A nurse working at a Jacksonville hospital stole vials of fentanyl, drained some of the medication used for extreme pain and replaced it with saline, according to a Florida Department of Health administrative complaint.
The complaint starts the professional discipline process against Monique Carter, a 35-year-old registered nurse.
On the criminal side, Carter was charged with obtaining a controlled substance via fraud and possession of a controlled substance. Duval County court records say Carter went into the pre-trial intervention program on Nov. 12. Carter’s program participation has been deemed satisfactory because the two charges were dropped Monday.
That doesn’t affect the possible professional consequences.
Saline-for-fentanyl swaps at Baptist Medical Center?
Carter’s address on her Florida license is Middleburg, but she didn’t receive her Florida registered nurse license until Oct. 1. Before that, as allowed by her Georgia multistate license, she worked in Florida on the license she achieved in 2018 while based in Valdosta, Georgia.
According to the administrative complaint filed Jan. 6 and the emergency restriction order filed Nov. 19:
Carter was working in Baptist Medical Center Jacksonville’s Neurological Intensive Care Unit on Sept. 28 when “a coworker observed that Ms. Carter appeared antsy and fidgety, that she sniffed a lot and that she stayed after hours to complete her charting.”
That’s also the day that a risk manager found there was a fentanyl syringe that wasn’t accounted for in the Omnicell controlled substance dispenser. An audit of Carter’s withdrawals found she had a habit of taking out fentanyl, then canceling the transaction, and withdrew fentanyl more often than other nurses.
From Aug. 29 through Sept. 29, the director of pharmacy found, Carter canceled fentanyl withdrawals 24 times, a pattern not repeated with other controlled substances. Also on Sept. 29, the pharmacy director and risk manager found two fentanyl syringes “whose anti-tampering caps had been glued on, evidence that those syringes had been tampered with.”
Also, she took out the fentanyl hours before the doses should have been given to patients, but didn’t put the withdrawal in the patient records.
Carter “later admitted...that she had been divertying fentanyl during her shifts. She would remove the fentanyl syringe from the Omnicell and “pop” the cap, and use a saline flush with a red blunt needle to draw out approximately half the drug. She would replace the missing fentanyl with saline from a saline wash to make the syringe appear full.”
Carter said she began “self-medicating” with fentanyl in June to deal with “family issues, that she self-administered the fentanyl at home, and that there were times she used the fentanyl prior to reporting to her work.”