May 30, 2013
MDH investigation confirms drug thefts at nursing home
An individual employee at North Ridge Care Center in New Hope was responsible for exploiting vulnerable adults at the facility by stealing narcotic medications for the employee’s own use, according to a Minnesota Department of Health (MDH) investigation.
A patient was admitted to the facility for rehabilitation following surgery. A physician prescribed the patient oxycodone for pain management. The nursing home worker responsible for administering medication admitted to taking two oxycodone tablets from the patient.
After discovering the incident, North Ridge Care Center took the initiative to report it to the local police department and the MDH Office of Health Facility Complaints, which investigates suspected violations of regulations and the Minnesota Vulnerable Adults Protection Act. At the conclusion of the MDH investigation, the matter was also forwarded to the county attorney’s office by MDH for possible prosecution, and to clinical licensing authorities for appropriate action. MDH is not able to identify the vulnerable adults or the nursing home worker involved, or other private data in these incidents, according to Minnesota law, https://www.revisor.mn.gov/statutes/?year=2012&id=626.557.
The investigation found that although North Ridge had provided required training and supervision, the individual nursing home worker did not follow the training, and therefore was individually found responsible for maltreatment against the patient. During further interviews, the nursing home worker also admitted taking narcotic medication from 12 to 24 residents over a four month period. MDH’s investigation did not find evidence that patients failed to have their pain managed due to the thefts. North Ridge Care Center fired the worker and put in a system to randomly audit narcotic logs to look for patterns and prevent future narcotic diversion. The complete MDH report is available at http://www.health.state.mn.us/divs/fpc/directory/surveyapp/ohfcfindings/h5183093.pdf.
“This situation and multiple other instances of health care worker drug diversion in Minnesota and elsewhere illustrate the seriousness of drug thefts by health care workers and that we need to be on guard to prevent them,” said Ellen Benavides, assistant commissioner, Minnesota Department of Health (MDH). “We want to partner with long-term care and raise awareness about this issue so that nursing homes and other facilities implement best practices and take steps to protect patients.”
MDH has been working with providers to identify and put in place best practices to prevent drug thefts in health care facilities. In May 2011, MDH and the Minnesota Hospital Association (MHA) invited a coalition of hospital, provider, law enforcement, licensing and other health care stakeholders to form a collaborative group to address the issues surrounding health care worker drug diversion.
The coalition completed its work in April 2012 and issued a final report and a road map of resources for health care facilities to use for enhancing their drug diversions prevention programs. The coalition has created a road map and tool kit that will improve health care providers' controlled substance storage and security, procurement, prescribing, preparation and dispensing. The road map includes training materials, sample policies and procedures, and a flow chart of reporting guidelines and requirements that providers can use when they suspect a drug diversion has occurred.
The road map is a collection of about 100 best practices for preventing and responding to controlled substance diversions in hospitals. Some examples include camera surveillance in high risk areas, keeping prescription pads in locked locations, implementing a clearly defined process for controlling and accounting for keys, rules against sharing passcodes, utilizing bar codes for tracking, deploying secure and locked delivery carts, and using tamper resistant packaging.
Resources for health care providers can be found at http://www.health.state.mn.us/patientsafety/drugdiversion/index.html.