A staff member who allegedly stole drugs from eight clients at the Benedictine Living Community of Duluth told an investigator it was easy to do so because "storage and management of medications was poor."
The Minnesota Department of Health's Office of Health Facility Complaints on Tuesday reported a substantiated finding of maltreatment at the complex's Marywood assisted-living facility because of a staff member who allegedly "diverted medications from multiple clients."
The administrator of the Benedictine Living Community of Duluth said his team discovered the theft, reported it and took steps to prevent it from happening in the future.
The state's report, by special investigator Darin Hatch, found the staff member took 222 units of hydrocodone/acetaminophen, 42 units of an anticonvulsant and an unknown amount of liquid units of hydromorphone, among other medications. Most were opioids or other forms of pain reliever.
The report refers to the staff member as female, but doesn't identify her. It says she no longer works for the facility.
The maltreatment finding applies only to the former staff member, it states. But it found Marywood in "non-compliance" with statutes regarding medication.
Based on interviews with staff, Hatch concluded that "staff members rarely counted the medications, key control was not exclusive and access to medications were often uncontrolled."
It also cited nurses and "the provider's internal investigation documents" as claiming the facility didn't have enough qualified and competent nurses to ensure security and accountability of clients' medications.
"We are truly saddened by this alleged incident," wrote Brian Pattock, administrator of Benedictine Living Community of Duluth in an email. "Because we place a high priority on the safety and security of our residents, we launched an extensive internal investigation when we became aware of the potential theft of medications. We reported the incidents to the police, the Drug Enforcement Agency and the appropriate state agencies."
Even before the thefts, Marywood's medication storage practices met legal requirements and industry standards, Pattock wrote. But within a day of identifying the potential theft, procedures and policies were strengthened and staff were trained on the new procedures.
Marywood's staffing is "consistent with legal requirements and industry practice," he wrote.
All prospective employees are screened for criminal backgrounds, Pattock wrote.
No residents were harmed by the absence of medications, he wrote, and all the medications were replaced at no cost to the residents.
Seven known and one unknown client were victims of the drug diversion, according to the report, but none was able to provide usable information. Two of the clients were dead by Jan. 29 and 30, when Hatch made his unannounced visit to the facilities. The report was concluded on Feb. 13.
Police were investigating the alleged diversion at the time of Hatch's visit, according to the report. Duluth police did not respond to a query about the investigation in time for this story.
The staff member substituted acetaminophen tables for hydrocodone/acetaminophen tablets, Hatch reported, and someone diluted the liquid medications.
The staff member admitted to diverting hydrocodone and possibly diverting hydromorphone and a cough syrup, the report states.
Marywood opened in 2014 with 48 units near the College of St. Scholastica off of Kenwood Avenue.