Oversight Glitches

How nurses slip through the system

October 12, 2008 

A flawed method for tracking nurses who break the law isn’t the only loophole in the state’s criminal tracking system, some investigators say.

Scores of cases bury investigators. Sometimes it takes months to complete an investigation and years to mete out discipline, which allows dangerous nurses to remain on the job, records show.

Nurse Diana Kutz, of Pismo Beach, for example, was reported to the nursing board shortly after an incident in 2005 at Sierra Vista Regional Medical Center in San Luis Obispo, where she abandoned five patients during her shift. But the case was not resolved until June of this year, according to a board report.

And when a nurse’s license is canceled or suspended, or if a nurse is put on probation or restricted from handling certain narcotics, hospitals don’t necessarily find out, investigators say.

Nurses are required to notify employers of disciplinary action, but some nurses have continued to work on expired licenses until they’re caught.

License renewals occur every two years. Between renewals, a nurse could work unnoticed on an invalid license.

Matters are further complicated when investigators have trouble finding nurses for whom they issue arrest warrants. The problem arises because the state keeps mailing addresses on file that are not always updated by nurses, as required by state law, or some use post office boxes or relatives’ addresses.

Problems at the core

Even when the state criminal tracking system is operating properly, some nurses still slip by regulators undetected.

People caught for drug possession and other low-level offenses aren’t always arrested and booked into jails. Police write them citations instead. But the booking process is what triggers a notification to state nursing boards. So when a nurse is not booked, a notification is not sent.

State law requires all defendants to be booked during their criminal cases, but that doesn’t always happen.

In 1993, Kutz was cited for allegedly being drunk in public but was never booked into jail. And when a CHP officer cited nurse Margaret Troutman of Nipomo in 1994 for DUI and reckless driving, she was never booked, according to court records.

For those nurses who are caught, fingerprinted and added to the criminal tracking system, unexplained glitches still leave regulators unaware of some of their criminal offenses.

Troutman, then an Atascadero State Hospital nurse, was disciplined and fingerprinted, but regulators never learned of her 2004 assault with a deadly weapon conviction in San Luis Obispo County.

“We’re looking into it as best we can. At this point, I don’t have a specific answer,” said registered nursing board spokeswoman Heidi Goodman.

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