' Prescriptions

Erie, Pennsylvania

The Pharmacy Chief at the Veterans Affairs Medical Center in Erie, Pennsylvania unlawfully obtained hydrocodone and oxycodone from pill bottles that were awaiting delivery to VA patients. The diversion took place over more than three years, from January 2017 to June 2020, while he held the top pharmacy leadership role at the facility. He pleaded guilty to a federal drug-law violation, with sentencing scheduled for 2022 and a maximum exposure of four years in prison and a $250,000 fine.

Ann Arbor VA Nurse Anesthetist Stole 2,000+ Vials of Opioids

Ann Arbor, Michigan

Elizabeth Prophitt, a certified registered nurse anesthetist, used her position as a surgical nurse to steal more than 2,000 vials of fentanyl, hydromorphone, morphine, and midazolam from hospital dispensing machines at the Ann Arbor VA hospital, using protected patient information and falsified medical documents to justify the withdrawals. She pleaded guilty to five counts of obtaining controlled substances by fraud and was sentenced in November 2021 to three years of probation.

Pharmacy technician surrendered registration after admitted theft of controlled substances from Walgreens pharmacy

Gulfport, MS

According to a Mississippi Board of Pharmacy order, a pharmacy technician admitted to theft of controlled substances from the Walgreens pharmacy where the technician worked. The Board found the technician committed the violation as charged and accepted the voluntary surrender of the pharmacy technician registration. The registration was revoked, and the technician was ordered to pay $150.00 in investigation costs.

Pharmacy technician surrendered registration after admitting to ingesting THC-infused chocolate while working at Kroger pharmacy

Brandon, MS

According to a Mississippi Board of Pharmacy order, a pharmacy technician admitted to ingesting chocolate infused with THC while working at Kroger Pharmacy #493 in Brandon, MS. The Board found the technician committed the violation as charged and accepted the voluntary surrender of the pharmacy technician registration. The registration was revoked, and the technician may petition for reinstatement after at least one year.

Pharmacy technician took controlled substances from a pharmacy

A default board order from the Texas State Board of Pharmacy states that a registered pharmacy technician took controlled substances from the pharmacy. The board revoked the technician's registration. The violation date is listed as November 30, 2020.

Colorado Nurse Stole Fentanyl in Hospital Catheterization Lab

Colorado

Kurt Vasquez, a contract advanced nurse practitioner and registered nurse placed in a hospital catheterization lab in summer 2019, obtained more fentanyl, midazolam, and propofol than scheduled procedures required and kept the excess for personal use between June and September 2019. He falsely documented in patient charts that he had administered drugs he had not given, and on some occasions used filled syringes himself before falsely claiming they had been used on a patient. He was sentenced in September 2021 to three months in federal prison.

Carterville Nurse Diverted Hydrocodone at Disability Care Center

Carterville, Illinois

A nurse employed at Progress Port, a residential care center for adults with intellectual disabilities in Williamson County, Illinois, obtained 25 hydrocodone pills he falsely claimed to have dispensed to a resident and diverted them for his own use. He also took hydrocodone pills intended for the same resident and replaced them with over-the-counter Tylenol on three separate occasions, then billed Medicare for the diverted medication. He was sentenced on felony drug diversion and health care fraud charges to four years of probation, a $500 fine, and a $200 special assessment.

South Dakota pharmacy technician diverted medications from employer pharmacy

Sioux Falls, South Dakota

A registered pharmacy technician in Sioux Falls pleaded guilty to Misrepresentation to Obtain a Controlled Substance, a class 4 felony, for diverting medications from the pharmacy where she worked. The South Dakota Board of Pharmacy accepted the voluntary surrender of her technician registration effective September 16, 2021. The board's disciplinary report does not specify the drug or the quantity diverted.

DC nurse license stays suspended after fentanyl and oxycodone relapse

Washington, DC

A registered nurse at George Washington University Hospital was suspended by the hospital on or about March 15, 2018 over suspected diversion and resigned in April 2018. The nurse referred herself to the Board of Nursing, applied to the Committee on Impaired Nurses in May 2018 and entered a three-year monitoring agreement. The monitoring record shows compliance in 2019 but relapses in June 2018 and again in approximately March 2020, when the nurse began using fentanyl and oxycodone. The relapse and a missed hair-sample collection in August 2020 violated the agreement; a new agreement was offered, and the nurse did not complete a further scheduled collection on November 24, 2020, leading the Committee to expel her on December 22, 2020. The Board's final order of September 1, 2021 adopted the hearing panel's recommended decision: the license remains suspended until the nurse establishes sustained abstinence and full recovery through a new monitoring agreement and satisfies the Board that she is competent to practice safely, and the Board will enter a revocation order if a new agreement is not executed within 60 days.

Southeast Missouri medical center paid $1.6 million to resolve invalid opioid prescribing claims

Saint Francis Medical Center of Southeast Missouri agreed to pay $1,624,957.67 to settle a federal civil suit under the Controlled Substances Act. The government alleged that a physician it employed wrote prescriptions for opioids without a legitimate medical purpose while ignoring warning signs of diversion or misuse, such as aberrant urine drug test results. The settlement resolves the claims and is not a finding of liability; the medical center cooperated with the investigation and agreed to keep cooperating regarding individuals not released by the agreement.

Florida emergency room nurse accused of diverting hydromorphone after syringes found in work bag; probable cause panel dismissed case

A registered nurse working in a Florida hospital emergency room was accused of diverting hydromorphone after a co-worker reported seeing syringes in the nurse's work bag and a search turned up two mostly empty pre-drawn 1 mg hydromorphone syringes. The nurse stated the syringes were leftover from administered doses that had not been wasted, and a drug test was negative, but the hospital reported the nurse to the Florida Department of Health, which issued a letter of intent alleging diversion, malpractice and unprofessional conduct. The matter was presented to a probable cause panel, which found no probable cause and dismissed the case without a finding.

Two Colorado nurses held accountable for taking controlled substances from patients

In two separate federal cases, the U.S. Attorney's Office for the District of Colorado held nurses accountable after, according to the office, they took controlled substances from their patients. The cases were investigated by the FDA Office of Criminal Investigations and the DEA. The release does not specify the drugs involved or the individual sentences.