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Troubled Nurses Skip from State to State Under Compact

A 24-state compact has provided cover for nurses suspected of negligence or misconduct, leaving them free to work across nearly half the country and potentially put patients in jeopardy.

Illustration by Suzy Parker/USA TODAY

This story was co-published with USA TODAY.

Nurse Craig Peske was fired from a hospital in Wausau, Wis., in 2007 after stealing the powerful painkiller Dilaudid “whenever the opportunity arose,” state records say. In one three-month period, he signed out 245 syringes full of the drug — nine times the average of his fellow nurses.

Hospital officials reported him to Wisconsin nursing regulators and alerted police.

Six months later, Peske was charged with six felony counts of narcotic possession. But by that time, he had used a special “multistate” license to get a job as a traveling nurse at a hospital 1,200 miles away in New Bern, N.C.

“When I went to go for the job in North Carolina, I looked at the status of my license and it was still active,” said Peske, 36, who was later convicted of two felony drug charges. “That kind of surprised me, so I figured I would take it.”

The ease of Peske’s move illustrates significant gaps in regulatory efforts nationwide to keep nurses from avoiding the consequences of misconduct by hopping across state lines.

The two states in which Peske worked are part of a 24-state compact created to help get good nurses to areas where they are needed most. Under the decade-old partnership, a license obtained in a nurse’s home state allows access to work in the other compact states.

But an investigation by ProPublica found that the pact also has allowed nurses with records of misconduct to put patients in jeopardy.

In some cases, nurses have retained clean multistate licenses after at least one compact state had banned them. They have ignored their patients’ needs, stolen their pain medication, forgotten crucial tests or missed changes in their condition, records show.

Critics say the compact may actually multiply the risk to patients. There is no central licensing for the compact, so policing nurses is left to the vigilance of member states.

Outside the compact, each state licenses and disciplines its own nurses. But within it, states effectively agree to allow in nurses they have never reviewed.

“While any state can make mistakes, in a single-state license system, the errors impact one state,” said Genell Lee, head of Alabama’s nursing board, which is not part of the compact.

By comparison, when a compact state is slow to act or fails to share information, nurses suspected of negligence or misconduct remain free to work across nearly half the country, Lee said.

Joey Ridenour, chairwoman of the compact’s national board, said she believes the compact has promoted more and faster communication among states. She also said the number of compact nurses disciplined outside of their home states is very small.

But compact officials do not track how many nurses are sanctioned by their primary state for misconduct elsewhere. They also don’t question whether states are adequately policing visiting nurses: 10 states have disciplined three or fewer such nurses in the past decade, compact records show.

Ridenour acknowledged that the pact is only as good as the performance of its individual members. If a state has been historically lax, she said, joining the compact will not change that.

“I am very careful to say that this is not a cure-all,” said Ridenour, who also is executive director of Arizona’s nursing board. “I just believe it’s better than what we had before.”

A lack of screening

 

Twenty-four states (shaded in blue here) are part of the nationwide nursing compact.

Weaknesses in the state-based system for disciplining problem nurses have surfaced as a public health issue during the past year. California, for example, revamped its nursing board and its executive officer resigned following reports of ineffective oversight that put patients at risk.

The state recently discovered that 3,500 of its nurses had been disciplined by other states but had kept clean California licenses.

With no federal licensing system, the compact has been seen as at least a partial solution for policing nurses who work in different states.

To test its effectiveness, ProPublica examined the disciplinary actions taken by five compact states — Arizona, Virginia, Texas, Kentucky and North Carolina — in recent years.

Reporters found four dozen examples of nurses whose primary licenses remained clean for months or longer after another compact state barred them from working there.

Among the cases detailed in nursing board records:

  • Therese Morgan, who now goes by Therese Holmes, retains a multistate license in Maryland. Arizona banned her in January 2009 after incidents at five hospitals in the Phoenix area, including failing to show up for work, flunking orientation and frightening a patient whose catheter she removed. Doctors and staff asked that she not be assigned to certain patients. Holmes could not be reached for comment, and officials from the Maryland board would not discuss the case.
  • Stephen Woodfin, a nurse anesthetist, surrendered his right to practice in North Carolina in January 2006 because of substance abuse. Even so, he was able to keep a clean multistate license in Texas. Nearly two years later at an Amarillo, Texas, hospital, he passed out during a surgery, bleeding from a vein in his arm. The Texas Board of Nursing found he had abused the narcotic Fentanyl. In September 2008, the board suspended him. He now is on probation and is limited to working in Texas. Kathy Thomas, executive director of Texas’ nursing board, said she could not comment on Woodfin, who did not return calls. But Thomas noted that in some cases involving substance abuse, one of the most common reasons nurses get in trouble, discipline might not begin until after a nurse has flunked out of a confidential recovery program.
  • Dayna Hickman was suspended from practicing in Texas in September 2006, after she administered undiluted vitamin K too quickly to a patient at a Dallas hospital. The patient died a short time later. The next year, Hickman was placed on probation in California because of the Texas discipline. But her multistate license in Iowa remains clear.

Hickman, who now works as a critical care nurse in Mason City, Iowa, said she notified the Iowa nursing board about the incident in Texas. “I have an exemplary record outside of this as a nurse, so Iowa chose to not do anything,” Hickman said.

The Iowa board would not comment, citing privacy restrictions.

Allegations about nurse Craig Peske’s drug use did not stop once he reached North Carolina.

Within days of his arrival, a parent complained that Peske was falling asleep while attempting to insert an IV in her child. A hospital review found that he signed out the painkiller Demerol on dozens of occasions without a physician’s order. When he refused a drug test, he was fired in April 2008, nursing board records show.

Six months later, North Carolina banned him from working there. But Peske’s home state of Wisconsin did not revoke his multistate license until January 2009, giving him the ability to work in any of the other states until then.

Even Peske, who said recently he was sober and had a job as a home inspector in Wisconsin, questions why he wasn’t stopped sooner.

“Should I have been allowed to work in North Carolina? Probably not,” Peske said, then added more firmly, “No, I shouldn’t have been.”

Concern about gaps in licensing

Nationwide, nursing shortages have forced hospitals to rely on traveling or temporary nurses. Nurses working in one state now take medical-advice phone calls or use teleconferencing to see patients in another.

The compact is routinely touted as a success. Just last year, compact administrators said there was “no evidence” the compact compromised public protection, as the American Nurses Association asserted. But officials in nonparticipating states say they worry that the compact gives its members a false sense of security.

Differing laws, standards and staffing levels at state agencies, they said, make cooperation difficult. Even within the compact, state standards vary. Most states have the ability to immediately suspend a nurse’s license, but some can’t — even when the allegations are severe.

Likewise, some states require criminal background checks as a condition of getting a license, while others don’t.

That is one reason the Ohio Board of Nursing elected not to join.

“If an applicant has been convicted of certain crimes such as murder and rape, among others, the applicant cannot be considered for licensure in Ohio,” the board wrote. The majority of compact states, it noted, does not have the same tough standard.

Kansas’ attorney general in 1999 wrote that the state could not legally join. If one compact state, for example, decided that “a correspondence course in aroma therapy” was all that was needed to be licensed, Kansas would be required to let those nurses in.

Two national databases — one run by the National Council of State Boards of Nursing, the second by the federal government — are supposed to alert regulators and employers to disciplined nurses. But that doesn’t always happen. ProPublica has previously found discrepancies and missing records in both databases.

Amid such confusion, nurses accused of wrongdoing or incompetence keep working.

Alma Rice
Alma Rice (Dyer County, Tenn. Sheriff Office)

Alma Rice, 40, was able to work as a nurse in several states for seven years after she first got in trouble. Tennessee revoked her license in mid-2008 — only after she’d been accused of stealing drugs at four hospitals in three states and had racked up criminal convictions in each state.

Rice had been high on the job, tried to shred patient records to conceal her thefts and hid bottles of urine in her clothes in case she was drug-tested, nursing board and court records from several states show.

A forensic psychologist in Texas wrote in 2006: “It is still doubtful that (Rice) will be able to consistently behave in accordance...with generally accepted nursing standards.”

Rice also had been indicted for alleged child abuse by a Dyer County, Tenn., grand jury in February 2008 after her 18-month-old son was found with needle marks on his arm and tested positive for a powerful anesthetic, court records and newspaper reports said. Rice called police after she forgot where she left him, a report said. She later was convicted of misdemeanor assault in the case. Neither Rice nor her attorney returned calls and e-mails.

Shelley Walker, a spokeswoman for the Tennessee Department of Health, defended the process in Rice’s case. Three states took action against her within eight months of each other, she said.

Walker and other compact officials noted that nurses cannot be disciplined before they’ve had a chance to defend themselves.

But records show that while Tennessee and Texas were investigating, Rice was accused of stealing drugs from a hospital in Raleigh, N.C.

Nurse Krystal Bauer, like Rice, moved so fast she amassed allegations in multiple states before her home state caught up. Bauer, 37, was accused of stealing drugs in October and November 2007 while working at a Glendale, Ariz., hospital, in December 2007 while at a Weston, Wis., hospital and in June 2008 at a Greenville, N.C., hospital.

She finally surrendered her license in her home state of Iowa in November 2008 after the other three states banned her.

Ridenour, head of the compact, said even the best communication can’t stop nurses when they are intent on manipulating the system. But she said the compact strives to elevate the licensing standards across state lines by, among other things, encouraging states to require criminal background checks.

Nurse Bauer, who said in an interview that she is sober, said the various boards’ obligations to give her due process allowed her to keep moving.

“Until an investigation is closed,” she said, “it’s not going to look like there’s anything going on.”

This the Indian Health Service nationwide, compacted malpractice! And if that was not bad enough, we have legal malpractice to coverup medical malpractice!

Dr Gayle Eversole

July 15, 2010, 7:40 a.m.

It would be helpful is nursing QA panels would investigate claims that are filed under whistleblower protection laws that involve an NP who engaged in falsifying patient records, putting patients at risk of harm, insurance and Medicaid fraud, filing false claims and other irregularities when they are protected by state nursing organizations in WA (WSNA) These abusers are politically protected yet the whistleblower is attacked.

This has the stink of a Meg Whitman campaign hit piece. This also reminds me of the fear mongering that led to mandatory drug testing of truckers who have never been cobcicted of a drug offense. I don’t claim to know where this is going but I’m sure it will involve less freedom for honest hard working nurses and greater freedom for worthless, incompetant management parasites to mess with those who are deemed “troublemakers”. No govt. for the corporations; big govt. to keep the good people down.

It was not reported if the individuals named in this article went on to worked in large metropolitan hospitals or small towns or long term nursing facilities, etc

One could reasonably guess that an individual who is high on drugs, who may appear functional during the interview process would stand out when a large number of nursing personnel were around.  In small area hospitals, where the shortage of nurses may be more profound, that quality may not be as important as quantity, as JCAHO requires a specific RN to patient ratio.

I seriously doubt that this is not an issue unique to RN’s, as other Health Care Professionals only require Nat’l Certification…but certainly RN’s are the most visible.

I agree that there are errors in the process.  When calling a previous employer for a recommendation, because of confidentiality, the previous employer is limited in their response and is not able to release all pertinent information.

No answer to the problem, but thanks for keeping this problem in the public eye.

Dr Gayle Eversole

July 15, 2010, 2:14 p.m.

I was a Service Unit Director with IHS at the first tribal health program funded under PL 93-638.  In IHS it isn’t just the staff, its the bureaucrats in the PHS that play all sorts of games to prevent proper health care delivery.  I do have to be happy that our program came into concensus mgt and was used as a model for newer tribal health programs.  We had many programs funded that were atypical like dental, orthodintics, mental health and alcohol tx in addition to medical and pharmacy, nutrition,. Elders.

As the need for medical professionals continue to rise the Feds will encourage more and more of these professionals to enter the U.S.. Who pray tell will be checking their records (if any exist)? I can assure you it will not be the Feds.

I must say, that I am quite disappointed not just with the situation, but with the way this article seems to paint Travel RNs as “troubled” or travel nursing as a stomping ground for bad nurses. I am a Nurse, and I have been a traveler at that, from one of the compact states you claimed to have examined. During that time I was subjected to random testing, as well as mandatory drug screens and background checks between every assignment, every three months.

And as an extra note, JCAHO does NOT require certain Nurse to patient ratios. They don’t even look at the subject, as I have reported facilities with dangerous ratios in the past with NO effort or concern on their part. A decent pay and patient ratio was the appeal to me of traveling.

How about we put down the broad-brush catchy titles for the sake of honesty. Ya think?

multi compact states need to communicate with the original boardof licensure-and utilize total backgound checks-also see the need for nurse advocay panenls made of of staff nuruses who will objectively investigate these matters-in my state we have a don that get her thrills out of firing nurses and reporting them to the board for disipline-these poor new grads do not stand a chance under her-it is whether or not she likes you and is not threatened by you—these nurses are more dangerous to the profession than the drug addict is,

James RN, I think you have a point. Sometimes we all have a knee-jerk reaction and need to be put in our place.

We, I am sure, agree that in the Medical profession and for example the Teaching profession there are bad apples but so many good apples.

Let’s not forget the recent horror stories of the Catholic Church clergy administering to its flock. Lots of bad apples.

I suppose what we must do is not take it personally when you know that you are an excellent RN and acknowledge there are some who are bad apples.

IAs a floor nurse and traveler, I never saw any drug abuse by other travelers.  As a floor nurse in several hospitals, I have found staff nurses who were impaired, through misappropriation of narcotics;  I think that California now fingerprints ALL nurses with licenses. Hopefully this will cut down on those with fingerprints on file with state and or federal agencies.

I live in California and was anxiously watching a bill that would have forced more scrutiny and background checks on nurses. I won’t go into my story but a temp nurse almost cost my father his life. So I was cheering on this bill.  Now I find that of all people the California Nurses OPPOSED that bill and killed it.  They actually said they didn’t want anyone looking at the background of temp nurses and certainly didn’t want temp nurses to be able to be stripped of their license - their reason was supposely because it would mean fewer nurses. Well fewer nurses who steal drugs, molest patients and fall asleep in critical care units would be a lot better than the alternative!  Proof yet another bunch of overpaid selfish union m0r0ns care more for themselves than even critically sick patients! SHAME ON CALIFORNIA NURSES ASSN.!!!!

Laurel Jackson

July 17, 2010, 10:15 a.m.

The fact that bad nurses are able to move easily from state to state doesn’t make me feel very good about going to the doctor or having to stay in the hospital.  Hoever, with that being said I don’t have a solution to the problem, but from now on I will never leave a family member alone in a doctors office or a hospital.

Regulation of nursing licensure is key to protecting the public’s safety. Multiple factors contribute to problem nurses continuing to practice. There are “bad actors” in every profession- consider the priesthood, law enforcement, financial advisors & lenders to name a few. The Nurse Licensure Compact, or NLC, is actually an IMPROVEMENT to the traditional fragmented nursing licensure process put into place when HC delivery systems & the practice of nursing, both telephonically & on-site, was unrecognizable from current practice. Communication & collaboration among the 24 participating Compact states is greatly enhanced with regard to disciplinary investigation & actions, ask any Compact state board of nursing, or check out the NCSBN website for actual reports, surveys etc. Mr. Ornstein preferred to focus on qoutes from state boards that do not participate in the NLC, not exactly balanced reporting. This is like asking Bernie Madoff & his investors what they thought of pyramid schemes when the money was rolling in. Please do your homework about the NLC..it is an essential regulatory enhancement needed to bring nursing regulation into the 21st century.

Let’s see; another hysterical article about a few bad apples.  There are several hundred thousand nurses in the US.  Most are hard working and dedicated.  But due to the implications of this article, you get comments by people like Laurel Jackson who will now never leave a loved one alone in a hospital or a doctor’s office?  Crimony. Kudos to USA today for further eroding what trust is left in nursing.  Now, as an aside, let’s talk about the verbal and sometimes physical abuse heaped upon nurses by patients and family members.  I have been a nurse for 35 years and simply cannot wait to retire and get out of this thankless profession.  I am not a waitress and NO I cannot move your 400# mother by myself.  Nurses are injured daily on the job because of the increased acutiy and obesity of patients today.  Thanks to all of you jerks out there for driving so many of us away from the profession.  Even new nurses are leaving in droves…gosh; wonder why?

Anyone want to do a report on bad doctors stealing drugs, or prescribing them to people who don’t need them for part of the profits (or pills?). No, didn’t think so, let’s attack the nurses instead. Know one ED doc who when he wasn’t screwing anything he could in the break room, got in trouble three times for Demerol abuse. Guess who is still an ED doc? And don’t think that is the only “bad apples” doc story I could tell you…

That double standard (by the public, by the health care facilities and regulatory organizations) churns my stomach.

Yes, nursing regulation needs to be a more federal issue than a state one, in other words, the “compact state” direction is a good one in that it does that somewhat. But it does need the kinks ironed out, without a doubt. But this fearmongering is unacceptable to me. Shame on the Authors and pro-Publica for not better considering this piece.

Please James RN lets not suggest that the Federal Gov’t be tasked to regulate Nurses. The Fed Gov’t with all its agencies is broken. Individual States would do a better job.

Now, I agree there are bad Doctors and yes there exist questionable Nurses. I would not want to be a Nurse since Doctors require too much from them and so do patients (read demanding).

Having recently been in a hospital for ten days I was most appreciative of the Nurses I had as overworked as they were, they watched me like a Hawk.

I am glad that I was lucky and received the best from these professionals.

pgillenw:

If states did that good a job at it, then we wouldn’t see some of the issues mentioned in this article. Different boards work and monitor different issues differently. In Kentucky, no focus is held on safe Nurse/patient ratios, or on Nursing administrators who willfully place nurses and patients in very risky situations, often to detrimental effects for both. State agencies are more easily influenced too it seems, for example also in Kentucky, groups have asked the federal government to take over our EPA water regulations. The state agency hasn’t been enforcing it, and the pollution in our streams recently found that every stream tested in our region was heavily polluted with mining byproducts.

And I respectfully disagree with the notion that “The Fed. Gov’t with all its agencies is broken”.

It is appalling the power a few bad nurses have in to shaping & forming the opinions of many of what we nurses are.  Thanks to these few bad apples who with the help of the media,  healthcare industry colleagues, the government,  our various professional nursing organizations and the public at large   believe that nurses are drug addicts, molesters, murderers and thieves, sluggards-on-the-job.  We are seen as preying on the most vulnerable and that through compact licensure, it widened our hunting grounds.  We are to be feared and not to be trusted.  Well, with that mentality,  we need to turn back the hands of time.  Let’s us return to the days when it was family members who cared for their sick or injured or aged family members.  No more nurses!!!  It won’t happen.  Can anyone fathom?  There are several hundreds of MILLIONS of people in this country alone cared for by a much smaller few hundred THOUDAND nurses.!!!  Try to wrap your brain around that.  Now what is the nurse-to-patient ratio?  There are the very few numbers of individuals who are caring for a sick or rehabbing or aged or terminal family member or friend but even there, there is a nurse lurking behind the scenes.  Most cannot do what we do.  They cannot handle cleaning up human excrement day in and day out, bathing, positioning, feeding, administering meds either orally, thru feeding tube, etc., transferring from bed to chair (and back), to a vehicle for physician appointments, etc., exercises of the limbs,  airway hygiene,  the physically grueling tasks coupled by the mental and emotional fatigue.  They cannot do what we do.  No more sleeping in (in fact, little sleep due to cries out due to basic needs or restlessness/confusion/dementia/pain & cries), no more vacations, no more dinners out, no more freely coming and going even on a whim.  There will be back-breaking lifting, pushing, pulling, carrying and holding as our population is not only living longer, but is also much, much heavier.  They cannot do what we do.
Nursing really is a thankless profession.  Whether it be myself or sadly seeing it happen to other nurses, we have been subjected to being cursed at, spit on, waste thrown at us, hit, kicked, pushed, slapped, pinched, things thrown at us, shot, raped, stalked, robbed, accused falsely, you name it.  All at the hands of either patients themselves or their family members/friends.  All the while as Hospital Administrators turning a deaf ear or just plain turning away or worse get, putting the blame on the nurse as they protect themselves and the bottom dollar.  “Nurses are a nickel a dozen.” 
But nearly 35 years ago, I didn’t become a nurse for the “thank yous.”    I wanted to help others. I wanted to help alleviate pain and suffering.  I wanted to learn how to better care for myself so I could teach others how to care for themselves and their loved ones.  I just wanted to care.  Though I rarely ever hear a thank you,  it is enough for me to know that what I have contributed through my nursing care has helped many smile another day,  walk another day,  play another day,  sing another song,  wake up another day,  another chance to live longer, fuller, happy, healthier lives.
While ProPublica and other rags like that spew their poison of the evil, villainous nurses out there, I will be proud that I am part of a group of people who practice the art of caring, healing and nurturing.  I will not allow a few bad nurses steal our light, they will not steal our thunder.  Those who entrust their loved ones into my care need not fear me.  Go home and rest easy.  They cannot do what I CAN do, what WE do.

My wife who is an RN in Arkansas went to court over a bad check, and the case was thrown out because the check had already been paid and prosecuted by mistake.

Just going to court over it got a nasty letter from the board of Nursing threatening the revocation of her license - yet this article makes the industry seem so lenient…  I don’t get it.

This story is typical half hearted jounalism.  As a nurse recruiter I deal with out of state nurses with Compact Licences constantly.  There is no excuse NONE ZERO excuse for hiring someone with a black mark on their record.  Every single one of these states has a way to look up the licence online in a matter of seconds for any HR or Staffing agency to see.  To me this is more about unethical Travel agency’s that are willing to send any nurse out and never do a proper vetting that they promise they are doing

http://www.eglencekeyfi.com

Aug. 11, 2010, 5:03 p.m.

thank you

This article is part of an ongoing investigation:
When Caregivers Harm

When Caregivers Harm: America's Unwatched Nurses

California has failed to protect patients from nurses who are incompetent and dangerous.

The Story So Far

In California, nurses accused of serious wrongdoing have often been left free to practice for years while their cases were being investigated—with patients unaware of the danger.

The board that oversees the state’s registered nurses has taken more than three years, on average, to discipline nurses with histories of drug abuse, negligence, incompetence and violence.

More »

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