Problem Nurses Stay on the Job As Patients Suffer

08/13/2009 05:12 am ET | Updated Nov 17, 2011

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 Bales failed to respond to the board's accusation, and her license was revoked in 2008.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.