The Minnesota Department of Health (MDH) substantiated a finding of financial exploitation following an investigation into alleged narcotic medication diversion at a nursing home. The investigation was concluded on April 8, 2026, under the Minnesota Reporting of Maltreatment of Vulnerable Adults Act.
The allegation involved a nurse who was suspected of taking morphine from a resident’s medication supply. MDH determined that the nurse was responsible for the maltreatment based on a preponderance of the evidence.
According to the investigation, a concern arose during a routine narcotic count when a bottle of liquid morphine could not initially be located. When the bottle was later found, staff observed differences in the medication, including a lighter color, a higher volume than expected, and indications that the seal had been opened. The bottle was found to contain approximately 40 milliliters of liquid rather than the expected 30 milliliters.
Facility staff reported that the nurse had possession of the morphine bottle before the concern was identified. A staff member also reported seeing the nurse in the medication cart where the morphine was stored. When asked about the bottle, the nurse stated she had removed it to complete an audit.
Further review of the bottle showed a stopper inside the liquid, moisture on the outside of the bottle, and blood on the label. Staff noted that the stopper did not match the original packaging and appeared to be a different size.
Interviews conducted during the investigation indicated that the nurse had noticed concerns with the bottle but did not share those concerns with other staff at that time. The investigation also found that the nurse completed a controlled substance audit without a second licensed staff member, which was not consistent with facility policy.
The resident involved lived at the nursing home and had diagnoses including Alzheimer’s disease. The resident’s care plan included assistance with medications and daily care. Due to the resident’s condition, an interview was not conducted.
MDH reviewed interviews with staff, facility records, and other documentation as part of the investigation. The department concluded that the nurse had possession of the morphine bottle and the opportunity to tamper with it before the discrepancies were identified.
Based on the findings, MDH determined that financial exploitation was substantiated and that the nurse was individually responsible for the maltreatment.
The facility conducted an internal review of the incident, and the nurse is no longer employed there. MDH also noted that the matter had been reviewed previously during a standard survey, which resulted in a finding of noncompliance with federal long-term care regulations.
Compliance Perspective
Issue
Failure to maintain proper control and oversight of controlled substances can create opportunities for drug diversion in healthcare settings. Diversion of medications, particularly narcotics, may compromise resident safety, result in ineffective pain management, and constitute maltreatment under state and federal regulations. Facilities are responsible for ensuring that controlled substances are securely stored, accurately accounted for, and handled in accordance with established policies. Breakdowns in communication, inconsistent practices, or failure to follow required procedures during medication handling and monitoring may contribute to undetected discrepancies and potential regulatory noncompliance.
Discussion Points
- Review policies and procedures related to the management of controlled substances, including storage, access, dispensing, counting, documentation, and reconciliation and investigation of discrepancies. Policies should clearly define staff responsibilities and require timely reporting and review of any concerns identified during medication counts. Facilities may benefit from working with an experienced healthcare consultant to evaluate current practices, identify gaps, and support alignment with regulatory requirements and best practices.
- Provide education and training to licensed staff on proper controlled substance handling, including shift-to-shift narcotic counts, recognizing discrepancies, and appropriate response when concerns are identified. Training should reinforce adherence to established procedures, accurate documentation, and accountability in medication management. Med-Net Academy offers the course Drug Diversion: What Every Nursing Facility Needs to Know, which identifies commonly abused prescription medications, reviews warning signs of substance use disorder in nurses, discusses signs of possible drug diversion, outlines actions to support prevention, and explains steps to take when drug diversion is suspected.
- Conduct routine audits of controlled substance records, including narcotic counts, medication administration records, and waste documentation, to ensure accuracy and compliance with facility policy. Audits should also evaluate whether discrepancies are consistently identified, documented, and addressed. Utilizing mock surveys or focused reviews, including those performed in collaboration with a consultant, can help identify areas of risk and strengthen oversight processes. Contact Med-Net Healthcare Consulting or info@mednetconcepts.com for more information.
*This news alert has been prepared by Med-Net Concepts, Inc. for informational purposes only and is not intended to provide legal advice.*