Pharmacist Sentenced for Tampering with Injectable Fentanyl

On 7/20/22, Chief U.S. District Judge Timothy J. Corrigan has sentenced Monique Elizabeth Carter (36, Middleburg) to one year and one day in federal prison for tampering with a consumer product, specifically, injectable fentanyl. The court further ordered that after serving her prison sentence, Carter will serve one year of home detention as a condition of a two-year term of supervised release. During this time, Carter will also be prohibited from working in any position in which she would have access to prescribed medications. Carter had pleaded guilty on April 13, 2022.

According to court documents, Carter is a registered nurse who had previously been employed by a hospital in Jacksonville. She worked in a neural intensive care unit or ICU, which is a specialized unit that provides intensive and specialized care to critically ill patients with life-threatening neurological problems. Certain ICU patients were prescribed intravenous doses of fentanyl, a synthetic opioid used as a pain medication and as anesthesia.

After Carter’s shift on September 28, 2021, a hospital pharmacist examined the ICU wing’s inventory of fentanyl and found a fentanyl syringe with a tamper-proof cap missing, but with some form of foreign adhesive remaining at the tip. A second fentanyl syringe had a cap that appeared to have been glued back on. After reviewing hospital records, a pharmacist supervisor noted a pattern of Carter checking out doses of fentanyl for patients, but then cancelling the transactions and checking syringes back into the hospital’s inventory. Records showed that Carter did so 24 times between August 29 and September 28, 2021. Carter was the only nurse on her ICU wing who persistently checked out fentanyl and returned it to the hospital’s inventory.

The next day, when Carter arrived for work, hospital representatives interviewed her. Confronted with the pharmacists’ findings, Carter eventually admitted that—to obtain drugs for personal use at home—she had been removing injectable fentanyl from syringes, replacing the drug with saline, and then gluing the plastic tampering caps back on the syringes with an adhesive that she obtained from the hospital. She admitted that she had been tampering with fentanyl syringes since the summer of 2021. Carter denied injecting fentanyl while on duty at the hospital, but in her bag, law enforcement investigators later located needles, saline syringes, and adhesive.

Carter is a trained healthcare professional and knew that her activities likely resulted in critically ill patients receiving diluted fentanyl, which was not safe and effective. Having been deprived of sterile, medically necessary medication, such patients were exposed to possible infection and endured unnecessary pain and suffering. In addition, Carter knew that the failure to anesthetize or control pain in ICU patients can result in increased risks of illness or death, stemming from, among other things, respiratory, cardiovascular, and musculoskeletal complications.

This case was investigated by the U.S. Food and Drug Administration, Office of Criminal Investigations and the Jacksonville Sheriff’s Office – Pharmaceutical Diversion and Designer Drug Unit attached to the North Florida High Intensity Drug Trafficking Area. It was prosecuted by Assistant United States Attorney Michael J. Coolican.