Journalism in the Public Interest

More Nurses Fallout: Head of Investigations Unit Resigns

 The head of investigations for California’s Department of Consumer Affairs has resigned, continuing the fallout from our investigation into lengthy delays in disciplining nurses accused of egregious misconduct.

According to a spokeswoman for the California State and Consumer Service Agency, the decision by Lynda Swenson to quit was tied to revelations by The Los Angeles Times and ProPublica about problems at the Board of Registered Nursing. Most investigations of errant nurses are handled by the Division of Investigation, which Swenson headed.

Our investigation detailed how the nursing board takes an average of three years and five months to investigate and close complaints. The biggest bottleneck occurs at the investigation stage, where the nursing board shares a pool of fewer than 40 investigators with up to 25 other licensing boards and bureaus. Meanwhile, nurses with criminal records and documented histories of incompetence and drug abuse continue to practice.

After our article was published, Gov. Arnold Schwarzenegger replaced four members of the nursing board and filled two vacancies on the nine-seat board. Two holdover members remain and one position remains vacant. Longtime executive officer Ruth Ann Terry resigned Tuesday.

Yes, the governor responded quickly to the pro publica report, but he replaced a more diverse board with an all-white board (see:  This does not reflect the diverse make up of California’s nursing community, nor does it actually address the problem. 

The governor fired his own appointees, replacing them with more of the same.  He’d known about the issue for years, yet cut the investigative budget and left vacant two of the board’s seats.  The former Director, Ruth Ann Terry, contends the process, not the people, are the problem, but we’ll never know because the governor did not order an investigation, he just did the media-happy thing of firing some figure heads, Hollywood-style, without actually looking into the situation. 

And to top it off, an all-white board to represent a profession where latino and filipino nurses make up nearly half of all California nurses?  Come on.  What, exactly, has pro publica’s hard work accomplished?


July 17, 2009, 4:25 p.m.

Mr or Mrs NotSoSure.
I ´ve read your comment and I felt a strong necessity to respond to your concerns about the issue. First of all it could be interesting if we separe apples of peaches,just to put things on the accurate side.You asked : what has ProPublica´s hard work accomplished?.(Charles Ornstein investigative reporter´s investigation).Allow me to respond: Pro Publica´s hard work accomplished a constitutional duty how it is the act of reporting ,(good or bad news,single or complicated issues) and in the case of the nurse´s board (as well as in the medical board,everybody knows) nothing more accurated with the existing facts than Ornstein´s work. Same pattern of handling cases,same way to dismiss almost every valid complaint,same pattern to waste years and years to finnaly post set phrases on final reports,avoiding to disciplinate people supossedly skilled to take care of human beings. Only malfeasance,only misfeasance and nonfeasance to accomplish lawfully with their duties. Meanwhile,health care quality in California sinked in a deep black hole.Meanwhile,innocent people,patients, is widely harmed and killed, due to irresponsibles and unskilled professionals.I don´t want to generalize.obviously there are numerous skilled,merciful and decent nurses and doctors (black and white people of course…just in case) But,the existing weakness of the enforcement agencies which duties are the close control and disciplination of healthcaregivers,(including facilities, doctors and nurses of course )allowed and increased the wide number of wrongdoers still on practice geopardizing the life of patients,human beings.Ornstein´s investigative report,deserves a respectful,polite recognition because,there´s no doubt: that represents the voice of the “silent majority” That´s all. By the way, I´m notsosure about your concerns with the possibility of some kind of racism under governor´s actions .However,it has nothing to do with Pro Publica´s excellent report.I know of what I´m talking about, far.Believe me: something smell nasty on said boards and Ornstein´s report will hellp to improve moving changes.I´m sure that you´ll agree with me,but,I am a liberal and lawful man, so you can disagree with me. That´s freedom,freedom of speech.
I am absolutely sure about that.
With the due respect to your opinion

Roberto Alejandro Glaubach, the father of Veronica Glaubach,killed at the young age of 28 years at the Huntington Memorial Hospital(Pasadena) due to the aw..full ignorance and negligence of some caregivers (nurses and doctors).

Mr. Glaubach,

First, let me say that I am sincerely sorry for your loss.  I completely agree with you that something must be done. 

In fact, my contention is that Pro Publica has done an excellent job shining light upon the issue of BRN oversight and investigatory delays.  The problem is that the governor has replaced board members rather than assign a committee to investigate whether or not it was the board members or the bureaucracy that was at fault.  Schwarzenegger fired his own appointees and replaced them with more of his appointees.  What did that accomplish?  Where is the investigation?  Who is to blame?  What is the truth? 

As Pro Publica points out, the board relied upon a shared pool of less than 40 investigators, who work for 25 boards.  Isn’t it possible that the under-funded and under-staffed investigation unit is the reason for the delay more than the board members?  Pro Publica thinks so, yet the governor, by showboating with the “Hollywood-style, heads will roll,” press conference, left the false impression that he’s done something, that the problem’s been addressed. 

I don’t think it has.  I think Pro Publica should be asking the administration, “where’s the investigation into Ruth Ann Terry’s claims?”


July 20, 2009, 5:25 p.m.

Mr/Mrs notosure
I have to agree with you,but ,I wonder , it´s possible to give the governor just a little while,and see..?.maybe he is already taking actions to head and accomplish a full investigation into Mrs Ruth´s performances.This issue is just starting,and I believe it´s quite early to figure out the end of this story.Maybe I´ve misunderstood your previous message.
Roberto Alejandro Glaubach, Veronica´s father.

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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