Ridgewood Living: Drug Theft by Nurses - NC

The scheme unraveled when Nurse #7 discovered that seven oxycodone tablets in Resident #22's medication supply had been replaced with Buspirone, an anti-anxiety drug, and sealed back up with medical tape to hide the tampering.

Nurse #7 immediately called Nurse #5 on her mobile phone to report the discovery. When Nurse #5 arrived at the facility, she learned that nursing staff had been documenting that Resident #22 frequently refused her Buspirone medication, though no one knew how many pills had actually been replaced.

The Director of Nursing arrived after being notified of the theft, though she later told inspectors she couldn't remember who contacted her about the incident. She spoke directly with Nurse #7, who explained that the oxycodone had been replaced with Buspirone and the medication container resealed with medical tape.

The DON immediately reported the theft to the Administrator and ordered drug tests for everyone who had worked with that medication cart. She and Nurse #5 then wasted the seven Buspirone pills that had been used to replace the stolen oxycodone.

Pharmacy records revealed the scope of the theft. A delivery slip dated June 28, 2025 showed that exactly seven oxycodone 5 mg tablets had been delivered to the facility for Resident #22 that day. The Pharmacy Director confirmed during an inspector interview that seven oxycodone pills were dispensed for the resident on that date, with Resident #22's insurance being billed and paying for the medication.

Crucially, pharmacy records showed no Buspirone had been ordered or sent to the facility for Resident #22 during the entire month of June 2025. The anxiety medication used to replace the stolen oxycodone had to have come from somewhere else within the facility.

When inspectors interviewed Resident #22, they found her lying in bed in her room. She told them that when she was in pain, she asked for pain medication, and that nurses gave it to her when she requested it. The resident appeared unaware that her prescribed oxycodone had been stolen and replaced.

The Administrator confirmed she had been notified of the missing pills by both the DON and Nurse #5. She immediately contacted local law enforcement about the theft and stated that the facility paid to replace the stolen oxycodone.

However, the Administrator revealed she was unaware that Resident #22's insurance had been billed for and paid for the original oxycodone that was stolen. When asked about this billing issue, she had no knowledge of the insurance charges.

Drug testing revealed the theft's perpetrators. Both Nurse #7 and Nurse #8 tested positive for oxycodone after the investigation began. Despite this evidence, facility leadership concluded they could not substantiate abuse or neglect in their internal investigation.

The Medical Director, when interviewed, acknowledged he was aware of the drug diversion incident but stated he didn't believe the resident was adversely affected by having her pain medication stolen and replaced with anti-anxiety pills.

The pharmacy's handling of the billing created additional confusion. During a follow-up interview, the Pharmacy Director said she vaguely remembered the situation and recalled having a conversation with someone at the facility about payment. She claimed that billing Resident #22's insurance was a pharmacy error, stating the facility should have been charged instead.

An email from the Pharmacy Director to the Administrator, sent on September 4 at 2:35 PM, confirmed that the pharmacy had reversed the charges to Resident #22's insurance and billed the facility instead.

The theft went undetected for months. The oxycodone was delivered on June 28, but the tampering wasn't discovered until sometime before the September inspection. During that period, nursing staff documented that Resident #22 was refusing her Buspirone medication, not realizing they were actually giving her anxiety medication instead of her prescribed pain pills.

The facility's response included implementing new education and systems designed to prevent similar incidents, according to the Administrator. However, the fact that two nurses tested positive for the exact medication that was stolen suggests the theft was not an isolated incident of tampering.

The DON told inspectors she didn't believe the resident experienced pain or anxiety due to the medication switch, but this assessment came after the fact. Resident #22 had been prescribed oxycodone for pain management, and replacing it with an anti-anxiety medication could have left her without adequate pain relief for an unknown period.

The case highlights gaps in medication security and monitoring at the facility. The theft required access to the medication cart, knowledge of how to open and reseal medication containers, and the ability to obtain Buspirone from elsewhere in the facility to use as replacement pills.

Local law enforcement was notified of the theft, though the inspection report doesn't detail any criminal charges. The facility's internal investigation, despite positive drug tests for both nurses, concluded it could not substantiate abuse or neglect.

The incident also exposed billing irregularities. The resident's insurance was initially charged for medication that was stolen before she could receive it, requiring the pharmacy to reverse charges and bill the facility instead. The Administrator's lack of awareness about the insurance billing suggests communication breakdowns between the facility and its pharmacy provider.

For Resident #22, the theft meant potentially going without prescribed pain medication while unknowingly receiving anxiety medication instead. She told inspectors she received pain medication when she asked for it, but the documentation showing she frequently "refused" Buspirone suggests staff may have attributed her medication refusals to behavioral issues rather than recognizing the pills had been switched.

The positive drug tests for both nurses involved in the medication cart access, combined with the precise replacement of seven oxycodone pills with seven Buspirone pills, indicates a deliberate scheme rather than accidental tampering or medication error.

Full Inspection Report

The details above represent a summary of key findings. View the complete inspection report for Ridgewood Living & Rehabilitation Center from 2025-09-05 including all violations, facility responses, and corrective action plans.

Additional Resources

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