State board slow to deal with problem nurses, investigation shows

By Charles Ornstein & Tracy Weber, InsideBayArea.com

Nurse Owen Jay Murphy Jr. twisted the jaw of one patient until he screamed.

He picked up another one — an elderly, frail man — by the shoulders, slammed him against a mattress and barked, “I said, ‘Stay in bed.’”

He ignored the alarms on vital-sign monitors in the emergency room, shouted at co-workers and once hurled a thirsty patient’s water jug against the wall, yelling, “How do you like your water now?” according to state records.

Murphy’s fellow nurses at Kaiser Permanente in Riverside Medical Center finally pleaded with their bosses for help.

“They were afraid of him,” a hospital spokesman said.

Under pressure, Murphy resigned in May 2005. Within days, Kaiser alerted California’s Board of Registered Nursing: This nurse is dangerous.

But the board didn’t stop Murphy from working elsewhere, nor did it take steps over the next two years to warn potential employers of the complaints against him. In the meantime, Murphy was accused of assaulting patients at two nearby hospitals, leading to convictions for battery and inflicting pain, board and court records show.

Even Murphy, who has since taken classes to curb his anger, was surprised the board didn’t step in earlier.

“The nursing board is there to protect the public from me,” he said in an interview.

The board charged with overseeing California’s 350,000 registered nurses licenses often takes years to act on complaints of egregious misconduct, leaving nurses accused of wrongdoing free to practice without restrictions, an investigation by The Times and the nonprofit news organization ProPublica found.

It’s a high-stakes gamble that no one will be hurt as nurses with histories of drug abuse, negligence, violence and incompetence continue to provide care across the state. While the inquiries drag on, many nurses maintain spotless records. New employers and patients have no way of knowing the risks.

One nurse linked to a lawsuit against John Muir Medical Center in Walnut Creek that was settled in 2003 still works at John Muir. A separate complaint lodged with the nursing board over the same incident remains unresolved six years later.

Reporters examined the case of every nurse who faced disciplinary action from 2002 to 2008 — more than 2,000 cases in all — as well as hundreds of pages of court, personnel and regulatory reports. They interviewed scores of nurses, patients, families, hospital officials, regulators and experts.

In interviews last week, the board’s leaders and other state officials defended its record.

“We take what we do — protecting the public — very, very seriously,” Executive Officer Ruth Ann Terry said.

Terry, at the helm for nearly 16 years and on staff for 25, acknowledged that the pace of the disciplinary process has “always been unacceptable” and said the system was being streamlined. But she blamed other parts of the state bureaucracy for delays and was vague about what changes would be made.

Later, the state Department of Consumer Affairs, which oversees the board, sent reporters a three-page list of “process improvements.” Many were mundane or incremental adjustments — such as revising disciplinary guidelines or planning expert witness training. Others seemed more directly aimed at reducing delays: adding staff, meeting with investigators about stalled cases and using computer systems to better track complaints.

Patricia Harris, acting chief deputy director of the department, stood behind the board.

“I think they do a good job,” she said.

It’s impossible to measure the number of nurses whose conduct endangers patients, but it is presumed to be a small fraction. The board disciplines several hundred a year.

But even a small number of troubled nurses can have wide impact. Registered nurses are required to perform or oversee complex treatment, and each one can see dozens of patients a week.

Patients generally don’t have a choice in which nurse they get. Most trust that, at minimum, the government wouldn’t allow a nurse with known problems at their bedside.

In California, the board’s vigilance is especially important. The state has among the fewest registered nurses per capita of any state, with an estimated 654 working nurses for every 100,000 residents, compared with 836 nationwide.

Putting even greater strain on the nursing supply is a unique state law that limits how many patients each hospital nurse can treat at one time.

With demand outstripping supply, nurses have readily jumped from one hospital to another, and employers have relied heavily on the board to screen out poor performers.

Despite its critical mission, the board faces little outside scrutiny or pressure to change its ways. Public board meetings, held five times a year, are filled with praise for staffers’ efforts. During the five recent meetings attended by reporters since November 2007, Terry never focused on the delays in discipline.

And board members — including both nurses and public appointees — never publicly challenged staffers or urged quicker action even though they review every disciplinary action. (Board President Susanne Phillips said such questions are often raised with staff privately.)

While the board tarries, nurses like Owen Jay Murphy Jr. keep working.

In 2006, more than a year after Kaiser warned the board about him, Murphy was employed at Riverside Community Hospital. There, according to a criminal investigator’s affidavit, he forcibly grabbed the face of a patient whose arms were tied down.

“I was helpless,” said Christy Ledebur, now 50. “Why would they have someone like that working in an emergency room?”

Ten days later, Murphy punched and elbowed another restrained patient in the face, the investigator’s statement said.

“I don’t even recall the first two hits,” said Murphy, 41, adding that his stress and anger at the time clouded his memory. “They said I hit ‘em three times.”

Riverside Community fired him in July 2006 and immediately alerted the nursing board. He later pleaded no contest to misdemeanor charges in both incidents.

A month later, a patient at Arrowhead Regional Medical Center in Colton, San Bernardino County, complained that Murphy had put her in a headlock and shoved her against the wall, leaving clumps of hair on the bed and floor, according to hospital officials and board records.

The board took its first public action in June 2007, filing a formal accusation detailing the administrative charges against Murphy.

The former Army medic said in an interview that he had been provoked in some cases by aggressive or mentally impaired patients. But he said he was a good nurse and confident that court-ordered anger management classes had taught him self-control.

Still awaiting his first board hearing, he works in the emergency room of Parkview Community Hospital in Riverside with an unrestricted license.

Racking up accusations
The Times and ProPublica found more than 60 nurses disciplined since 2002 who — like Murphy — were accused of committing serious misconduct or mistakes in at least three health facilities before the board took action.

At least five employers reported Los Angeles nurse Carolyn Fay Thomas to the board after she was accused of making medication errors and falsifying charts to hide her drug thefts.

And John Michael Jones racked up complaints from at least three hospitals for stealing and using drugs during work. Yet the board waited five years to revoke his license, even after he was accused of dozing off while performing CPR on a dying patient in 2002.

“I was high some of the times that I was working. Yes, I was,” Jones, who denies falling asleep during CPR, said in an interview.

Several hospital administrators expressed shock when reporters told them that nurses they had turned in for dangerous failings went on to work at other facilities. No one tracks these nurses, who typically aren’t required to tell the board where — or even if — they are working.

“There’s got to be a better system than now to protect our patients and their safety,” said Deborah Hankins, chief nursing officer at Bakersfield’s San Joaquin Community Hospital, one of the hospitals that complained about Jones.

As it stands, complaints often take a circuitous route through several clogged bureaucracies: From the nursing board for initial assessment to the Department of Consumer Affairs for investigation, to the state Attorney General’s Office for case filing and the state Office of Administrative Hearings for trial. Only then does the case go back to the board for a final decision.

Other California health licensing boards are also hampered by delays — but the registered nursing board stands out because of the sheer volume of licensees it regulates.

The biggest bottleneck occurs at the investigation stage, as Consumer Affairs staffers struggle to handle complaints against nurses as well as those against facing cosmetologists, acupuncturists and others. The nursing board must share a pool of fewer than 40 field investigators with up to 25 other licensing boards and bureaus. Some investigators handle up to 100 cases at a time.

All told, cases closed by the nursing board in fiscal 2008 took an average of 1,254 days. The pace surprised officials at other states’ nursing boards.

“I don’t think it’s ever to anybody’s advantage to have a case open for three years,” said Valerie Smith, associate director of Arizona’s board, which typically takes six-and-a-half months from complaint to final resolution.

State Nursing boards nationwide vary widely in how they investigate and discipline nurses. But many do it faster.

Officials from Arizona, Texas and Ohio say they handle almost everything within their own agencies, exercising tight control and questioning cases that take too long.

“Where there’s the greatest risk, we want to take the fastest action,” said Betsy Houchen, head of Ohio’s board, which requires 95 percent of the most serious complaints to be investigated within five working days.

Boards with the fairest and quickest outcomes hire their own investigators, usually nurses themselves, as well as their own attorneys, according to a 2004 trade group report.

Terry could ask the state Legislature for broader authority or permission to hire her own investigators, but she said she has no plans to. Rather, she said, she intends to adhere to the “process that the state of California has set up in terms of protecting the public.”

She said her staff had recently begun working with Consumer Affairs investigators to prioritize and expedite the handling of complaints.

It’s not a new goal. In a 2002 report to the Legislature, the board said that “there has been a steady and unacceptable increase” in length of disciplinary cases and called for “strategies to expedite cases.”

Current and former state attorneys say funding has been an issue — at times they’ve been asked to suspend work on nursing board cases to save money. But Phillips said the board, which is funded by licensing fees paid by nurses, has enough money. It hasn’t raised its fees in 18 years.

There is no legal pressure for the board to act faster. Unlike with disciplinary cases against doctors, there’s no statute of limitations on nurses. The delays make the pursuit of cases more difficult: Witnesses die. Records are purged. And former co-workers cannot be found.

A girl asks why
Caitlin Greenwell grinned slyly as she sat before a special computer at her family’s ranch home in Lafayette. Her eyes darted around a keyboard on her screen, as a sensor tracked her gaze and allowed her to spell out words.

“Let’s test my mom,” she typed, then looked up with a devilish smile. “We will test my mom on math.”

Julia Greenwell laughed.

“In so many ways, she’s typical,” she said.

But the 9-year-old has begun questioning why she is trapped in a wheelchair, unable to control her limbs or speak, said her father, Steven.

Caitlin, he said, is “very aware that things didn’t go right and some were due to people not doing their jobs.”

Like many aggrieved patients and their families, the Greenwells say they feel doubly victimized, first by nurses and then by the board itself. Steven Greenwell said he won’t rest until the board disciplines Candyce Warren, the nurse he holds primarily responsible for Caitlin’s injuries at birth.

In October 1999, Warren and the trainee she was overseeing missed crucial signs during Julia Greenwell’s labor that the baby’s condition was deteriorating, according to accusations in a 2000 lawsuit by the Greenwells against John Muir Medical Center in Walnut Creek.

Caitlin was deprived of oxygen and as a result has cerebral palsy, according to the suit, settled in 2003. A doctor paid a separate settlement.

Attorneys for the Greenwells said that Warren was responsible for the trainee, who had little experience reading fetal monitoring strips, and that both nurses tried to cover up their mistakes by altering the medical record.

Steven Greenwell lodged a complaint with the nursing board in June 2003 — waiting, as his attorney advised, until after the civil case was resolved. The board filed an accusation relatively quickly — a year or so later. Then the case disappeared into the state’s bureaucracy.

There was no word on the matter until 2008, when the board amended the charges against Warren to fault her handling of a different baby’s distress back in 2002. That child was stillborn.

Still there was no resolution for the Greenwells and no explanation for the delays.

“I kept calling the nursing board and getting nothing,” Steven Greenwell said.

Greenwell said he also spent hours on the phone imploring a deputy attorney general to see the case through — only to learn recently that she had left her job.

Warren, who still works at John Muir, feels wronged by the board as well. She disputes the accusations and wants to clear her name but wouldn’t discuss specifics while the case is pending. At least five hearings have been set, then put off, she said.

“What they are doing is torturing us,” she said. “It’s not right.”

Data not demanded
The nursing board says it can’t act on cases it doesn’t know about. But it’s not set up to find out what it needs to know, The Times and ProPublica found.

Most states require hospitals to report nurses who have been fired or suspended for harming a patient or other serious misconduct. So, for that matter, does California’s vocational nursing board.

Not the registered nursing board.

Heidi Goodman, the board’s assistant executive officer, told The Times in 2007 that the board could be overwhelmed if such reports were mandated.

“We have to work within existing resources,” she said. “You get the flood. What are you going to do about it?”

The board also largely shuts itself off from information about nurses licensed in California who get in trouble elsewhere.

It is not part of a national compact of 23 state nursing boards that shares information about nurses who are under investigation or have been disciplined.

And unlike 35 states, California does not put the names of all its registered nurses into an industry database. So if a California-licensed nurse gets in trouble in another state, that state may not know to notify California.

Terry said last week that the board would consider requiring plans to look into imposing a requirement on California hospitals to report errant nurses — a proposal that has come up before but never gained traction. She also said the board wants to arrange a one-time computer sweep of other states’ actions to determine which of them involve California nurses.

Until recently, the state did not even ask nurses renewing their licenses whether they had been disciplined elsewhere or convicted of crimes. It only began doing so after The Times and ProPublica highlighted the loopholes last fall.

More than half the nurses who respond to accusations from the board are handed a second chance. Each year, California places at least 110 nurses on probation, warning that if they get in trouble again, their licenses may be yanked.

In reality, such action seldom happens quickly, if at all, according to a review of nurse disciplinary records.

Just five board monitors oversee about 470 nurses on probation. Often nurses must undergo physical and mental exams, take drug tests, submit to workplace monitoring and attend rehabilitation or support groups.

But when they don’t meet some — or any — of those requirements, years often pass before the board tries to revoke their probation.

At times the punishment for violating probation is more probation.

Terry cautioned that improvements in the board’s performance would take time.

“It’s not going to happen overnight,” she said.

Among the findings
- California’s Board of Registered Nursing took more than three years, on average, to investigate and discipline errant nurses, according to its own statistics. In at least six other large states, the process typically takes a year or less.

- The board failed to act against nurses whose misconduct already had been thoroughly documented and sanctioned by others. Reporters 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 — yet have blemish-free records with the nursing board.

- The board gave probation to hundreds of nurses — ordering monitoring and work restrictions — then failed to crack down as many landed in trouble again and again.

- The board obtained emergency suspensions of nurses’ licenses just 29 times from 2002 to 2007. In contrast, Florida’s nursing regulators, which oversee 40 percent fewer nurses, take such action more than 70 times each year.