Keeping problems out of sight
Georgia is one of a dozen states that do not require hospitals and health professionals to report to the state when a nurse has a substance abuse problem or makes medical errors endangering patients. That means hospitals or nursing homes can quietly fire a bad nurse and save the embarrassment or liability of reporting the nurse to the state for discipline.
The General Assembly this year passed a bill that contained a “mandatory reporting” provision, a measure that was supported by both the Georgia Board of Nursing and the state nurses association. The bill stipulated, however, that mandatory reporting would not go into effect unless the nursing board received additional funding to handle the anticipated increase in reports. The bill passed, but not the funding increase.
“That was the only way we could get it into law,” said Rep. Sharon Cooper, R-Marietta, who sponsored the bill. “We felt it was better for the law to go into the books.”
On April 18, 2007, a patient at an addiction and behavioral health clinic in Valdosta died after a nurse neglected to check on him for five hours, instead of every 30 minutes as required. Five years later, the Georgia Board of Nursing ordered the nurse to take remedial coursework and issued a public reprimand.
On Sept. 22, 2009, two nurses at an Atlanta rehabilitation center found a patient unresponsive, consulted his chart and read that the patient had a “do not resuscitate” order. But the nurses had grabbed the wrong chart. The patient, who had no such order, died.
The board again acted with reprimands and additional training — nearly three years later. In all these cases, after taking years to act, the board declared the nurses’ licenses free of conditions within a few months and wished all of them “continued success in your professional nursing career.”
The complaints lodged with the state nursing board read like horror stories for anyone afraid of needles. Scarier still are the dates stamped on them.
A review of more than 100 public orders for 2012 and 2013 found the board takes an average of 15 months to decide a complaint against a nurse. Currently there is a backlog of hundreds, perhaps thousands of complaints against nurses around the state. Board officials cannot come up with an accurate number.
Officially the board has 3,340 open cases. Poor record-keeping makes it hard to home in on what that number means, but it does include 434 nurses on continuing probation.
The board does not deny the problem. In fact, board president Barry Cranfill is pretty hot about it. Cranfill, a nurse himself, said the board regularly takes upward of two years to process a complaint and issue a ruling.
“All the while that nurse is continuing to practice at the bedside of your loved one and mine,” he said.
‘How can you put people at risk?’
In November 2010 nurse anesthetist Phil Barber reported to the nursing board that he had been taking propofol — the powerful and addictive sedative-hypnotic that figured in the death of Michael Jackson.
In addition to nursing, Barber had been a devoted youth soccer coach. Before they divorced, he and his wife, Marian, had four sons together, and they remained on friendly terms because of the boys. That same November of 2010, Marian learned that her ex-husband had been struggling with addiction for almost two years.
When he finally did self-report his drug use, the nursing board waited weeks while Barber continued treating patients, she said.
“I had his license number and I kept trying to see if it was documented (on the state’s website) that he self-reported,” Marian Barber said. “People may not care that he was a drug addict, but what about the general public? How can you put people at risk?”
State law does not require hospitals, clinics and other health care providers to report nurses who commit treatment errors or abuse drugs on the job. This makes it possible for a nurse who is fired because of a drug addiction to move on to another job without disclosing his or her problem. According to Marian Barber, this is what her ex-husband did, bouncing from job to job as hospitals and private surgical practices quietly dismissed him rather than report him.
Cranfill, who is familiar with Barber’s case, said the board could do little because none of Barber’s previous employers had ever turned him in.
Barber was lined up to go into rehab, records show, but he never showed up for the treatment. At the age of 50, he died of an overdose four days after Christmas 2010. He is survived by his sons.
Marian Barber said her ex-husband was a good man with a problem, and no one stepped in to help him. He might still be alive if his employers had been required to report his drug use, Cranfill said.
3,340 cases? ‘They never told me that’
The nursing board raises about $4 million a year in licensing fees from the nearly 150,000 registered and licensed practical nurses in the state, but it only gets half of that money back from the General Assembly. The rest is used to plug gaps elsewhere in the state budget.
Rep. Sharon Cooper, a Marietta Republican who is also a nurse, said she is concerned about the nursing board’s funding and its case backlog, but even she was caught off guard by the scope of the problem.
“They never told me that or testified to that,” she said of the 3,340-case official count.
Cranfill, who was appointed in 2010, said his board has streamlined the process; for example, it enabled staff members to handle less complex cases without board approval. But the low-hanging fruit is gone, he said.
Secretary of State Brian Kemp acknowledged that funding is a chronic problem: since 2008, the budget for the Professional Licensing Boards Division has decreased 25 percent and staff has been cut by a third. The division includes the nursing board but also boards for barbers, accountants, private detectives and a host of other professions.
“I am very sympathetic to the situation that the nursing board and all the professional licensing boards find themselves in,” Kemp said. “Due to a lack of resources, licensure and enforcement simply takes too long.”
The Georgia Nurses Association pressed for more funding this past legislative session. Short of that, the association suggested that license fees could be cut in half to equal the money allotted to the board.
“The only reason you have licenses is to protect the public, and the collection of those fees is supposed to be budget-neutral,” said Debbie Hackman, CEO of the nurses association.
In North Carolina, a quick resolution
Cranfill endorses the idea of cutting fees as a kind of protest, pointing to a state law that says a licensing board may only charge fees equal to its total budget. But the real solution is greater resources, he said.
“If they would just give us what we are supposed to get, we could do what we’re supposed to do,” he said.
There’s no reason it has to be this way.
The North Carolina Board of Nursing regulates about the same number of nurses as the Georgia board, but it processes complaints in a fraction of the time. It takes an average of 45 days to resolve malpractice complaints and little more than four months to settle drug cases, said Kathy Chastain, associate director for regulation and quality for the board.
“That’s receiving the complaint, the investigation and the decision of the individual to enter into an agreement with the board,” she said.
The North Carolina board can do this because it is semi-autonomous and retains 100 percent of licensing fees, giving it a $7.3 million budget and a staff of 50. Georgia’s nursing board has a dedicated staff of eight.
The North Carolina board has an investigative staff of eight, five of whom are registered nurses, while the Georgia board shares investigators with the other licensing boards. Cranfill said he regularly loses his investigators during election years as the Secretary of State’s office deals with ballot investigations.
‘We can’t do anything about it’
The Georgia board’s slow pace has consequences.
While some of the cases before the board involve malpractice or licensing questions, commonly they are tales of drunk and drug-addicted nurses, some facing felony charges, others risking their careers and health by stealing patients’ pain meds to feed their habits. A complaint against such a nurse might reach the board six months after it is filed, even if the problem was reported by the nurse himself.
And that’s when the system is working. Such cases can take years because there aren’t enough investigators to handle all the complaints, Cranfill said.
“You know these people are at the bedside and we can’t do anything about it,” he said. “I don’t want it to sound like Georgia is full of Nurse Jackies, but if there is one bad nurse, we want to deal with it.”
The board received a report in January 2012 that a nurse at Rockdale Medical Center had been fired after she was found asleep at her post and subsequently tested positive for drugs. While that complaint worked its way through the system, the board received complaints about the same nurse allegedly stealing drugs from hospitals in Oconee and Coweta counties. On June 1, the board learned she had applied for a fourth position in DeKalb County when her arrest on drug possession and theft was discovered.
The board suspended her license June 28, a relatively quick resolution. But Hackman, the nurses association CEO, said states surrounding Georgia get these cases cleared much quicker.
The scope of the problem is hidden from taxpayers and consumers by an exemption in the state open records law that shields all of the complaints and many of the board’s orders. That means the public cannot see the backlog of open discipline cases stretching back years. What the public can access is certain “public consent orders” that offer few details on the infraction.
One such case involves a nurse from Newnan that began more than five years ago. In that case, staff at Southern Regional Medical Center in Riverdale noticed the nurse was acting “erratic” while on duty. A drug test came up positive for amphetamines and the hospital fired him.
That was in January 2008, but state records show he has an active license with no disciplinary demerits. That could change soon. The board recently posted a public notice on the case and scheduled a hearing this month.
‘I can’t get an honest answer’
Board members and staffers have a hard time talking about the backlog, mostly because they know so little about it.
The board’s record-keeping software cannot keep track of how many of the cases involve nurses accused of malpractice or being caught using narcotics. It can’t even distinguish between a nurse who might endanger a patient and a nurse with a paperwork problem like an expired license.
Complaints are manually sorted and individually assigned “based on the level of complexity,” said Opie Bowen, board attorney. Some can be handled by staff, while other, more serious claims require the full board’s attention. Bowen said the board cannot say how many cases fall into either category.
Bowen said it is believed that many — maybe even most — of the 3,340 cases marked in the system as open are closed but they have not been marked as such. Going back and cleaning up the data would be a “tedious” process, Bowen said, and the board doesn’t have the manpower.
As a result, the board does not know the scope of the problem. In reporting the story, the AJC received wildly divergent figures from various sources on the precise number of complaints against nurses waiting for board action.
“I can’t get an honest answer and I’m on the board,” Cranfill said.
Nurses on probation
slip through the cracks
All these thousands of reports are supposedly monitored by the board, but Cranfill said the board has one staff member assigned to the task. As a result, the board can only randomly monitor nurses on probation to see whether they are meeting their requirements.
Because of staffing and software problems, the board cannot even say how many of these probationers are working as nurses or how many came off probation in the past year.
“It is horribly ineffective,” Cranfill said. Nurses who don’t file required progress reports, drop out of treatment or even fall back into addiction may not be detected, he said.
Recently, the board adopted a policy requiring nurses to file a form at the end of their probation certifying that they met the terms of probation and asking that their licenses be fully restored. This is because the board is not likely to know whether the nurse completed her probation satisfactorily.
Last month, the nursing board suffered another setback when many of its staff were reassigned to help process tens of thousands of license renewals for other boards before the start of the new fiscal year July 1. Kemp spokesman Jared Thomas said some 57,250 professional license applications were up for renewal, including some nurses, each of which had to be verified to make sure the licensee is a citizen.
Cranfill said the board is ignored in its pleas for more money then criticized for its poor performance. With no other avenues available, he said he has even begged the Georgia Association of Nurses to sue the state over the withheld license fees.
“I know what my costs are. It’s going to be $4 million,” he said. “We know what we need to run the damn place.”