Problem Nurses Stay on the Job As Patients Suffer
The following stories are sidebar reports by Charles Ornstein and Tracy Weber that were taken from their extensive investigation "When Caregivers Harm: Problem Nurses Stay on the Job as Patients Suffer" that was published by the Los Angeles Times and ProPublica this past weekend.
The complete investigation -- which includes a searchable database of the 2000 nurses and what they were disciplined for, a narrated video feature where some victims' stories are told, a timeline that charts the course of nursing board's disciplinary process and more - can be read here.
Dr. Iraj Zandi: Appalled By Delay
In the midst of delicate eyelid surgery in April 2006, a patient who was supposed to be sedated yelled that the drugs weren't working.
Plastic surgeon Iraj Zandi turned to nurse Jennifer Bales: "Are you sure you gave me Demerol? Show me the bottle!"
Later, staffers checking the Fremont surgery center's drug locker found hairline cracks around the tops of vials of the painkiller. Bales, they later learned, had removed the drugs in all but two of the vials, then refilled them with saline, Zandi said. Any nurse would know the consequences for a patient: pain during surgery and possibly serious infection from unsterile saline, he said.
Zandi alerted police and reported Bales to California's Board of Registered Nursing. "They said, 'We can't stop her until we go through the process,' " he recalled. It was a frightening thought, he said: She could go to work anywhere.
Over months, Zandi and his staff relentlessly pushed for Bales' criminal conviction. In December 2006, Bales was found guilty of embezzlement for stealing drugs and hypodermic needles.
But it would be another year before the nursing board filed an accusation. The board's documents told Zandi something he hadn't known -- that several years before, Bales had allegedly pilfered drugs from a hospital. Bales failed to respond to the board's accusation, and her license was revoked in 2008.
Zandi's wife, Mitra Ara, who works at the practice, said she couldn't believe the board didn't act faster. "Somebody who takes away a painkiller from patients is capable of doing anything."
Veronica Glaubach: Joy of Birth, Then Tragedy
Veronica Glaubach told her father to wait until the week after she gave birth before flying to California from Buenos Aires to meet the baby. When the infant was a day old, however, Roberto Glaubach was told to come immediately.
Veronica was brain-dead.
The cause of her 2002 death was complications from pre-eclampsia, a relatively common condition in pregnancy that can be fatal if not treated promptly.
Roberto Glaubach has spent years and more than $100,000 seeking to hold someone responsible. He has made 20 trips to California and sent letter after letter. In one missive to the state Board of Registered Nursing, he attached Veronica's photo: "The face of a human being who some irresponsible and little-prepared nurses killed at 28 years of age," he wrote.
In 2005, state hospital regulators faulted three nurses for not telling doctors of Veronica's high blood pressure or assessing her for pre-eclampsia. Glaubach also obtained a $550,000 legal settlement for his granddaughter after suing the hospital and two doctors.
Five years after Veronica's death, the nursing board weighed in, saying in a letter to Glaubach that an outside expert found the treatment "within the standards of care" under state law.
"The board appreciates the profound depth of your loss. However, any further review of this matter would not result in a different opinion."
"I was astonished," Glaubach said. "My loss is for the rest of my life."
Charles Ornstein and Tracy Weber are senior reporters for ProPublica, America's largest investigative newsroom.
Follow ProPublica on Twitter: www.twitter.com/@propublica
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Dissolving the State Board of Nursing and forming a new oversight agency would set back public safety, not promote it. As a nurse for over three decades who has focused exclusively on the issue of chemical dependency in nurses, throwing the baby out with the bath water by dissolving the board is not the answer. Do changes need to be made? Absolutely. But there needs to be great deliberation in the selection process of who sits on the board; what is their experience and training regarding this dilemma; what can reasonably be expected of just how many investigators overseeing just how many licensees; how keen are healthcare employers in pulling out all the stops to prevent the issue from occurring in the first place rather than waiting to identify a problem after the fact? For the many nurses who have ever signed witness to a controlled waste they did not thoroughly eyeball from the sealed manufactured state through to actually being wasted, you must acknowledge yourselves as at least a part of this problem. Paula Davies Scimeca, RN, MS
So, tell me about the nurse who is on drug probation because she was set up after being threatened if she reported what the Charge Nurse was doing?
Records are incorrect on an 'overdosed' patient; they combined records for a *24 hour shift. Pharmacy stated "above the mean" in giving out pain meds on a CCU, but they did not factor in she worked 48 & 60 hours b/c of short staffing. What happened to "Pain is what the patient says it is?" What about all the wastes/returns of actual "in the bubblepack or syringe" she could have said she gave the patient, but returned it?
This nurse did not divert, use illegally, and had complete neuropsych exam by PhD, hair analysis, and has over 50 negative random screens. I've known her 30+ years; she is as clean as they come. She even has left over pain drugs in her house from Rx for a kidney stone.
The Board of Nursing FAILED TO INVESTIGATE FULLY. BON did back down by NOT requiring a Treatment Program/ counseling, a 'monitoring person' on the unit, and she CAN give out and sign off of narcotics. She could not afford an attorney.
She has NOT been able to get a job in nursing. She has been hired UP to the point that she tells HR or Administration about Probation.
This is a *total waste of a BSN honor graduate with 3 "Nurse of the Year" awards.
In my state, there is not enough budget, there is not enough investigators, and things move slow. In one year, there may be 1,000 cases....i
On the flip side of the coin, there are many in those other cases where there is no evidence, there is incorrect information, or another person was trying to set a nurse up for something that they did not do. The Board may not investigate fully and a good nurse gets disciplined or their license revoked
I know this from personal contacts.
Examples:
A nurse put medications in another nurse's locker by using hemostats to push the bubbled-packed pills in through the vents of the locker.
I also know of an experienced, good nurse who made a mistake because was pushed for time. The patient was okay. The nurse was fined and reprimanded by the Board.
So many nurses are hard pressed for time, have too many patients, and have to make decisions they do not want to make. They are afraid of loosing their licenses under the conditions they are forced to work. This is why so many leave nursing.
I would say infuse new people into the Boards of Nursing, hire more investigators and have the nurses *appointed an attorney* if they cannot afford one. The Boards are their own "Nurse administrative' laws and codes and can do what they want.
how can it take a YEAR to dismiss a nurse (or de certifiy).
Some of the people who go into nursing are truly dedicated professionals.
However, for many, particularly girls in small towns, nursing is just about the
only professional career available that only requires a junior college degree,
so my take is that a lot of them go into it for the money rather than any
altruistic desire. But the state boards need to be dissolved and a new
oversight agency formed.
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