Does licensing nurses work?
I read an interesting article from the Oakland Tribune about how nurses move to avoid the consequences of misconduct. There is a dangerous gap in the way states regulate, license, supervise, and sanction nurses: They fail to effectively tell each other what they know. As a result, caregivers with troubled records can cross state lines and work without restriction, an investigation by the nonprofit news organization ProPublica and The Los Angeles Times found.
Using public databases and state disciplinary reports, reporters found hundreds of cases in which registered nurses held clear licenses in some states after they'd been sanctioned in others, often for serious misdeeds. In California alone, a months-long review of its 350,000 active nurses found at least 177 whose licenses had been revoked, surrendered, suspended or denied elsewhere.
State regulators aren't using their powers to seek out this information, or act on what they find, the investigation found.
By simply typing a nurse's name into a national database, state officials can often find out within seconds whether the nurse has been sanctioned anywhere in the country and why. But some states don't check regularly or at all. The failure to act quickly in such cases has grave implications: Hospitals and other health care employers depend on state nursing boards to vouch for nurses' fitness to practice.
Because there is no federal licensing of nurses, each state sets its own standards on punishable behavior. In general, states can discipline a nurse based solely on the actions taken by another state. But they vary widely in how quickly — or harshly — they act on this information, according to interviews with regulators in 14 states.
Delays in several states left Craig Smart free to practice. In 2000, he surrendered his license in Florida after testing positive for cocaine and flunking a treatment program. It took eight years for five other states in which he was licensed to respond to Florida's action. California was the last to revoke his license, in 2008, after he had practiced here for several years.
Even when states share borders, they sometimes fail to heed each other's disciplinary actions. At least 10 nurses, for example, hold clear licenses in Massachusetts despite being disciplined next door in Rhode Island, including suspensions for drug thefts and violence.
There is ample information available for states to identify nurses disciplined by other jurisdictions. Two separate databases attempt to track disciplinary actions from every state. States are required to report to one, run by the federal government, within 30 days of taking an action. Reporting to the other, operated by the National Council of State Boards of Nursing, is voluntary.
Each database can be programmed to alert a state whenever a nurse it has licensed runs into trouble in another state. When checking a nurse's record, nursing officials say they almost uniformly use the council's database; it's free and the government's is not. In fact, federal statistics show that nursing boards accessed the government database fewer than 300 times total in 2007 and 2008.
In addition, ProPublica and The Los Angeles Times found that the federal database is incomplete, despite the requirement that all states report discipline to it. Many actions appeared to be missing when reporters tried to match known cases by date of discipline to a version of the database in which confidential information had been removed.
The council cannot force states to submit names, and states have a financial incentive not to: They make money by charging nurses to verify their licenses, test scores and training to authorities in other states. For example, a nurse licensed in California who wants credentials to practice in Arizona must pay California $60 to confirm her background. Those sorts of checks netted California nearly $1 million in fiscal 2009. New York, which charges $20 a check, earns more than $250,000 a year.
When states turn over their lists of licensed nurses to the national council, that group earns such verification fees. "The decision to join is a revenue loss for them," said Kathy Apple, the council's chief executive officer. "That's difficult for some states."
Reporters went further, checking the full roster of 350,000 licensed nurses against a public version of the council database. They found that at least 643 California nurses had sanctions elsewhere, including the 177 whose licenses had been revoked, suspended, denied or surrendered.
Jose Martinez, who surrendered his license in Texas in July 2008 after being accused of performing a rectal exam on an 11-year-old girl without a doctor's order or a witness present. In a letter to the Texas board, Martinez acknowledged his misconduct. "Yes, I made a mistake and, yes, I am guilty. After 4 years as a tech and 12 years as a nurse I slip and fall. "... I guess I deserve what is coming to me." His California license is active, without restrictions, and does not expire until July 2010.
Randy Hopp, who was convicted in 2004 of assaulting a nursing home resident in Minnesota. It was the fourth facility since 1998 at which he had been accused of mistreating a resident, records show. The nursing boards in Minnesota and Missouri placed him on probation, and Kansas imposed restrictions on his practice. Hopp surrendered his license in Texas. In California, his license remains clear.
In the past the board took a median of 13 months to file public accusations against nurses after their licenses were first revoked, surrendered, denied or suspended by another state, according to a review of 258 such cases since 2002.
Three of these nurses got work and stole drugs from California hospitals after they had surrendered their licenses across the border in Nevada for previous wrongdoing there.
