Editor Note: The following story ties in with an upcoming article we have in August JEMS about Calif. Assembly Bill 2917, which requires the California Emergency Medical Services Authority to develop statewide standards for EMTs.
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 narcotics 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," says 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 the non-profit news organization 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," says 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 says.
Joey Ridenour, chairwoman of the compact's national board, says she believes the compact has promoted more and faster communication among states. She also says the number of compact nurses disciplined outside 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 acknowledges that the pact is only as good as the performance of its individual members. If a state has been historically lax, she says, joining the compact will not change that.
"I am very careful to say that this is not a cure-all," says 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
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 after 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 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 a hospital in Amarillo, Texas, 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, says 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 says.
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 says he is now sober and has 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 says, then adds 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 non-participating 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 say, 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, do 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, 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 had 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 on charges of 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. Neither Rice nor her attorney returned calls or e-mails.
Shelley Walker, a spokeswoman for the Tennessee Department of Health, defends the process in Rice's case. Three states took action against her within eight months of each other, she says.
Walker and other compact officials note 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 hospital in Glendale, Ariz., in December 2007 while at a hospital in Weston, Wis., and in June 2008 at a hospital in Greenville, N.C.
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, says that even the best communication can't stop nurses when they are intent on manipulating the system. But she says 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, says the various boards' obligations to give her due process allowed her to keep moving.
"Until an investigation is closed," she says, "it's not going to look like there's anything going on.