Problem nurses escape punishment
State agency often withholds key details of violations
By Michael J. Berens
Tribune Staff Writer

September 12, 2000

Last of three parts

Correction published Sept. 28, 2000:

In a Sept. 12 story on the state's disciplinary process for nurses, the
Tribune described the actions of a registered nurse suspended for overdosing
a patient with a chemotherapy drug "at Highland Park Hospital." The nurse
was not employed by the hospital but by a private physician group leasing
space from the hospital.

Lax government oversight and a shoddy system of reporting medical errors
allow negligent, incompetent and impaired registered nurses to return to
work in Illinois even after committing deadly errors. In Chicago, registered
nurses have injected themselves with heroin and cocaine, then committed
dozens of errors. They have stolen prescribed medications, then left
patients to suffer in pain for hours.

They have been convicted of felony crimes, from child molesting to drug
trafficking. They have injured through neglect and killed through
inattention.

And in each of these cases, they continued working even after they were
caught and, in many cases, after signing admissions of wrongdoing.

Registered nurses are the primary guardians of hospital care. It is their
job to monitor patients, detect sudden declines in condition and call for
help in emergencies. Nurses across the country save countless lives every
year, and the vast majority never face disciplinary action.

But because they work with more patients for longer periods of time and
because they are vulnerable to inadequate staffing, nurses make the majority
of the nation's medical errors, state and federal healthcare records show.

As Congress this year considers proposals to combat a rising toll of medical
errors, one of the hidden components of this issue is the role of states in
licensing and disciplining of registered nurses, the nation's largest
healthcare profession.

Illinois is one of 37 states that do not require healthcare facilities to
report cases of nurse misconduct, even if injury and death occur. In a
majority of states, licensing agencies embrace a second-chance philosophy
based on a belief that registered nurses are a treasured resource to be
saved no matter the risk.

"Just because you rob a bank doesn't mean you can't be a good nurse," said
Leonard Sherman, director of the Illinois Department of Professional
Regulation, which oversees nurse licensing and disciplinary cases.

Each year, more Illinois nurses lose their licenses for failure to repay a
student loan than any other violation, from drug or alcohol impairment on
the job to felony crime convictions.

The Tribune's examination of Illinois DPR records found the agency exhibits
a pattern of leniency toward problem nurses and lacks the resources to
determine which nurses pose a potential danger. Among the findings:

Investigators for the understaffed DPR sometimes close cases without
examining medical records and even without determining if patients were
harmed. Registered nurses number about 110,000, but there are only six DPR
inspectors assigned to nursing; most, but not all, have law enforcement
backgrounds.

In at least 43 cases in the last six years, DPR did not refer nurses
suspected by hospital administrators of committing felonies to the state's
attorney office for investigation or possible prosecution. Cases ranged from
a nurse who forged more than 50 prescriptions at Chicago-area pharmacies to
a nurse who stole controlled substances for more than a year at a suburban
Chicago hospital, according to state investigative reports.

Nurses aren't disciplined or even investigated when settled lawsuits raise
issues of negligence. The Tribune examined 32 lawsuits filed in Illinois
courts that incorporated substantial evidence that inattentive, impaired or
incompetent nurses played a primary role in the death or injury of a
patient. None of those nurses has been disciplined, nor is there evidence
that any state investigation was conducted.

Of the 924 case files on nurses closed since 1995, three of every four have
been stripped of the most basic information, such as where the violation
occurred, the specific nature of the violation or if patient harm occurred.

DPR's system for identifying problem nurses relies on the cooperation of
hospitals, but state law requires hospitals to notify regulatory authorities
only if a nurse is fired, not if the incident is handled in house or if the
nurse resigns. DPR officials search media reports statewide to find possible
cases.

State licensing laws were established decades ago to regulate professions
and safeguard the public, and the system in Illinois now includes 60
professions, from alarm contractors to social workers.

But across the country standards are routinely twisted, sometimes secretly,
to protect unsafe and unqualified nurses, a Tribune analysis of disciplinary
actions nationally found.

As a result, dozens of states have become havens where problem nurses can
move job-to-job without discovery, where crimes are committed with impunity,
where even the deaths of patients have been withheld from public records.

In Wisconsin, a registered nurse twice convicted in the early and mid-1990s
for stealing patients' cash and jewelry kept her license this year despite
testing positive for cocaine.

In Utah this year, a registered nurse whose record-keeping errors led to the
fatal overdose of an elderly patient continued to work without benefit of
training after agreeing to pay a $1,000 fine.

In Washington, a registered nurse fired from three jobs in three years
because of incompetence retained her license last year even after she
committed a medication error that critically injured a patient.

Lacking manpower and funding, hobbled by dual roles of fostering and
policing professions, most states conduct superficial investigations and
mete out token punishment, an analysis of state records shows.

"If there is any chance of all, state licensing boards will always lean
towards remediation. A nurse is a valuable resource," said Vicki Sheets,
director of policy and credentialing for the National Boards of Nursing.

The need for thorough, balanced and consistent disciplinary action has never
been greater as more nurses travel across state borders, holding licenses
simultaneously in up to a dozen states, Sheets said. About 10 percent of
registered nurses licensed to practice in Illinois live in other states,
state licensing records show.

Here, as in most states, complaints involving nurses are first reviewed by a
team of investigators. The Illinois DPR forwards its investigative findings
to the state Nursing Board.

The board and a DPR lawyer contact the nurse under investigation to
determine if he or she will seek an administrative hearing, which is public,
or agree to a settlement conference, which occurs behind closed doors.

DPR director Sherman reviews settlements. He has final authority to issue
discipline ranging from a written reprimand to indefinite suspension.