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Middleburg Nurse Pleads Guilty to Tampering with Intensive Care Patients’ Medication

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Department of Justice
U.S. Attorney’s Office
Middle District of Florida

Wednesday, April 13, 2022

Jacksonville, Florida –United States Attorney Roger B. Handberg announces that Monique Elizabeth Carter (35, Middleburg) today pleaded guilty to tampering with a consumer product, specifically, injectable fentanyl.  Carter faces a maximum penalty of 10 years in federal prison. A sentencing date has not yet been set.

According to the plea agreement, Carter, a registered nurse who previously was employed by a hospital in Jacksonville, worked in a neural intensive care unit (ICU) providing intensive and specialized care to ocritically ill patients with life-threatening neurological problems. Certain ICU patients were prescribed intravenous doses of fentanyl, which is 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 missing a tamper-proof cap, 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 onto the syringe.  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 engaged in such conduct.

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 onto the syringes with an adhesive that she obtained from the hospital. Carter admitted that she had been tampering with fentanyl syringes since the summer of 2021. Carter denied injecting fentanyl while on duty at the hospital, however, law enforcement later located needles, saline syringes, and adhesive in her bag.

Carter, as a trained healthcare professional, knew that her activities likely resulted in critically ill patients receiving diluted fentanyl that 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 is being prosecuted by Assistant United States Attorney Michael J. Coolican.  


USAO - Florida, Middle

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