What Happened
A licensed practical nurse at a long-term care facility in Pembina County, North Dakota was charged in April 2020 with theft of a prescription and reckless endangerment, in the first case ever prosecuted by the state's newly created Medicaid Fraud Control Unit.
Investigators allege that between March and November 2017, the nurse substituted over-the-counter medication for residents' prescribed opioid pain medication, including hydrocodone/acetaminophen, oxycodone, and transdermal fentanyl patches. The scheme allegedly came to light in November 2017, when a resident's medication card was found tampered with: pills that were supposed to be hydrocodone/acetaminophen had been broken open, emptied, and taped back together, with acetaminophen substituted inside. The facility fired her at the time. The Pembina County Sheriff's Office later referred the matter to North Dakota's Medicaid Fraud Control Unit, which concluded its investigation and filed nine felony counts of theft of a prescription, two felony counts of reckless endangerment with extreme indifference, and one misdemeanor theft count in April 2020.
What Went Wrong
- A blister-pack medication card could be opened, emptied, and resealed with tape without the substitution being caught before it reached a resident.
- The alleged substitution scheme continued for roughly eight months before a tampered card was noticed, rather than being caught by routine reconciliation.
- Detection relied on a chance discovery of a single altered card rather than proactive auditing of medication packaging integrity.
How It Could Have Been Prevented
- Periodically inspect blister-pack and unit-dose medication integrity against pharmacy dispensing records, not only when a problem is visually obvious.
- Reconcile long-term care medication administration records against pharmacy counts on a routine basis to catch substitution patterns early.
- Report suspected tampering promptly to the state board of nursing and to DEA so that a pattern across residents can be identified sooner.
Related Guidance
- Diversion Prevention Checklist — Self-assessment covering long-term care medication administration controls.
- 15 Red Flags of Drug Diversion — Behavioral and transactional indicators of diversion.
- Diversion Case Registry — More documented cases of long-term care controlled-substance theft.
- Employee Screening & Fitness for Duty — DEA screening requirements for staff with controlled substance access.