Lax government oversight and a shoddy system of reporting medical errors allow negligent, incompetent and impaired registered nurses to return to work in Illinois even after committing deadly errors. In Chicago, registered nurses have injected themselves with heroin and cocaine, then committed dozens of errors. They have stolen prescribed medications, then left patients to suffer in pain for hours.
They have been convicted of felony crimes, from child molesting to drug trafficking. They have injured through neglect and killed through inattention.
And in each of these cases, they continued working even after they were caught and, in many cases, after signing admissions of wrongdoing.
Registered nurses are the primary guardians of hospital care. It is their job to monitor patients, detect sudden declines in condition and call for help in emergencies. Nurses across the country save countless lives every year, and the vast majority never face disciplinary action.
But because they work with more patients for longer periods of time and because they are vulnerable to inadequate staffing, nurses make the majority of the nation’s medical errors, state and federal healthcare records show.
As Congress this year considers proposals to combat a rising toll of medical errors, one of the hidden components of this issue is the role of states in licensing and disciplining of registered nurses, the nation’s largest healthcare profession.
Illinois is one of 37 states that do not require healthcare facilities to report cases of nurse misconduct, even if injury and death occur. In a majority of states, licensing agencies embrace a second-chance philosophy based on a belief that registered nurses are a treasured resource to be saved no matter the risk.
“Just because you rob a bank doesn’t mean you can’t be a good nurse,” said Leonard Sherman, director of the Illinois Department of Professional Regulation, which oversees nurse licensing and disciplinary cases.
Each year, more Illinois nurses lose their licenses for failure to repay a student loan than any other violation, from drug or alcohol impairment on the job to felony crime convictions.
The Tribune’s examination of Illinois DPR records found the agency exhibits a pattern of leniency toward problem nurses and lacks the resources to determine which nurses pose a potential danger. Among the findings:
Investigators for the understaffed DPR sometimes close cases without examining medical records and even without determining if patients were harmed. Registered nurses number about 110,000, but there are only six DPR inspectors assigned to nursing; most, but not all, have law enforcement backgrounds.
In at least 43 cases in the last six years, DPR did not refer nurses suspected by hospital administrators of committing felonies to the state’s attorney office for investigation or possible prosecution. Cases ranged from a nurse who forged more than 50 prescriptions at Chicago-area pharmacies to a nurse who stole controlled substances for more than a year at a suburban Chicago hospital, according to state investigative reports.
Nurses aren’t disciplined or even investigated when settled lawsuits raise issues of negligence. The Tribune examined 32 lawsuits filed in Illinois courts that incorporated substantial evidence that inattentive, impaired or incompetent nurses played a primary role in the death or injury of a patient. None of those nurses has been disciplined, nor is there evidence that any state investigation was conducted.
Of the 924 case files on nurses closed since 1995, three of every four have been stripped of the most basic information, such as where the violation occurred, the specific nature of the violation or if patient harm occurred.
DPR’s system for identifying problem nurses relies on the cooperation of hospitals, but state law requires hospitals to notify regulatory authorities only if a nurse is fired, not if the incident is handled in house or if the nurse resigns. DPR officials search media reports statewide to find possible cases.
State licensing laws were established decades ago to regulate professions and safeguard the public, and the system in Illinois now includes 60 professions, from alarm contractors to social workers.
But across the country standards are routinely twisted, sometimes secretly, to protect unsafe and unqualified nurses, a Tribune analysis of disciplinary actions nationally found.
As a result, dozens of states have become havens where problem nurses can move job-to-job without discovery, where crimes are committed with impunity, where even the deaths of patients have been withheld from public records.
In Wisconsin, a registered nurse twice convicted in the early and mid-1990s for stealing patients’ cash and jewelry kept her license this year despite testing positive for cocaine.
In Utah this year, a registered nurse whose record-keeping errors led to the fatal overdose of an elderly patient continued to work without benefit of training after agreeing to pay a $1,000 fine.
In Washington, a registered nurse fired from three jobs in three years because of incompetence retained her license last year even after she committed a medication error that critically injured a patient.
Lacking manpower and funding, hobbled by dual roles of fostering and policing professions, most states conduct superficial investigations and mete out token punishment, an analysis of state records shows.
“If there is any chance of all, state licensing boards will always lean towards remediation. A nurse is a valuable resource,” said Vicki Sheets, director of policy and credentialing for the National Boards of Nursing.
The need for thorough, balanced and consistent disciplinary action has never been greater as more nurses travel across state borders, holding licenses simultaneously in up to a dozen states, Sheets said. About 10 percent of registered nurses licensed to practice in Illinois live in other states, state licensing records show.
Here, as in most states, complaints involving nurses are first reviewed by a team of investigators. The Illinois DPR forwards its investigative findings to the state Nursing Board.
The board and a DPR lawyer contact the nurse under investigation to determine if he or she will seek an administrative hearing, which is public, or agree to a settlement conference, which occurs behind closed doors.
DPR director Sherman reviews settlements. He has final authority to issue discipline ranging from a written reprimand to indefinite suspension.
On April 30 this year, Sherman sat at his desk in the Springfield office of DPR and scrawled his signature across a dozen disciplinary cases.
In the stack was the four-page file of Mary Jo Wisniewski, an Evanston registered nurse accused of committing a medication error. She had already signed an agreement to accept a 30-day suspension.
Sherman, who was appointed to the post by Gov. George Ryan in January 1999, said he quickly read through the pages, then signed his approval, closing the case.
Because Wisniewski had settled without a full-blown hearing, grateful board members–who press hard for consent agreements–agreed to purge embarrassing details from Wisniewski’s public file, internal state records show.
What the public never was supposed to find out, and what Sherman didn’t know, was that the patient involved in the case died.
Evelyn Cohen, 82, received an overdose of nearly five times the prescribed dosage of a chemotherapy drug from Wisniewski, who is accused of miscalculating the dose, at Highland Park Hospital in 1998, where the nurse was employed by a private physician group leasing space from the hospital, according to a lawsuit filed at Cook County Circuit Court (this paragraph as published has been corrected in this text).
Despite her age, Cohen had been expected to survive the cancer and was in the advanced stage of treatment, according to medical records filed with the suit.
Sherman said his department routinely agrees to withhold vital details, such as a patient’s death, from disciplinary files as part of a plea bargaining process to expedite cases.
Numerous state-based healthcare advocacy groups–such as the Citizens of Equal Treatment–believe that failure to disclose all the facts not only protects unqualified nurses, but also leaves future employers in the dark about the extent of problems in a nurse’s past.
And, last week, Sherman told the Tribune that he is reconsidering this practice.
“I agree as a rule if there was patient harm, then it should be in public files,” he said. “We really ought to say why a nurse is being disciplined.”
To establish more accountability, Sherman said he plans to create a training program this year to help DPR investigators learn how to better uncover medical records that might establish whether patient harm occurred.
In Wisniewski’s case, however, he said he would not have imposed a harsher decision even if he had been aware of the patient’s death.
Sherman defends his approach to nurse discipline. While it rarely leads to long-term suspensions, he said it offers a “healing approach.”
“I don’t think a nurse should lose a license for making a mistake,” Sherman said.
Second chance for impaired nurses
In 1996, Indiana registered nurse Tammy Neubaum, 29, knew the discovery of her drug thefts and addiction to prescription painkillers at Methodist Hospital in Gary could hobble her career.
She obtained a clean slate just across the border.
Neubaum mailed in her application for an Illinois nursing license with a personal check to cover a $30 filing fee. She didn’t disclose her prior thefts or drug use. Within two months, the state sent her a license.
Her new license stayed unblemished for less than a year.
She landed a job at the 700-bed Northwestern Memorial Hospital, where she stole an undisclosed amount of controlled substances to feed her ongoing addiction.
She later was hired at Hinsdale Hospital, a 462-bed complex in the west suburbs, where she was caught stealing drugs while on duty. Both hospitals reported the incidents to state licensing officials.
Neubaum, who agreed to enroll in a drug rehabilitation program, signed a consent agreement with DPR stipulating that she was a chronic drug user who had been caught stealing drugs at three hospitals and had lied to get her nursing license.
Her signature came only after the state promised she could keep her Illinois license.
In her case file, state officials wrote that the decision was “consistent with the best interests of the people of the State of Illinois.”
Yet, state records show no evidence that the public welfare was ever considered. Investigators, who have subpoena power, did not seek any medical records to determine if Neubaum’s addiction resulted in harm to patients, internal files obtained by the Tribune show.
Neubaum did not respond to numerous messages left at her Indiana home or with other people in her household.
Her case underscores fundamental flaws in the way Illinois safeguards the public interest, as well as highlights a national dilemma over how to balance rehabilitation against punishment.
Carol Caponirgo, director of Hinsdale Hospital’s New Day Center, a treatment center for nurses, said nurses should not lose their license because of impairment problems if they agree to seek treatment.
“Addiction is a disease,” she said. “Would we discriminate against someone who has cancer? No we wouldn’t.”
Most states impose an investigative checklist used to grade the severity of impairments. In Alabama, for instance, disciplinary action is balanced by whether a nurse stole drugs from a patient or took excess medication.
But Illinois has no grading system. With rare exception, nurses judged to be impaired are placed on probation the first time they’re caught–no matter the circumstances, state records show.
For example, a licensed practical nurse–whose known drug addictions had raged for 15 years–was allowed to roam from job to job throughout Illinois. State officials investigated Judith Perry six times over nearly two decades, invoking only mild disciplinary action each time.
The only person, though, who apparently thought that Perry shouldn’t be entrusted with patient care was Perry herself.
She requested that her license be terminated on May 20, 1998.
“I am writing to you to please retire my nursing license,” wrote Perry, 62, of Bloomington in central Illinois. “I am paying dearly for my drug addiction … I have one thing to ask: when you deal with more people like me, please, please send them to AA (Alcoholics Anonymous) and/or NA (Narcotics Anonymous).”
Perry declined to comment about her letter or battle with drugs. State files show that as far back as 1993 Perry had refused to submit to random drug screenings and show proof that she was attending rehabilitation sessions, as required by a previous consent agreement signed by Perry and state officials.
Yet, by 1998 the state had yet to revoke her license.
Impaired nurses ranks as the most prevalent disciplinary issue in all but a handful of states. In Illinois, substance abuse is second to defaults by student loans.
Illinois does significantly differ from most states, however, in the way it handles complaints of impaired nurses.
Nurses in 35 states can voluntarily enroll in rehabilitation programs without fear of formal disciplinary measures marring their professional record. Such programs have encouraged more nurses to get desperately needed help, program officials from six states said.
Illinois does not have this treatment option. Instead it immediately initiates proceedings upon learning of a case involving nurse impairment. The state’s system drives more nurses to hide their problems, floating from job to job to avoid discovery, critics say. It also allows a nurse accused of impairment to continue to work up to a year or more while the case is decided.
An Illinois task force of nurses is studying ways to pay for a treatment program, which could be established within a year, said DPR officials who support the initiative.
In all of the 10 largest states except Illinois, nurses accused of being impaired are immediately suspended pending a formal disciplinary hearing. Most states impose temporary suspensions, usually no more than 2 months, so that nurses can focus on treatment.
Illinois’ impaired nurses are seldom suspended, no matter how egregious the accusation. The state allows nurses to immediately return to the workplace–sometimes before treatment has begun.
The result, sometimes, has hurt patient care, state disciplinary files show. Those records outline cases in which patients’ pain medications were stolen or instances in which patients were denied prompt treatment because impaired nurses failed to perform their duties.
In June of 1994, state investigators charged registered nurse Vicki Wilson with “diverting” pain medications from her job at a central Illinois hospital.
Wilson appeared at disciplinary hearing held in Chicago and admitted to stealing drugs. Denying any addiction, she said the medications were used to alleviate her chronic back pain, state records show.
DPR placed her on 2 years’ probation. Rehabilitation was not mandated because state investigators concurred that a drug problem did not exist.
State officials picked up Wilson’s trail two years later. On May 16, 1996, Wilson is believed to have stolen drugs from at least three patients while working at the Park Avenue Nursing Center in Herrin, Ill. To cover the thefts, she forged medical records to make it appear patients had received the pain medications, Percodan and Vicodin, state records show.
The nursing home fired Wilson and reported the incidents to DPR. But the investigation languished 10 months without action.
Meanwhile, Wilson began working in January 1997 at Pinckneyville Community Hospital, also in central Illinois, state investigators later learned.
On Jan. 6, 1997, Wilson showed up to work with a bloody nose and was abnormally drowsy during her shift, hospital and state records show.
Hospital officials, suspicious that Wilson was stealing medications, found traces of Meperidine, a sedative, after ordering Wilson to submit to a blood test.
While not formally acknowledging an addiction, Wilson signed a “work agreement” contract with the hospital agreeing that she would not seek access to medication and that she would submit to random drug-screening tests.
Hospital findings that Wilson had stolen and consumed medications were not reported to DPR.
On Feb. 10 that year, Wilson once again appeared to be severely drowsy and nauseated and she exhibited slurred speech, hospital records show. A month later, she reported to work drowsy, nauseated, exhibiting slurred speech and had a “staggering gait” on her way to patients’ rooms, hospital records show.
More than a year after the allegation of nursing home drug thefts, DPR filed formal charges against Wilson. But she kept working at the hospital.
Once again, on May 14, Wilson reported to work drowsy, exhibiting classic signs of impairment. About three weeks later, the hospital ordered Wilson to take another blood test. This time she tested positive for codeine, a pain medication, state records show.
It took until May 1999 for DPR to finalize the nursing home case and order an indefinite suspension. On Jan. 7 of this year, DPR took action for the hospital incidents, restating that Wilson was suspended.
However, the state left the door open for her return. The suspension can be lifted after five years, and Wilson can reapply for a license if she “has been sufficiently rehabilitated to warrant the public’s trust,” state records show.
Officials from the Illinois Nurses Association, the state’s largest nurses union, said that returning bad nurses to work without ensuring proper training or treatment undermines the credibility of all nurses.
Registered nurse Marlene Winter, a leading substance-abuse counselor and founder of an Illinois program for impaired nurses, said, “There are definitely some nurses who shouldn’t be nurses.”
However, the majority of impaired nurses can be treated and have successfully returned to nursing with the stipulation that their disease will require a lifetime of vigilance and maintenance.
“Everyone deserves to be salvaged,” she said.
Winter, a recovering alcoholic who has been sober for 28 years, is a substance-abuse counselor at Hinsdale Hospital’s treatment program. In 1983, she founded the Peer Assistance Network for Nurses in Illinois.
Endorsing a disciplinary practice found in dozens of states, Winter said she believes impaired nurses would benefit from a short suspension so that their attention could be focused on rehabilitation.
“Part of the healing process is having your license suspended,” she said.
A death goes unnoticed
The state’s inability to police bad or impaired nurses not only can be seen in the way cases languish, but in the cases that are missed–even when there is a patient death attributed to nursing.
Vincent Gargano died after three nurses accidentally administered medication overdoses. But this mistake never resulted in any disciplinary action by state officials.
Obscured beneath a mass of tubes and machines at the University of Chicago Hospitals, Gargano hoarsely whispered his final words before a video camera.
The 41-year-old Des Plaines father knew he was dying. On June 9, 1995, with his attorney Howard Schaffner and video camera by his bedside, Gargano agreed to preserve a final statement for his family and anyone else who might wonder what had happened.
“What is your name?” his lawyer asked.
“What day is it?”
“Do you know where you are?”
Despite his outward appearance, his face bloated and his body soaked in sweat, Gargano proved he was of sound mind with short, simple answers.
Two weeks earlier, the dark-haired, gregarious father of three children entered the hospital to receive his last chemotherapy treatment for testicular cancer. The survival rate for the cancer was 95 percent. In his case, it was nearly certain, doctors said.
“Do you know what happened?”
The postal worker who had an uncanny recall for sports statistics struggled to speak before the camera. He took a deep breath, his eyes glassy but focused, his face twisting in pain as he slowly named his killer.
“Overdose,” he said.
For four consecutive days from May 26, 1995, three registered nurses administered four times the correct dosage of chemotherapy, hospital records show.
Cisplatin is a common cancer-fighting drug, destroying parts of the body before it can do its job.
By the time the error was discovered on the fifth day, too much of the potent drug had tainted too many cells. He would die slowly, but within weeks.
Hospital records show that the overdose originated with a doctor who wrote the correct medication amount on one record, but the incorrect amount in another file. The pharmacy relied on the incorrect record when filling the prescription, which was delivered by the nurses.
Under a standard of care endorsed by all hospitals, the three nurses were supposed to double-check the prescription against the doctor’s original order, which had the correct dosage.
The nurses’ failure to check the original order, or to recognize that dosages were abnormally high, underscores the daily, indispensable role placed on nurses to serve as a final, error-free checkpoint.
A fourth nurse newly assigned to Gargano’s care on the fifth day sounded the alarm when recognizing the danger of the medication amount.
Although the hospital settled the case last year for $7.9 million after instituting numerous internal changes, none of the nurses or any other healthcare professional has been disciplined by the state Department of Professional Regulation.
Larry Volkmar, vice president and chief nursing officer for the University of Chicago Hospitals, said state regulators were notified of Gargano’s death. He is positive because he was a member of the state nursing board, which helps the state resolve disciplinary cases. To avoid conflicts of interest, Volkmar said he did not participate in the probe.
Tony Sanders, spokesman for the department of regulation, said the agency cannot comment on specifics of that investigation other than to confirm that no charges were filed. For Vito Gargano, 72, the death of his son remains unresolved.
He and his wife make daily treks to the cemetery. “He’s my son,” he explained. “By not going to the cemetery, it means we’re separated. And by going there it means I can talk to him and it means somewhere I’m still connected to him.”
The Gargano family has never received a full explanation of what happened–and why.
“The state has never contacted anyone in the family. They’ve never asked for our eyewitness accounts. They’ve never asked for our medical records,” he said.
“It’s unbelievable to me that the state hasn’t taken action. Something must be done to make everyone accountable. Who’s making these decisions?”
DISCIPLINING NURSES IN ILLINOIS: NOT A SIMPLE PROCESS
The Department of Professional Regulation is the state agency responsible for overseeing nursing and 59 other professions in Illinois. It investigates allegations against nurses who are accused of everything from making fatal medical mistakes to working under the influence of drugs. Nurses, however, often are able to avoid accountability.
Steps to disciplining a nurse–and how a nurse can circumvent it
It can take a year or longer to settle an allegation made against a nurse, who is allowed to keep working during that time.
AN INCIDENT OCCURS
Even if a patient is killed or seriously injured, hospitals in Illinois (and 36 other states) are not required to report a nurse’s error.
Since reporting is not required, the incident may never come to light in the first place, and the nurse’s actions are not investigated.
ALLEGATION IS REPORTED TO DPR
DPR can be alerted by the hospital, an employee, the public or anonymously. Sometimes it learns about misconduct allegations through media reports.
DPR INVESTIGATES
Illinois has only six investigators assigned to all of the nursing cases in the state. It can take three months for an investigation to end. (If DPR finds no merit in the allegation, the case is closed with no mark on the nurse’s record.)
A nurse can resign his or her license during the investigation. The state often drops the case then. The nurse can reapply for a license in another state.
IF DPR FINDS ALLEGATION HAS MERIT
The agency files a complaint against the nurse. A DPR lawyer and the state Board of Nursing then order an informal meeting with him or her. DPR and the board push the nurse to sign a consent agreement, in which he or she agrees to the charges without a formal hearing. If the nurse declines, a formal hearing is scheduled.
CONSENT AGREEMENT
A nurse has the upper hand in negotiating a consent agreement with DPR. The state often agrees to withhold damaging details from the nurse’s record –for example, that a nurse’s error led to a patients death–in exchange for a quick agreement.
FORMAL HEARING
The agency presents its case against the nurse (who may have a lawyer) to a state administrative law judge. The judge issues an opinion.
CONSENT AGREEMENT OR OPINION IS REVIEWED
The 10-member Illinois Board of Nursing makes a recommendation for discipline–if any–which could include a reprimand, probation, or indefinite suspension. It is a subjective process with no established guidelines.
DIRECTOR OF DPR MAKES FINAL APPROVAL
The governor-appointed director can affirm or overrule the board’s recommendation (the director usually agrees). If a consent agreement was reached, the director sees only that–not the nurse’s whole file–which means that some of the evidence against a nurse could be overlooked.
Source: Illinois Department of Professional Regulation
Chicago Tribune
