ANNAPOLIS – It takes years for the Maryland Board of Nursing to take disciplinary action against negligent nurses, including four whose actions resulted in patient deaths, according to a study of probation records done by Capital News Service.
Of the 17 cases of nurses now on probation for practice errors that affected patient care, it took an average of 39 months from the time of the incident for the board to discipline the nurse.
CNS selected these 17 probation records, called consent orders, from among 33 cases where the subject’s probation was continuing and 86 active cases, because they dealt with negligent actions by a nurse that resulted in patient problems, including the four deaths.
Until the board was made aware of an incident, conducted an investigation, held a hearing and came to a decision, these nurses continued to possess a valid license to practice nursing.
The Board of Nursing blames the length of time on a lack of investigators. Investigators say they take only the time they need to do the job right. And at least one national expert said many factors could be at work in the delays.
The review of nursing probation records comes at a time when Maryland hospitals are in the midst of “the largest, most severe nursing shortage in more than a decade” according to an August survey by The Association of Maryland Hospitals and Health Systems.
In many of the consent orders, nurses reported stress and overwork as causes for their errors.
In the case of Debra Shantz Liebrecht, she was the only registered nurse for 70 residents at a Kensington assisted-living facility when in September 1994 she gave an elderly woman blood thinners that had been ordered discontinued. She missed signs of the medication error and delayed tests. Yet it took the Board of Nursing nearly 68 months to put her on probation.
In many of the board’s cases, the nurse’s negligence was easily preventable.
For example, Rita Williams was the shift supervisor at the Hebrew Home of Greater Washington in Rockville when, on Sept. 20, 1992, an 84-year-old woman vomited and became unresponsive, according to the consent order. Under Williams’ supervision, life-saving efforts the patient had authorized were suspended and no doctor or ambulance was called.
Williams failed to follow standard nursing practice and nursing home procedure, the board eventually found. Though it was made aware of the incident that same month, the board took four years to put Williams on probation. Blood-thinners figured in another negligence case.
Margaret Quade was a registered staff nurse at Calvert Memorial Hospital in Prince Frederick when she made her second major medication error in 14 months, according to the consent order. She misread the physician’s order and administered four times the amount ordered of blood-thinning drugs, even after the patient questioned her about the amount.
The patient ended up in the intensive care unit. It took the board almost two years to put Quade on probation.
The delay in processing cases is caused by a shortage of investigators, said Donna M. Dorsey, board executive director.
“We ended up having a real backlog of cases,” said Dorsey. “It’s been a terrible problem.”
But one national official was not sure that any one thing could be blamed for the length of the investigations.
“There are so many variables that effect that processing” of cases, said Donna Nowakowski, National Council of State Boards of Nursing associate executive director, that it’s hard to say what too long a time is for an investigation.
Nowakowski said finding witnesses, finding nurses, the nature and complexity of the cases, all figure into the time of the investigation.
“I want to make sure I have everything there. I’ll either prove that you did it or I’ll prove that you didn’t do it,” said Robert Hauf, a board investigator for the last nine years. “I will do the best job that I can to get the job done.”
Lengthy investigations do cause problems, said at least one nursing expert.
“It would seem that there should be some sort of parameters that would help to ensure reasonable processing of the complaints,” said Kathryn Hall, Maryland Nurses Association executive director. “It would be a concern for there to be so much lag time, that someone who should not be practicing could possibly be.”
Nowakowski disagrees patients are put at risk.
“It’s the systems and processes and environment of care that help to protect patients,” while nurses under investigation continue to practice, said Nowakowski.
The board recently hired two more investigators about six weeks ago for a total of five full-time investigators. They handle about 300 cases per year among the 70,000 licensed nurses in Maryland.
The board had some trouble finding investigators because salaries range from $20,000 to $35,000 – a pay cut for most nurses, Dorsey said.
Probation is the Board of Nursing’s major form of disciplinary action; about one-third of the total cases result in probation.
The conditions of probation vary but generally require the nurse continue to practice under strict supervision, submit to regular evaluations and take continuing education courses.
Nurses under investigation can practice nursing. They lose no rights during the investigative process, said Dorsey.
“I think it’s been really great…I think we get better nurses,” when we put them on probation, said Dorsey. “A nurse being monitored is probably the best kind of nurse to deal with.”
Nurses in many walks of life agreed.
“I think particularly with hospitals being understaffed as we all know because of the nursing shortage and nurses having to, in some cases, work mandatory overtime, longer shifts or carrying bigger caseloads, I think they do get tired and accidents do happen,” said Delegate Marilyn R. Goldwater, D- Montgomery County, a registered nurse.
“I would assume that the board is doing everything they can to ensure that patients’ safety is not jeopardized by nurses who have really serious problems,” said Goldwater. “I wish it would work faster. I wish they had enough money.”
Dorsey said she’s confident that board is back on its feet and cases will clear as the new investigators get to work.
The reality is that no matter how devastating the mistake may be for the patient or the nurse, everyone deserves due process, said Nowakowski. “And as you know, due process is a lengthy process at times.”