How well does your state oversee nurses?

By Charles Ornstein and Tracy Weber, ProPublica
charles.ornstein@propublica.org & tracy.weber@propublica.org

Nurses, not doctors, provide the bulk of the care patients receive in hospitals and nursing homes. Nurses are charged with monitoring patients' conditions, giving them medications and keeping their pain under control. They are responsible for alerting doctors if patients aren't doing well and coordinating with others on the care team, including therapists, respiratory care providers and dieticians. Ensuring that regulators properly oversee nurses is crucial for ensuring quality patient care.

It's impossible to know the number of nurses whose conduct endangers patients; one can reasonably assume that it’s small. The consequences can be deadly, however. Patients may be so ill that they can’t speak up if a nurse doesn’t respond to an alarm. And family members may not have the medical knowledge to question why a nurse hasn’t given a particular medication. Most people believe that the government wouldn't allow a nurse with known problems at their bedside.

In examining the California Board of Registered Nursing, my colleague Tracy Weber and I found widespread problems. Last fall, we reported that the board took years to discipline nurses convicted of serious or multiple crimes. One attempted murderer was able to renew his license for years while in prison. In some cases, including nurses convicted of sex offenses, the board never acted at all.

We broadened our review to look at the board’s overall disciplinary process. Our most troubling finding was that the board took more than three years, on average, to investigate and discipline errant nurses. When we compared the board’s performance to its peers in other large states, we found that several handled the process in a year or less.

We also found that the board hadn’t disciplined nurses who had been sanctioned by others. We identified more than 120 nurses who were suspended or fired by employers, disciplined by another California licensing board or restricted from practice by other states – but they could freely practice in California with a clear record.

The board often gave nurses probation rather than revoke their licenses outright. Even then, though, we found that officials didn’t follow up—or even know—when they got in trouble again and again. Positive drug tests, criminal convictions and working without permission didn’t trigger immediate consequences.

After our stories ran, Gov. Arnold Schwarzenegger replaced the majority of the nursing board, and the board's longtime executive officer resigned. The governor also pledged wholesale reform of all health licensing boards in the state after determining that they suffered from many of the same problems as the nursing board.

How can you access the quality of your state's nursing board? Here are some suggestions:

• Start by finding the board's Web site and determining what information is available to the public.

A list of all boards and their Web sites is available here. Be advised that some states (like California) have two different boards that oversee registered and vocational/practical nurses. Other states supervise both types of nurses with one board.

Try to find annual reports, newsletters, disciplinary statistics, board meeting minutes, etc. Look at how much the Texas Board of Nursing provides to the public about its operations. The same is true in Virginia.

On a very basic level, most states allow members of the public to verify a nurse's license for free online, but some (including Kansas) actually charge to do this.

• Pick a time period and examine all disciplinary actions taken by the board.

When we first embarked on this project, we asked California officials for a list of all nurses disciplined since 2002. Because most disciplinary records are online, we were able to look up each nurse on the list and determine why he/she got in trouble. It quickly became apparent to us that it took the board a very long time to discipline nurses. We saw some cases in which nurses were disciplined 10 years after their alleged offenses. We also spotted dozens of nurses who moved from hospital to hospital before they were ultimately disciplined.

Working alongside Los Angeles Times researcher Maloy Moore (who provided us with invaluable help), we entered each case into a Microsoft Access database, identifying the names of all employers, the nature and date of all convictions and any discipline by other states. We opened large parts of this database to the world when we published our stories. You can see it here.
You don’t have to look at cases over such a long period. Starting with one year may suggest a disturbing pattern worth additional review.

• Ask the board how it works.

Does it have its own investigators? Its own lawyers? Does it prioritize complaints when they first come in? How often does it suspend nurses' licenses on an emergency basis to protect the public? How many nurses are disciplined each year and what types of sanctions are imposed (revocations, suspensions, probation, surrendered licenses, work restrictions, reprimands, fines). How long does it take to process complaints from beginning to end (and how long does it take in each step of the process)?

We found that a complaint had to wind its way through four agencies before a nurse could be disciplined in California. The biggest bottleneck was at the investigative stage, which took more than 600 days, on average. The nursing board shares a pool of fewer than 40 investigators with up to 25 other licensing agencies. Some investigators handled upwards of 100 cases at a time.

• Look into how other boards function, both within your state and in neighboring states.

We surveyed boards in the 15 largest states and asked questions to help compare California with its peers. Understanding how other states worked showed that California lagged far behind. Some states routinely examine their performance and tracked it over time. They shared their metrics and talked about how they ensure problem nurses are removed from practice quickly.

• Try to find cases that your nursing board hasn't acted on.

We examined Civil Service files from public hospitals and state agencies to look for nurses who were fired or suspended from their jobs for misconduct. When we looked them up on the nursing board's Web site, we found that many had clear licenses. We also filed Public Records Act requests with public hospitals and agencies asking for discipline letters against health workers. We examined media clippings for nurses who had been convicted of crimes in our state. We ran the state’s Megan’s Law database against the board’s list of active nurses. Finally, we looked at the disciplinary logs of neighboring states to see whether nurses who were disciplined in those states had licenses in California. We found that many had clear records in California despite losing their licenses elsewhere.

To determine where a nurse is licensed, you can individually search most state board sites. You can also look at nursys, which aggregates information for 38 boards. It is not complete; you’ll have to look up other states one by one. To see which boards participate, check here.

• Attend board meetings and listen to the topics that are discussed and the questions board members ask staff.

Is the meeting self congratulatory or do board members inquire about statistics and timetables? How does staff answer these questions? Many states place their board meeting materials online.

• Determine whether your state's nursing board has a recovery program for drug abusers.

If so, what is the success rate? How is it monitored? What is the criteria for entering the program and what happens if a nurse relapses? Are nurses’ licenses inactivated while they are in the program? How many relapses are allowed before a nurse is kicked out? And when a nurse fails, what happens then? Is his/her license automatically suspended or is there a process in which the nurse can continue to work and care for patients? How long does that process take?

We found that California's program placed too much trust in addicted nurses and had no definitive way of removing them from practice or quickly acting against their license if they flunked out. It took a median of 15 months to file a public accusation against even those nurses that the board confidentially labeled “public safety risks” and kicked out of the program.