The facility’s clients sometimes went without pain medications as a result, according to the report.
The investigation by the Minnesota Department of Health’s Office of Health Facility Complaints also found that other staff members were aware of the theft but didn’t report it because of fear of retaliation by the employee and by management at the facility, Majestic Pines Senior Living.
The agency posted its findings online on Wednesday from an investigation that was concluded Nov. 16 after a visit to the facility on Oct. 16 and 17 by senior special investigator Darin Hatch.
Copies of the report were filed with the Itasca County attorney, the Grand Rapids city attorney and the Grand Rapids Police Department.
Jessica Wolf, executive director at Majestic Pines, said the facility reported the drug diversion to law enforcement and the health department as soon as it was discovered.
Itasca County and Grand Rapids attorneys weren’t available for comment Wednesday, but Wolf said criminal charges are expected to be filed. The employee no longer works for Majestic Pines, she said.
The medications were diverted on multiple occasions in 2017 and 2018 from 13 clients, according to Hatch’s report. The report didn’t suggest a dollar value of the stolen pills. A 10 mg tablet of Oxycontin, one of the most-prescribed opioids, costs $1.25 when legally sold, according to CT Clearinghouse, a resource center on substance use and mental health disorders. An 80 mg tablet costs $6.
“Investigation also revealed staff members were aware of the suspected diversions early on, but were afraid to report their suspicions … because the (employee) was friends with management and staff feared retaliation,” Hatch wrote.
Wolf declined to comment directly to that allegation but attributed the theft to an employee gaming the system.
“We have safeguards in place to prevent such a diversion,” Wolf said. “Unfortunately, we had a staff member that we trusted that manipulated these systems and created a diversion that was not easily detected.”
Clients he interviewed told him they weren’t aware of the diversion, Hatch wrote, but some recalled being told they had run out of medication when they didn’t think they should be out.
Family members also raised questions, he wrote. “Several family members said they notified staff at the facility of their concerns regarding missing medication, but nothing seemed to be done to address the problem.”
Wolf again said she was misled because the employee manipulated the process, and Majestic Pines administrators thought the family members’ concerns were being addressed.
Hatch wrote that staff members said the employee created an “overflow area” in her office, placing prescription medications in a filing cabinet there and that only that employee had access to the office. They said there was no need for an overflow area.
The staff members also said that when they ran out of medications in the main storage area and asked for drugs from the overflow area, the employee “made various excuses as to why she could not give them medications and would even refuse to come into work to get staff medications, causing clients to go without their pain medications.”
Staff members said they were frequently told by the pharmacy that it was too soon to refill clients’ medications, Hatch wrote.
The woman accused of the diversion was interviewed and denied the allegations, he wrote.
Wolf said the problem occured because of “a bad person in our community.”
“We take full responsibility for our vulnerable adults, and we take this very seriously,” she said.
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