Theft of Controlled Substances in Long-Term Care Homes: An Exploratory Study

Abstract

The theft of controlled substances has been studied in the community and healthcare settings including hospitals, pharmacies, hospice, and pain clinics. However, research on these thefts in long-term care homes has yet to be published. This exploratory study makes first steps toward bridging this gap. Using 107 Minnesota Department of Health’s investigation reports substantiated as “drug diversion” between 2013 and 2021 in assisted living residences and nursing homes, we found that 11,328.5 tablets were stolen from 368 residents (97.5% were controlled substances), with over 30 tablets stolen per resident. We also identified the types of medications stolen, duration of theft, extent to which nurses stole the medications or were those initially suspecting thefts, and the role of surveillance cameras in confirming allegations. The findings could raise awareness to this form of elder mistreatment in long-term care homes and call for action to address it.

Keywords

abuse and neglect crime financial abuse drug theft diversion opioid pain medications

What this paper adds

• There is a lack of studies on the phenomenon of theft of controlled substances (opioid pain medications) belonging to residents in long-term care homes. This exploratory study makes first steps towards bridging this major gap in research.

• The study identifies key characteristics of controlled substance theft, including the number of tablets and types of medications stolen, the number of victims, the duration of thefts, the extent to which nurses were found to steal the medications as well as those initially suspecting the thefts, and the role of surveillance cameras in confirming the thefts.

Applications of study findings

• The findings could inform efforts at different levels aimed at strengthening the security of controlled substances and the response to their theft in long-term care homes—from care providers, State Survey Agencies, Ombudsman Offices for Long-Term Care, law enforcement, Medicaid Fraud Control Units, Boards of Nursing, Pharmacy, and Medicine, care advocacy organizations, to the U.S. Drug Enforcement Administration.

• The findings could also be used to raise awareness to this largely invisible form of mistreatment and call for research, nursing practice, and policy action to address it.

Introduction

The phenomenon of drug diversion occurs when “medication is redirected from its intended destination for personal use, sale, or distribution to others. It includes drug theft, use, or tampering (adulteration or substitution)” (Nyhus, 2021). Extensive evidence shows that the majority of medications stolen in the community and healthcare settings are controlled substances (CS), most of which are opioid pain medications (OPM) (Berge et al., 2012; Inciardi et al., 2006; Minnesota Hospital Association, 2012).

Controlled substances are classified in the Controlled Substances Act as Schedule I to V depending on the drug’s “medical usefulness, abuse potential, safety, and drug dependence profile” (U.S. Drug Enforcement Administration, 2020). Schedule I is a designation for CS that has no accepted medical use for treatment in U.S., such as heroin. Schedule II has a “high potential for abuse,” which “may lead to severe psychological or physical dependence.” As the schedule level increases, the potential for abuse and dependence decreases.

Older adults have long been victims of CS theft by health care workers (Inciardi et al., 2006; Span, 2012) and family members (Roberto et al., 2021) in their homes. These thefts also occur in healthcare settings such as hospitals (Fan et al., 2019), hospice (Ware et al., 2021), pharmacies (Martin et al., 2013), pain clinics (Walker & Webster, 2012), as well as during people’s transition from hospitals to nursing homes (Kind et al., 2014; Tjia et al., 2009).

Theft of CS in healthcare settings can result in negative consequences on victims (e.g., increased pain), their families, the employees stealing them, co-workers, the long-term care (LTC) homes, and the public. Based on our review of the practice and research literature on these thefts in healthcare settings (Berge et al., 2012; Fan et al., 2019; Nyhus, 2021; Tanga, 2011; U.S. Office of the Inspector General, 2019), a summary of potential consequences on these different entities is provided in Supplementary Appendix A.

The theft of residents’ personal belongings (e.g., money and jewelry) in nursing homes (NH) (Harris & Benson, 1998; 1999) and assisted living residences (ALR) (Magruder et al., 2019) has been found as a prevalent problem. However, while the theft of CS in Long-term care (LTC) homes has long been recognized by care advocates (Assisted Living Workgroup, 2003; Edelman, 2010), nurses (Greenway, 2019), pharmacists (Martin, 2008), and state officials (Fields, 2012), to our knowledge, no study was published to date on this phenomenon in these care settings.

This major gap in research exists despite concerning factors which may contribute to theft of CS in LTC homes. These include the public health emergency of the opioid epidemic (U.S. Office of the Inspector General, 2019), the sharp growth in overdose deaths in recent years, driven largely by OPM (Centers for Disease Control and Prevention, 2022), and the relationship between misuse of CS and their theft (General Accounting Office, 2003; U.S. Drug Enforcement Administration, 2020). The longstanding concerns about medication management and safety of CS in ALR (Assisted Living Workgroup, 2003; General Accountability Office, 1999; Woods et al., 2010) and NH (Al-Jumaili & Doucette, 2017; Edelman & Hemmert, 2019; Martin, 2008) may further increase the risk of theft of CS in these care settings.

Guidelines and best practices for prevention of CS theft in healthcare settings other than LTC homes have been developed (Berge et al., 2012; Brummond et al., 2017; Fan et al., 2019; McClure et al., 2011; New, 2014) as well as educational initiatives aimed at addressing these thefts in hospitals (Minnesota Hospital Association, 2015) and LTC homes (Apiari, 2019). However, despite these ongoing efforts, the LTC sector continues to struggle in addressing CS theft in ALR (Magan, 2019) and NHs (U.S. Department of Justice, 2019).

This exploratory study makes first steps towards bridging this gap in research by examining the theft of CS in ALRs and NHs in Minnesota. Specifically, we aimed to identify the number of victims, the total number of tablets stolen (including in ALRs and NHs), types of medications stolen, duration of theft, types of employees stealing medications, extent to which employees stealing medications admitted or denied the thefts, reasons employees gave for stealing the medications, extent to which nurses initially suspected the thefts, the role of surveillance cameras in confirming thefts, and whether an employee and/or the LTC home were determined to be responsible for the thefts.

Methods

Thefts of medications are not being tracked nationally in the Centers for Medicare & Medicaid Services’ (CMS) F-tag (state survey deficiency citation) Coding System nor in the National Ombudsman Reporting System (NORS), which tracks mistreatment complaints in LTC homes. The Minnesota Department of Health (MDH) started using the unique mistreatment code “drug diversion” in fiscal year 2014 to allow internal tracking of this form of mistreatment (prior to it, it was classified using the broad “financial exploitation” code). The new distinction enabled MDH to track investigation reports confirming medication theft in LTC homes. It also allowed the first author to gain access to these data through data practices requests to MDH.

Dataset

The study dataset consisted of 107 investigation reports substantiated by the MDH as “drug diversion” in LTC homes between 2013 and 2021. MDH surveyors conduct on-site investigations of allegations of medication theft in LTC homes. They write up detailed narrative summaries of their investigations including the evidence they gathered as the basis for substantiating the allegations. The investigation reports included 74 (69%) from ALRs and 33 (31%) from NHs. Three ALRs had two investigation reports; and therefore, the total number of LTC homes where these thefts were confirmed was 104. All the data obtained from MDH were de-identified by MDH prior to release. The Institutional Review Boards of the University of Minnesota and Purdue University approved this study.

Analysis Strategy

The first author conducted secondary analysis consisting of a retrospective qualitative review and abstraction of the detailed narratives contained in the 107 investigation reports.

The process was complemented with a tabulation by aggregating the applicable attributes of the data elements described in Table 1. A similar analytic approach has been used in studies in LTC homes examining fatal physical restraints using MDH investigation reports (Miles & Irvine, 1992), resident-to-resident incidents using police reports (Lachs et al., 2007) and coroner’s review records (Caspi, 2018).

Table 1.

Data Elements and Attributes in Guide Used for Data Extraction and Analysis (n = 107 Investigation Reports).

Data Element	n*	Definition	Attributes	Comments
Date	107	The day when the investigation report was concluded	MM/DD/YYYY	**
Type of LTC home	107	Whether the theft occurred in ALR or NH	ALR/NH	**
Number of victims	107	Number of residents from whom medications were stolen	1–18	**
Number of tablets stolen	94	Total number of tablets confirmed as stolen	1–1,900	Calculated by adding up the number of tablets stolen from each resident within each investigation report. In 12% of the investigation reports, information about the number of tablets stolen was not detailed. We used a conservative approach and assigned the value “1” tablet stolen in these cases (the n = 94 reflects the original number of investigation reports prior to assigning value “1” to the remainder of the reports)
Types of medications stolen	105	Generic names of medications stolen	Names of medications	** And subsequently classified into Schedule I–IV, when applicable (i.e., 2.5% of the medications stolen were not controlled substances)
Duration of theft	73	Total number of days from first to last confirmed theft	1–730 days	**
Nurse theft	104	Whether or not a nurse stole the medications	Yes/No	Whether or not the Board of Nursing was cc’d on the investigation report
Theft for personal use	65	Whether or not the medications were stolen for personal use	Yes/No	**
Reason for theft	23	Employee’s explanation as to why s/he stole the medications	N/A	**
Admitted or denied	80	Whether or not the employee admitted or denied stealing the medications	Yes/No	A “Yes” attribute consists of admission to stealing, eventual admission (i.e., initially denied but later admitted), or only partial admission (i.e., admitting to stealing some but not all medications and/or admitting to stealing medications from certain residents but not from others)
Suspicion arose by whom	86	Who initially suspected the theft	Nurse/Direct care staff/Others	**
Caught on camera	103	Whether or not the theft was captured in video surveillance camera	Yes/No	**
Location of camera	27	Location of the camera confirming the theft	Resident’s bedroom/Public space (e.g., hallway)/Medication room or cart	**
Responsibility determination	107	Who was determined to be responsible for the theft	Employee/LTC home/Both	At the end of each investigation report, MDH surveyors determine who was responsible for the medication theft. No other information was included in the investigation reports pertaining to this data element. For information regarding the guidance MDH is required to use when assigning responsibility for mistreatment, see Minnesota Statute 626.557 subd. 9c

Note. n* = Total number of investigation reports in which information was available to determine the attribute of each data element. Cells marked with ** indicate data elements for which attributes were determined based on text-based descriptions in investigation reports. Acronyms: LTC = long-term care; ALR = assisted living residence; NH = nursing home; MDH = Minnesota Department of Health.

Our research team developed a structured guide to enable a systematic and consistent detection and extraction of excerpts pertaining to specific data elements representing various aspects of the medication thefts. The guide also detailed the attributes of each data element. For example, the data element “caught on surveillance camera” had two attributes “yes” or “no.” Attributes of some data elements were more numerical in nature. For example, the attribute of “duration of theft” was a number representing the total number of days from the first to the last confirmed theft.

The selection of data elements and their attributes for inclusion in the guide was based on the first author’s preliminary review of the 107 MDH investigation reports and the second author’s review of the research and practice literature. The first and third authors also conducted data entry of five randomly selected pilot investigation reports. This latter step enabled us to further refine the selection of the data elements and their attributes (i.e., modify a few of them and add others) including their definitions, until a consensus was reached, and the guide finalized. Table 1 outlines the data elements contained in the guide, their definitions, and attributes.

Qualitative review of the 107 investigation reports using the structured guide enabled the first author to identify and manually highlight all the narrative excerpts directly relevant to the data elements. These excerpts were then typed up and entered by the first author into an Excel spreadsheet which was organized around the structure of the guide (a single Excel row was used for qualitative data from each investigation report). Beyond definitions of the data elements, the Excel spreadsheet contained illustrative examples of narrative excerpts for each data element, and instructions for coding them using their attributes.

Based on a practice recommended by experts in qualitative research methods (Miles et al., 2014), the retrieved data excerpts from each investigation report for each data element were reviewed by the first author to generate descriptive statistics (e.g., total number of investigation reports in which nurses were found to steal medications) based on their attributes. The second author independently reviewed the extracted data excerpts, generated descriptive statistics, and compared with first author’s findings. A few discrepancies in a small number of data elements were re-counted by the first and second author until consensus was reached.

Results

Our examination of 107 MDH investigation reports substantiated as “drug diversion” in 104 LTC homes in Minnesota found that a total of 11,328.5 tablets were stolen from 368 residents between 2013 and 2021. The total number of actual tablets stolen is likely higher since 12% of the investigation reports did not include this information while thefts of CS are believed by experts to be underdetected and underreported (Nyhus, 2021).

Types of Medications Stolen

Table 2 provides a breakdown of the types of medications stolen based on data from 105 investigation reports (two investigations did not detail the types of medications stolen). An estimated 97.5% of the medications stolen were CS while 94% were OPM. Schedule II was the most common (77%) CS identified as stolen in our study. Only 3%, 16%, and 1% of the CS stolen were at Schedule III (i.e., less potential for abuse than the drugs or other substances in Schedules I and II), IV (i.e., low potential for abuse relative to drugs in Schedule III), and V (i.e., low potential for abuse relative to drugs in Schedule IV), respectively. None of the CS identified as stolen in our study were at Schedule I. The most common reports of CS stolen were (percentages were calculated based on the number of applicable investigation reports rather than overall volume of medications stolen) oxycodone (34.5%), hydrocodone (23%), tramadol (10.5%), hydromorphone (9.3%), and morphine (6.7%).

Table 2.

Types of Medications Stolen (n = 105 Investigation Reports).

	Generic Name	Narcotics (Yes = Y/No= N)	Schedule (I–V)	Frequency^b	Treatment
Controlled substances (97.5%; n= 186)	Narcotic (unspecified) (1.6%)	Y	Unknown	3
	Oxycodone (34.5%)	Y	II	66	Treat moderate to severe pain
	Hydrocodone (23%)	Y	II	44
	Tramadol (10.5%)	Y	IV	20
	Hydromorphone (9.3%)	Y	II	18
	Morphine (6.7%)	Y	II	13
	Methadone (1.6 %)	Y	II	3	Reduces withdrawal symptoms in people addicted to heroin
	Codeine syrup (0.5%)	Y	V (Cough medicines with codeine are examples of Schedule V drugs)	1	Treat symptoms caused by the common cold, flu, allergies, or other breathing illnesses
	Lorazepam^a (3.7%)	Y	IV	7	Treat anxiety, insomnia, or sleep difficulty due to anxiety or stress, status epilepticus
	Clonazepam (1.6%)	N	IV	3	Prevent and control seizures
	Methylphenidate (0.5%)	N	II	1	Treat attention deficit hyperactivity disorder (ADHD)
	Lyrica (0.5%)	N	V	1	Treat pain
	Acetaminophen (3%)	N	III	5	Treat minor aches and pains, and reduces fever
	Corticosteroids (0.5%)	N	III	1	Treat many diseases and conditions, especially those associated with inflammation
Non-controlled substances (2.5%; n = 5)	Neurontin (1%)	N	N/A	2	Prevent and control seizures
	Cyclobenzaprine (0.5%)	N	N/A	1	Treat muscle spasms
	Claritin (0.5%)	N	N/A	1	Treats symptoms such as itching, runny nose, and other allergies
	Levothyroxine (0.5%)	N	N/A	1	Treat hypothyroidism
	Total (100%)			191^b

^aAmong the controlled substances identified as stolen, Lorazepam is the only medication that is not a narcotic/opioid.

^bThe column “frequency” contains information pertaining to the number of times each type of medication was mentioned as stolen in the 105 investigation reports (tallied for controlled substances and non-controlled substances and displayed as n = in the left-hand column). Since in many investigations more than one type of medication was stolen, the total number of mentions is larger than 105 (i.e., 191).

Table 3 provides a summary of the study findings including those pertaining to ALRs and NHs. As can be seen in the table, 85% of the tablets were stolen from 208 residents in 71 ALR, and the remaining 15% were stolen from 160 residents in 33 NHs. On average, 106 tablets were stolen per LTC home, consisting of an average of 130 tablets stolen per ALR and an average of 52 tablets stolen per NH. On average, 30.7 tablets were stolen per resident with averages of 46.2 tablets stolen per ALR resident and 10.74 tablets stolen per NH resident. More than one victim was documented in over half (54%) of the investigation reports, with an average of 3.44 victims per investigation report. Nursing homes had an average of 4.84 victims per investigation, while ALRs had an average of 2.81 victims per investigation.

Table 3.

Substantiated Investigation Reports on Theft of Pain Medication in Long-Term Care Homes in Minnesota (2013–2021).

	Total LTC Homes(n = 104)	Assisted Living Residences(n = 71)	Nursing Homes(n = 33)
Number of investigation reports	107	74	33
Total number of victims	368	208	160
Average number of victims per MDH investigation	3.44 (median 2; range 1–18)	2.81 (median 1; range 1–13)	4.84 (median 3; range 1–18)
Total number of tablets stolen	11328.5 (100%)	9609.5 (85%)	1719 (15%)
Average number of stolen tablets per LTC home	106 (median 15; range1–1900)	130 (median 16; range1–1900)	52 (median 7; range 1–362)
Average number of tablets stolen per victim	30.7	46.2	10.74
Average duration of theft	56 days (median 3; range1–730.5)	38.5 days (median 2; range1–243)	97 days (median 14.5; range 730.5)
Average duration of theft	* 73 investigation reports	* 51 investigation reports	* 22 investigation reports
Employee stealing was a nurse	51 (49%)	23 (32%)	28 (87.5%)
Employee stealing was a nurse	* 104 investigation reports	* 72 investigation reports	* 32 investigation reports
Theft for personal use	65 (100%)	42 (100%)	23 (100%)
Theft for personal use	* 65 investigation reports	* 42 investigation reports	* 23 investigation reports
Employee found to steal tablets admitted to theft	64 (80%)	41 (79%)	23 (82%)
Employee found to steal tablets admitted to theft	* 80 investigation reports	* 52 investigation reports	* 28 investigation reports
Caught on surveillance camera	27 (26%)	19 (26%)	8 (27%)
Caught on surveillance camera	* 103 investigation reports	* 73 investigation reports	* 30 investigation reports
Location of camera with evidence of theft	13 (Medication room/cart)	8 (Medication room/cart)	5 (Medication room/cart)
	9 (bedroom)	8 (bedroom)	1 (bedroom)
	5 (public space)	3 (public space)	2 (public space)
	* 27 investigation reports	* 19 investigation reports	* 8 investigation reports
Suspicion arose by whom	Staff unspecified 36 (42%)	Staff unspecified 29 (47.5%)	Staff unspecified 7 (28%)
	Nurse 32 (37%)	Nurse 15 (24.5%)	Nurse 17 (68%)
	Nurse & other staff 5 (6%)	Nurse & other staff 4 (6.5%)	Nurse & trained medication assistant 1 (4%)
	Resident 5 (6%)	Resident 5 (8%)
	Family 3 (3.5%)	Family 3 (5%)
	Pharmacy 3 (3.5%)	Pharmacy 3 (5%)
	Witness 1 (%)	Witness 1 (1.5%)
	Other 1 (1%)	Other 1 (1.5%)
	* 86 investigation reports	* 61 investigation reports	* 25 investigation reports
Responsibility determination	Employee 78 (73%)	Employee 52 (70%)	Employee 26 (79%)
	Employee & LTC home	Employee & LTC home	Employee & LTC home
	22 (21%)	16 (22%)	6 (18%)
	LTC home 7 (6%)	LTC home 6 (8%)	LTC home 1 (3%)

Note. Unless otherwise noted with an asterisk * in the table, the findings reported for the different data elements are based on 107 MDH investigation reports. Three assisted living residences had two separate investigation reports; thus, the total number of unique long-term care homes (i.e., 104) doesn’t sum up to 107 investigation reports. The total number of actual tablets stolen is likely higher than reported in the table since 13 (12%) of the 107 investigation reports did not include this information; using a conservative approach, these cases were assigned a value of 1 stolen tablet. MDH = Minnesota Department of Health; LTC = Long-Term Care.

Duration of Theft

Based on data available in 73 investigation reports, the average duration of theft was 56 days, with an average of 38.5 days in ALR and 97 days in NHs.

Types of Employees Stealing Medications

In all but one of the 107 investigation reports, a single employee was stealing the medications. In the exception, an RN let an “unknown person” into the nurse’s station where the latter broke into the locked cabinet and took the toolbox containing the CS medications.

Our review of 104 investigation reports (i.e., the remaining three had missing data) found that half (49%) of the employees who stole medications were nurses. It also showed that a higher proportion of nurses were stealing in NH than in ALR (87.5% vs. 32%). Information about employees other than nurses found to steal medications was often missing or inconsistent. However, in those 35 investigation reports with adequate detail, 33 reports identified direct care staff (e.g., unlicensed personnel in ALR and nurse aides in NH) to be the non-nurse employees found to steal the medications.

Personal Use and Reasons for Theft

All 65 investigation reports containing information on the use of medication indicated that the employee stole the medications for personal use. Only 23 of the investigation reports included information pertaining to reasons for the theft. Eight employees stole the medications to treat their own pain (e.g., back pain, tooth pain, skin rash). One employee took the pills because they had been on them and were “running low.” Three took the medications “for family or friends” who needed them to treat pain. Other employees attributed the thefts to stressful life events. One employee “had a recent death in the family and it was a rough time for her or him.” Others attributed the thefts to addiction to painkillers—one of whom reported “struggling with addiction” and “having a weak moment.”

Admitting Versus Denying Thefts

Our examination of 80 investigation reports containing information about this data element revealed that 80% of the employees found to be stealing medications admitted the theft—consisting of 64% who admitted and an additional 16% who eventually admitted (i.e., initially denied but later admitted) or partially admitted (i.e., admitting to stealing some but not all medications and/or from certain residents but not others).

Initial Suspicion of Theft

Nurses played a key role in initially suspecting medication theft in 43% of the 86 investigation reports containing data to determine it (37% solely suspected the theft and another 6% did so with another staff member). In another 42%, “staff” (unspecified) were initially suspecting the theft. In other cases, a resident (6%), family (3.5%), pharmacy (3.5%), and other sources 5% (such as trained medication assistants) initially suspected the theft. In addition, initial suspicion by nurses was higher in NH (68%) compared with ALR (25%).

Role of Surveillance Footage

Surveillance camera footage provided evidence of theft in 26% (27 of 103) of the investigation reports. Of these 27 cases, 13 had the camera in the medication room or cart, nine in the victim’s bedroom, and five in a public space (e.g., hallway). Four employees who initially denied stealing later confessed when informed about the camera footage (lack of information in many investigation reports prevented us from determining the extent to which this was the case in other investigations).

Responsibility Determination

In each investigation, MDH surveyors determined whether an employee and/or the LTC home were responsible for the theft. In 73% of the 107 investigations, an employee was responsible (ALR 70% vs. NH 79%), in 21%, it was both an employee and the LTC home (ALR 22% vs. NH 18%), and in 6%, it was the LTC home (ALR 8% vs. NH 3%). That is, in slightly more than one-quarter of the investigations (27%) MDH assigned shared or sole responsibility to the LTC home.

Discussion

This is the first study on theft of CS in ALRs and NHs. A substantial number of tablets (11,328.5) were identified as stolen from 368 residents in these LTC homes over 9 years in Minnesota. The actual number is likely higher due to lack of detail in 12% of the investigations and the fact that CS thefts are underdetected and underreported in healthcare settings (Nyhus, 2021). On average, more than 30 tablets were stolen per resident, with the majority CS. The number and dangerous types of CS stolen combined with the fact that half the employees stealing the medications were nurses warrant attention on various fronts. That said, given the fact that, as of March 2017, there were 1,206 registered ALRs and 372 licensed NHs in Minnesota (with a combined total of 82,772 beds), medication thefts identified in our study were substantiated by MDH in only a small subgroup of these care settings in the state.

High-Risk Controlled Substances

With the majority of the medications stolen being CS (97.5%), a concern is that the majority (77%) of these mediations was at Schedule II, which has “high potential for abuse” that “may lead to severe psychological or physical dependence” (U.S. Drug Enforcement Administration, 2020). The most common CS stolen were OPM (94%), including oxycodone, hydrocodone, tramadol, hydromorphone, and morphine. The findings may suggest the need to develop and implement targeted prevention and detection measures tailored for these high-risk medications.

Nurses

Half of the employees who stole medications were nurses. While information was insufficient in many reports, the majority of the other non-nurse employees confirmed to steal medications were direct care staff. The theft of CS by nurses in other healthcare settings has been reported in the literature (Tanga, 2011), research (Bettinardi-Angres & Bologeorges, 2011; Inciardi et al., 2006; Trinkoff et al., 1999) and media (Hanners, 2015; Miller, 2009). However, while isolated cases of medication thefts by nurses have been reported in the media (Connors, 2012; Damon, 2019; Fields, 2012; Regan, 2018; U.S. Department of Justice, 2019), researchers have yet to examine the extent to which nurses engage in this form of elder mistreatment in ALR and NHs. Our findings raise awareness to this problem in these LTC homes and the urgent need to address it.

Virtually all the medications stolen were reported to be taken by employees for personal use. This finding is consistent with reports indicating that medication theft by healthcare workers is typically related to their involvement in prescription drug misuse (Inciardi et al., 2006) and “to support addiction, and less commonly for sale for financial gain” (Berge et al., 2012). Chemical dependence among nurses has long been recognized as a serious public health problem (Smith et al., 1998) and as “one of the most serious problems facing the nursing profession” (National Council of State Boards of Nursing, 2013). In fact, between 6% to 8% of nurses are estimated to practice while impaired (Tanga, 2011), that is, their performance may be adversely “affected by mental or physical illness, fatigue, substance abuse or personal circumstances” (Spring, 2015). In addition, many nurses with a substance use disorder remain unidentified, unreported, untreated, and continue to practice (National Council of State Boards of Nursing, 2013).

While addressing this issue, it is important to strike a good balance between holding nurses and other employees accountable for thefts—while ensuring residents’ right to have their CS protected—and supporting employees suffering from the disease of addiction. Ensuring a compassionate, dignified, and stigma-free approach towards employees suspected of or confirmed as stealing CS is important. This issue is addressed further in Supplementary Appendix B.

Nurses’ Role in Detection

Nurses played a key role in initially suspecting medication theft in 43% of the investigation reports. In addition, a higher proportion of nurses initially suspected the thefts in NHs than in ALRs. If confirmed in a larger-scale study using a rigorous quantitative research methodology, these findings may suggest a need to strengthen ALR nurses’ training in detection of medication theft. This is important also in NHs because nurses play a critical role not only in managing, administering, and reconciling CS but also in ensuring their security as well as in early detection, skilled and timely investigation, and external reporting of suspected medication theft.

Duration of Theft

Many of the thefts were found to take place over significant periods of time. This finding suggests a need to ensure that adequate policies and procedures are in place and implemented to increase early detection and strengthen internal and external reporting and investigations. These efforts should be informed by guidelines and best practices (cited in the Introduction) to ensure robust accountability systems for timely identification of discrepancies and unusual access patterns, as well as use of surveillance cameras (Berge et al., 2012).

Employee Education

A key component of CS theft prevention programs is ongoing employee education. Specifically, all employees must be educated in contributors and safeguards (e.g., policies and procedures) of CS theft (Fan et al., 2019; McClure et al., 2011; Nyhus, 2021) and methods of theft (Martin et al., 2013; New, 2014; Nyhus, 2021). They must also acquire knowledge pertaining to signs and symptoms of chemical dependence (Bettinardi-Angres & Bologeorges, 2011) and staff behaviors that raise suspicion of theft (New, 2014; Nyhus, 2021) so that they could “intervene immediately” to prevent residents from being compromised (Tanga, 2011).

Deterrence

The substantial number of CS tablets stolen (77% of which at Schedule II with “high potential for abuse”) in combination with the extensive duration of thefts may suggest that a subgroup of ALRs and NHs have a low “deterrent environment.” The deterrent environment, defined as the “perceived certainty of detection and perceived severity of punishment among those who are in a position to commit offenses within the organization,” has been found to be weak in NHs in a study on thefts of money and jewelry (Harris & Benson, 1999). Research studies are needed to shed light on CS theft deterrence in LTC homes.

Use of Surveillance Camera

The finding by which camera footages provided evidence of medication theft in only one-quarter of 103 investigation reports suggests a need for increased use of this assistive technology in LTC homes. This can strengthen deterrence, support auditing, deter forgery, detect theft (Fan et al., 2019), and protect innocent staff suspected of stealing. The recommendation to enhance the use of camera surveillance in key locations where CS are stored and used has been reported in pharmacies (Martin et al., 2013; McClure et al., 2011), hospitals (Minnesota Hospital Association, 2015), and LTC homes (Apiari, 2019). That said, when considering installing cameras in private spaces (e.g., residents’ bedrooms), it is important to protect residents’ right for privacy and follow applicable federal and state laws and regulations.

Assisted Living Versus Nursing Homes

The majority of the tablets were stolen in ALRs while a relatively smaller number were stolen in NHs. A higher number of victims of these thefts lived in ALRs compared to NHs, with more medications stolen, on average, per ALR resident than from a NH resident. However, our dataset did not include data on factors necessary to conduct comparative quantitative analysis between the two care settings. As noted earlier, as of March 2017, there were nearly twice as many beds in ALRs (54,125 beds) compared to NHs (28,647 beds) in Minnesota during the study period. Therefore, there is a need to avoid making unbalanced statements regarding the scope of medication theft in ALRs versus NHs. While previous research has shown that complaints related to financial exploitation (e.g., theft of money) were higher in ALRs than in NHs (Magruder et al., 2019), larger and more rigorous research is needed to examine whether ALR residents are at higher risk of CS theft compared to NH residents. If future research shows higher risk of CS theft in ALRs compared to NHs, identifying which factors account for the difference could inform the development of policy and practice interventions. Examples of factors to consider include stronger regulations pertaining to CS security in NHs, relatively stronger nurse staffing requirements in NHs, weaker integration of the nursing and medical professions in ALRs, heavy reliance on unlicensed staff in ALRs, and for-profit ownership status.

Limitations

The study findings should be interpreted with caution given limitations in the dataset and the analytic strategy used. First, certain data elements consisted of missing data that could have influenced the results. For example, incomplete information was reported in certain data elements including whether employees stealing medications were not nurses, duration of theft, whether employees admitted or denied stealing, and whether the medications were stolen for personal use. In addition, the data element responsibility determination did not contain any information beyond whether an employee, the LTC home, or both were responsible for the theft. Lack of further information prevented us from examining the quality of the MDH decision process underlying this finding. Furthermore, we used a single tablet as the unit of analysis since the dosage unit of stolen medications was not reported in many investigation reports. The lack of ability to account for differences in tablet dose (e.g., Oxycontin 40 mg vs. 80 mg) is a limitation because it may obscure differences in scope and patterns of theft such as between ALR and NHs. Future research should use a standardized measurement to consistently quantify the dosage unit of stolen medications.

Second, only six investigations included detail about the harm experienced by residents due to the medication theft. Four of these consisted of increased pain and one included a resident who became “very upset” over the missing medications. In another case, a nursing assistant stole a narcotic pain medication and replaced it with a blood pressure reducing medication which was given to a resident with low blood pressure. Staff and police stated that the substitution could have resulted in the resident’s serious injury or death. Future research should examine the physical and emotional harm caused by CS thefts in LTC homes. Third, the NH data subset was small; thus, the ability to draw practical implications pertaining to NHs is limited. Caution is therefore also needed when interpreting the differing results between NHs and ALRs. Lastly, the data examined came from investigation reports in Minnesota and thus the findings cannot be generalized to other states. Given the lack of centralized surveillance data on CS thefts in LTC homes in the United States, our exploratory study utilized secondary analysis of qualitative data (text-based summary narratives from investigation reports) and focused on generating simple descriptive statistics. We believe that this approach is adequate given the lack of centralized datasets and the fact that no other study was published to date on CS theft in LTC homes. Research on CS theft in LTC homes in Minnesota, other states, and other countries is urgently needed. Our exploratory study lays the groundwork for larger studies using rigorous quantitative research methodologies.

Conclusion

The findings from this exploratory study on theft of CS in ALRs and NHs could be used to raise awareness to the largely overlooked form of mistreatment in these care settings and call for nursing leadership and practice as well as policy action to address it. Centrally tracking these thefts in ALRs and NHs in all states and nationally (e.g., by CMS in NHs and NORS in NH and ALR) could assist in efforts to identify their magnitude and generate insights for prevention. Our hope is that the study will encourage researchers to examine CS theft in LTC homes, shed light on its prevalence, risk and protective factors, healthcare costs, and develop and evaluate interventions to reduce it. Finally, increased and well-coordinated efforts to addressing these thefts by key stakeholders (including LTC trade associations, American Nurses Association, owners and administrators of LTC homes, nurse leaders as well as policy makers, regulatory and law enforcement agencies (e.g., police, Drug Enforcement Administration), professional boards (e.g., nursing, pharmacy, medicine), Office of the Ombudsman for LTC, and care advocacy organizations) could ensure that residents’ right to have their pain medications protected is realized and adequate and timely pain relief is provided to them.

Supplemental Material

Supplemental Material - Theft of Controlled Substances in Long-Term Care Homes: An Exploratory Study

Supplementary Material for Theft of Controlled Substances in Long-Term Care Homes: An Exploratory Study by Eilon Caspi, Wei-Lin Xue, and Pi-Ju Liu in Journal of Applied Gerontology.

Footnotes

Authors’ Note

Some of the study findings were previously reported in: Serres, C. (July 31, 2022). Minnesota senior homes are besieged by staff stealing pain medications. The Star Tribune.

Acknowledgments

Special thanks to Lindsey Krueger, immediate past director, Office of Health Facility Complaints, Minnesota Department of Health, for her assistance in gaining access to the study data. We are grateful to Elder Voice Advocates for being the source of inspiration for this study through the organization’s commitment to the prevention of all forms of elder mistreatment in long-term care homes. The article is dedicated to LaVonne Borsheim (who was left in excrutiating pain after her pain medications were stolen from her home by a nurse) and to her late husband Roger Borsheim.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Ethical Approval

University of Minnesota IRB approval #: 00005470 and Purdue University IRB approval #: 2022-174

ORCID iDs

Eilon Caspi

Pi-Ju Liu

Supplemental Material

Supplemental material for this article is available online.

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