Diversion Case Studies

Registered nurse stole fentanyl vials at work and altered medication logs to conceal theft

A registered nurse admitted to stealing 255 vials of fentanyl 100 mcg/2 mL and altering medication logs to conceal the theft. The nurse also tested positive for fentanyl on a for-cause drug screen at work and pleaded guilty in federal court to felony acquiring or obtaining possession of a controlled substance by misrepresentation, fraud, forgery, deception or subterfuge. The Board placed the nurse's license on 36 months of probation, including restrictions on access to narcotics or controlled substances.

Michigan Practical Nurse Fined and Probated Over Gladstone Drug Diversion

Gladstone, Michigan

A Michigan licensed practical nurse in Gladstone was fined and placed on probation after the state licensing bureau's disciplinary action report cited drug diversion and incompetence as the basis for action.

Illinois hospital nurse fired over suspected opioid diversion loses federal discrimination appeal

A hospital nurse was terminated after two controlled opioids were improperly removed from the hospital's secure dispensing system on a shift during which coworkers reported she appeared disoriented and drowsy. A drug test was positive for opiates, which she attributed to a prescribed medication taken the night before. She sued for discrimination and retaliation; in August 2025 the Seventh Circuit affirmed judgment for the hospital while stating that whether the diversion suspicion was correct was not before the court.

Oklahoma grocery-chain pharmacy technician admitted stealing and selling hydrocodone and alprazolam

On May 9, 2025 the Oklahoma State Board of Pharmacy received a DEA 106 loss report from a grocery-chain pharmacy where a technician was employed. In a voluntary written statement on May 13, 2025 the technician admitted stealing one 60-tablet bottle of alprazolam for personal use, selling two 100-tablet stock bottles of hydrocodone at $5 per pill to acquaintances, and passing a 140-tablet bottle of hydrocodone-acetaminophen through the pharmacy drive-thru. The technician was terminated that day, the permit was later cancelled for non-renewal, and after an August 13, 2025 hearing the Board proposed permanent revocation and a $2,000 fine.

Stamford Nurse Tampered with Hydromorphone and Fentanyl Vials

Stamford, Connecticut

Kristen Carotenuto, 35, a nurse at an outpatient surgical center in Stamford, removed hydromorphone and fentanyl vials from secure storage in December 2024, extracted the drugs with a syringe for personal use, refilled the vials with saline or water, and returned them to storage where they could be distributed to patients. She pleaded guilty to tampering with a consumer product on August 7, 2025, and was sentenced to five months in prison, three years of supervised release, and a $5,000 fine. There is no evidence any patient received a tampered vial.

Lakeland Nurse Sentenced to 5+ Years for Stealing Fentanyl at Five Tampa Bay Hospitals

Lakeland, Florida

Eric Brewer, 30, of Lakeland, a Florida-licensed nurse who worked at hospitals across the Tampa Bay area, was sentenced to five years and three months in federal prison for tampering with and stealing fentanyl at five different hospitals. He diluted a fentanyl IV bag by about 50 percent with saline.

Tennessee Board of Pharmacy fines pharmacist over Dayton diversion

The Tennessee Board of Pharmacy disciplined a pharmacist in Dayton over controlled-substance diversion, according to the August 2025 disciplinary action report. The order records that the licensee diverted controlled substances from their employer, and the board assessed a civil penalty. A board order is an administrative finding on the board's own investigation, not a criminal conviction, and the report states no quantity.

Tennessee Board of Pharmacy suspends pharmacist over Nashville diversion

Nashville, Tennessee

The Tennessee Board of Pharmacy disciplined a pharmacist in Nashville over controlled-substance diversion, according to the August 2025 disciplinary action report. The order records that the licensee diverted controlled substances from their employer, and the board suspended the license. A board order is an administrative finding on the board's own investigation, not a criminal conviction, and the report states no quantity.

Certified nursing assistant alleged to have diverted controlled substances from a resident at an assisted living facility

Whatcom County, WA

In August 2025, the Washington State Department of Health charged a certified nursing assistant with unprofessional conduct. Between August and October 2021, the nursing assistant allegedly diverted controlled substances from a resident at an assisted living facility and attempted to conceal the theft.

Pharmacy Owner Sentenced for Diverting Opioids From His Own Iowa Pharmacy

Fairfield, Iowa

The pharmacist-owner and operator of Summit Pharmacy of Iowa in Fairfield diverted thousands of prescription pills from his own pharmacy for personal use between June 2022 and November 2023. He obtained the pills by ordering stock and not recording it in inventory, taking pills directly from pharmacy stock, and pulling pills from the pharmacy's controlled-substance take-back collection bin, ultimately diverting more than 3,500 oxycodone and hydrocodone pills and over 400 carisoprodol pills. He was sentenced in July 2025 to probation and a fine.

Indiana critical access hospital faces board complaint after DEA admonition over unreported diversion

An Indiana critical access hospital appeared before the Board of Pharmacy on an order to show cause after receiving a letter of admonition from the DEA related to what the minutes call a significant diversion. Hospital counsel described protocol changes made in response and said the DEA was satisfied with corrective actions, while board members asked why the diversion was not immediately reported. The board set aside the order to show cause and voted unanimously to have administrative complaints filed against the hospital and against its drug wholesaler; no findings had been made at that stage.

Indiana pharmacy board rejects settlement over chain pharmacy diversion tied to employee case

The Indiana Board of Pharmacy considered a proposed settlement with a chain pharmacy location arising from an employee diversion case heard earlier in 2025. According to the minutes, the diversion took place over about 10 days, but the state could prove only one instance, which capped the available fine at $1,000. Board members said diversion cases must be taken seriously, unanimously denied the settlement, and directed that a final hearing be held no later than September 2025; no finding against the pharmacy had been made.

Travel Nurse Sentenced for Diverting Hydromorphone at West Virginia Hospital

Beckley, West Virginia

A travel nurse employed at Raleigh General Hospital in Beckley, West Virginia, unlawfully accessed patients' identifiable health information to divert hydromorphone for her own use from automated medication dispensing/monitoring machines. She used her own biometrics and a patient's health information to open the machine's secure drawer, siphoned off a portion of the hydromorphone, diluted the remaining vial contents to disguise the theft, and canceled or nulled the transactions to conceal the removal. She carried out the scheme repeatedly between September 2021 and February 2022. She was sentenced in July 2025 to five years in prison, and the West Virginia Board of Registered Nurses indefinitely suspended her license.

Traveling Nurse Diverted Hydromorphone from Beckley Hospital Using Patients' Health Information

Beckley, WV

According to the U.S. Attorney's Office for the Southern District of West Virginia, a travel nurse who worked at Raleigh General Hospital in Beckley was sentenced to five years in prison for obtaining a controlled substance by fraud and wrongful disclosure of health information. She admitted using her biometrics and patients' health information to check out hydromorphone from dispensing machines, siphoning off part of each vial, diluting what remained, and voiding the transactions to conceal the diversion between September 2021 and February 2022.

Eastern Pennsylvania hospital network pays $2.75 million to resolve controlled substances allegations

Federal prosecutors announced in July 2025 that a Lehigh Valley hospital network agreed to pay $2,750,000 to resolve allegations that it failed to comply with Controlled Substances Act provisions meant to prevent diversion of controlled substances. The announcement describes a civil resolution of allegations, not a finding or admission of liability. The network worked with the United States Attorney's Office for the Eastern District of Pennsylvania and the Drug Enforcement Administration to identify potential violations and develop better practices.

Pennsylvania health system pays $2.75M to resolve DOJ claims over pharmacy technician diversion

A Pennsylvania health system agreed to pay $2.75 million to resolve U.S. Department of Justice claims that it failed to prevent theft and diversion of controlled substances from its hospital pharmacies. Prosecutors alleged that a pharmacy technician diverted drugs from one of the system's hospitals, forged paperwork and used another employee's login credentials to conceal the activity. According to the report, the health system admitted it failed to maintain adequate security and record keeping over controlled substances; the technician was not named and no charges against that individual were described.

Registered nurse accused of obtaining controlled substance by fraud from resident's supply at North Hills Lifecare and Rehab

Fort Smith, AR

According to the attorney general's announcement, a registered nurse at North Hills Lifecare and Rehab in Fort Smith was arrested on one count of Obtaining Drugs by Fraud, a Class D felony. The nurse allegedly signed out two tablets of a controlled substance from a resident's prescription supply even though the resident had been discharged and transferred to another unit. Documentation indicated the medication was administered, but the resident did not receive it, and the two tablets were later found missing from inventory.

Travel nurse at Beckley hospital diverted hydromorphone, sentenced to five years

A travel nurse from Kentucky who worked at a Beckley, West Virginia hospital was sentenced in federal court to five years in prison followed by three years of supervised release for obtaining a controlled substance by fraud and wrongful disclosure of individually identifiable health information. Prosecutors said that over several months in late 2021 and early 2022 the nurse accessed patient information to divert hydromorphone, removed portions of doses from automated dispensing cabinets, diluted vials so they appeared full, and voided transactions to conceal the activity. The West Virginia Board of Registered Nurses has indefinitely suspended the nurse's ability to practice in the state.

Pharmacist Sentenced for Diverting Controlled Substances From Mason City Pharmacies

Mason City, Iowa

A pharmacist who worked at three different pharmacies in Mason City, Iowa, between 2008 and 2023 diverted a range of controlled substances — including codeine, phentermine, alprazolam, clonazepam, lorazepam, pregabalin, and tramadol — for her own use. She created unauthorized prescriptions and falsified prescription and inventory records in the names of existing patients, primarily while the pharmacy was closed, then filled and paid for the prescriptions herself. She pleaded guilty in February 2025 to acquiring a controlled substance by fraud and misrepresentation and was sentenced in June 2025.

Registered nurse diverted and abused controlled substances from places of employment

A registered nurse admitted to diverting controlled substances from places of employment and abusing those controlled substances on multiple occasions in 2021, 2022, 2023, and 2024. The nurse also failed to answer truthfully about drug diversion and substance abuse on license renewal applications and during a Board investigation, and had medication documentation discrepancies including unaccounted medications and documenting administrations before logging out. The Board imposed suspension with conditions followed by probation.

Facility Administrator Sentenced for Diverting Opioids From Five Senior-Care Facilities

Iowa

An administrator employed at nursing and senior living facilities in the Southern District of Iowa diverted prescription drugs from at least five healthcare facilities between September 2021 and November 2022. She obtained fentanyl patches, hydrocodone, morphine, and oxycodone by stealing them from the facilities' narcotics emergency kits and locked medication carts and rooms. She was sentenced in May 2025 to probation, a fine, and restitution.

Illinois nursing-facility administrator sentenced to probation for diverting opioids from emergency kits and medication carts

A Colona, Illinois woman who worked as an administrator at nursing and senior living facilities was sentenced on May 28, 2025 in federal court in the Southern District of Iowa for diverting prescription drugs. According to public court documents cited by HHS-OIG, she obtained fentanyl patches, hydrocodone, morphine and oxycodone from at least five healthcare facilities between at least September 2021 and November 2022 by taking them from narcotics emergency kits and locked medication carts and rooms. She received three years of probation and was ordered to pay $1,975.61 in restitution, a $5,000 fine and a $200 special assessment. The source does not state in which state the facilities were located.

Oklahoma hospital night-shift nurse disciplined after morphine waste questioned and patient reported no dose

In May 2025 a registered nurse entered an agreed stipulated order with the Oklahoma Board of Nursing over a March 2024 night shift at a hospital. The order recites that the nurse displayed impaired behavior, obtained morphine from a colleague for a patient and charted it as administered, while the patient later reported not having received it; the nurse declined a reasonable-suspicion drug test and was terminated. The order imposed a severe reprimand, a $500 administrative penalty, education courses and twice-monthly body fluid testing for 12 months. After reviewing the nurse's required evaluation in November 2025, the Board proposed referral to its Peer Assistance Program with the license temporarily suspended pending entry.

Oklahoma pharmacy technician altered oxycodone counts under coworkers' credentials and sold the pills

The Oklahoma State Board of Pharmacy found at a May 7, 2025 hearing that a pharmacy technician was terminated on March 11, 2025 for theft after admitting to manually altering inventory counts for oxycodone 10 mg and 15 mg between January 8 and March 9, 2025, using the credentials of other pharmacy staff. The Board found the technician took 531 10 mg tablets and 640 15 mg tablets, a total of 1,171. The technician stated the oxycodone was not for personal use but admitted to selling it for $900 or more per bottle, and the Board proposed permanent revocation of the permit and a $2,000 fine.

Pharmacist and Spouse Sentenced for Diverting Opioids From Kentucky Pharmacy

Franklin, Kentucky

A pharmacist in Franklin, Kentucky, and his wife diverted oxycodone and hydrocodone from his pharmacy between May 2020 and January 2023, with the wife selling or trading the drugs for cocaine, methamphetamine, and marijuana. The pharmacist also fraudulently billed Kentucky Medicaid and private insurers for prescriptions never ordered or dispensed as billed, used another provider's identity to issue prescriptions without consent, and falsely reported a pharmacy robbery to the DEA to cover a shortage. Both were sentenced to federal prison and ordered to pay restitution.