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By Charles Ornstein and Tracy Weber, senior reporters, ProPublica
In examining the California Board of Registered Nursing, we found widespread problems. Most troubling, perhaps, is 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.
We also examined the state program for substance abusing nurses. We found that it 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.
The day after our first story ran, California Gov. Arnold Schwarzenegger replaced the majority of the nursing board. A day after that, the board’s longtime executive director resigned. Lawmakers are drafting legislation to close loopholes and the governor has requested an overhaul of enforcement for all boards overseeing health professionals in the state.
How did you get started?
We became interested in this issue because we were curious to find out what happened to nurses we had written about in 2003 and 2004 during an investigation of the now-closed King/Drew Medical Center in Los Angeles County. They were accused of turning down patients’ vital signs monitors and not noticing as their condition deteriorated, giving the wrong medications, ignoring patients in distress, falsifying records and even sleeping on the job. What we found surprised us. If the nurses were disciplined at all, it was years after the fact. Some of the nurses with the most serious allegations against them continued to have free and clear licenses. We decided to look at recent disciplinary actions by the Board of Registered Nursing and found that the King/Drew nurses were not the exception, they were the norm.
What were the key sources?
We examined the disciplinary records of more than 2,000 nurses who faced sanctions from 2002 to 2008 — as well as hundreds of pages of court, personnel and regulatory reports. We interviewed scores of nurses, patients, families, hospital officials, regulators and experts. We filed dozens of Public Records requests, forcing the state to publicly release statistical breakdowns of its own slow pace.
The most useful documents were the board’s own records and its own statistics over time. We also learned a lot by interviewing nursing board leaders in several other states, who were able to provide useful comparisons to California’s cumbersome process.
What was the biggest roadblock you had to overcome?
Ensuring that we had accurate information from the nursing board itself. Working alongside Los Angeles Times researcher Maloy Moore (who provided us with invaluable help), we discovered dozens of cases in which nurses’ disciplinary records were missing from the board’s website. We also found cases in which the board’s information was contradictory. Because we put up a massive database of all disciplinary cases online, we felt it was important to have correct information on more than 2,000 nurses.
Do you have any advice for journalists working on a similar story?
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.
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 at www.propublica.org/nurses.
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.
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.
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.
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 website, 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 www.nursys.com, 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.
Is the meeting self congratulatory or do board members inquire about statistics and timetables? How does staff answer these questions?
If so, what is the success rate? How is it monitored? What is the criteria for entering 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?
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