Nurse #2 admitted in an email to the Director of Nursing that she had signed narcotic disposal sheets "as a witness to the disposal of medications for Residents #6 and #9 at Nurse #1's request without observing the medication disposal."
The scheme unraveled when Nurse #3 noticed something wrong. She reported to administrators on November 17 that excessive pain medication was being signed out for residents, particularly noting that Resident #6 had oxycodone missing despite usually not requesting pain medication.
Resident #6 denied taking the medication when asked. The pills weren't marked as administered on medical records.
Both nurses involved were agency workers, not permanent staff. Nurse #1 worked only one 12-hour shift at the facility, from 7:00 PM on November 14 until 7:00 AM on November 15. Nurse #2 had worked multiple shifts since June 12 but hadn't worked since November 15.
The narcotic records tell the story of what happened that November night. Nurse #1 signed out oxycodone 10 mg tablets for both residents — one pill at 7:30 PM and another at 11:30 PM for Resident #6, and pills at 7:30 PM and 10:30 PM for Resident #9. Each time, Nurse #2 signed as witness to the disposal, though the time was illegible on the records.
Resident #6 had a physician's order for one oxycodone tablet three times daily for pain. Resident #9 was prescribed the same medication every three hours as needed.
The Administrator said it was standard practice for nurses to visually witness narcotic medication being wasted before signing as a witness. She didn't know why Nurse #2 had failed to follow this protocol.
When the facility discovered the potential theft, administrators moved quickly. They reported the allegation to the North Carolina Division of Health Service Regulation at 2:02 PM on November 17 and to local law enforcement at 2:30 PM the same day.
Both nurses were blocked from working at the facility as of November 17. Federal inspectors were unable to interview either Nurse #1 or Nurse #2 because they were no longer employed there.
The facility's investigation, completed November 21, confirmed that Nurse #2 had signed as witness to narcotic disposal for both residents without actually observing the waste process. The Director of Nursing had contacted Nurse #2 directly, who then sent the email confession.
Nurse #3's vigilance caught the problem. She told inspectors she became concerned after noticing that Resident #6 had some as-needed oxycodone medication missing, particularly suspicious because this resident typically didn't request pain medication.
The case highlights vulnerabilities in nursing home narcotic controls when facilities rely heavily on agency staff. Nurse #1 was able to potentially steal controlled substances during a single shift, with help from another temporary worker who violated basic witness requirements.
Federal inspectors found the facility failed to have effective systems for accurate reconciliation of narcotic medications, specifically when witness signatures were obtained without proper observation of the disposal process.
The investigation revealed a breakdown in the most basic safeguard for controlled substances — requiring a second person to actually watch narcotics being destroyed before signing attestation forms. This witness requirement exists precisely to prevent the kind of diversion that occurred.
Both residents affected were prescribed oxycodone for legitimate pain management. The theft potentially left them without needed medication while putting controlled substances into unauthorized hands.
The facility now faces scrutiny over how agency nurses were supervised and whether adequate controls existed to prevent narcotic diversion by temporary staff working short-term assignments.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for River Bend Health and Rehabilitation from 2026-01-30 including all violations, facility responses, and corrective action plans.