States Licensing Practices: Neglect and Abuse Falling Through the Cracks

An investigation spurred on by the death of a young boy has revealed a startling issue in the nursing world. In the investigation of the boy’s May 2005 death, state records show that the boy’s nurse had fallen asleep, then ignored — or possibly turned off — ventilator alarms that signaled the boy was not getting enough oxygen.

The boy, investigators learned, was the second child to die under the nurse’s care. Seven months earlier, she had lost her registered nursing license in another state for similar lapses in the death of another boy in 2002. In that case, the 21-month-old patient had stopped breathing while his nurse was caring for him at her home. Instead of calling 911, she tried CPR, then drove the boy's limp body three miles to his parents' house.

This nurse’s case highlights a dangerous gap in the way states regulate nurses: They fail to effectively tell each other what they know. As a result, caregivers with troubled records can cross state lines and work without restriction, an investigation by the nonprofit news organization ProPublica and The Los Angeles Times found.This same issue has been seen with nurses and CNA's in long-term care facilities such as assisted living and nursing homes.

Using public databases and state disciplinary reports, reporters found hundreds of cases in which registered nurses held clear licenses in some states after they'd been sanctioned in others. In one state, a month-long review of its 350,000 active nurses found at least 177 whose licenses had been revoked, surrendered, suspended or denied in another state.

This breakdown in the system can be easily fixed. Yet state regulators aren't using their powers to seek out this information, or act on what they find, the investigation found. By simply typing a nurse's name into a national database, state officials can often find out within seconds whether the nurse has been sanctioned anywhere in the country and why. But many states don't check regularly or at all.

Experts and regulators say the patchwork nature of nursing regulations in the country demonstrates the importance of a complete national database. State regulators should be required not just to submit their licensees, they said, but to routinely check to see if their nurses have been disciplined elsewhere. For more, read the story.

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Robert W. Carter, Jr. is a Virginia attorney whose law practice is dedicated to protecting the rights of the victims of nursing home and assisted living neglect and abuse in Richmond, Roanoke, Norfolk, Lynchburg, Danville, Charlottesville, and across Virginia.