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 Bales failed to respond to the board's accusation, and her license was revoked in 2008.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

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