A scathing report issued this week by state investigators confirms serious and unsettling shortcomings of the Oregon State Board of Nursing and should set in motion an immediate overhaul of the agency. For too long, the agency’s investigations of nursing complaints —and the discipline or suspension of serious offenders —have been slow and insufficient. As such, the agency has neglected its primary purpose, which is “to safeguard the public’s health and well-being.” The agency also has failed to best serve Oregon’s 65,000 nurses and nursing assistants — most of whom are excellent caregivers. As first revealed in a series of articles written by Portland Tribune reporter Peter Korn in March 2006, the nursing board routinely failed to investigate nursing complaints promptly and to revoke the licenses of many serious offenders. The Tribune’s investigation uncovered disturbing cases of nurses who were addicted to drugs, abused patients and incorrectly administered drugs — in some cases leading to patient deaths. Korn documented even more cases of alleged abuses over the next 14 months. More than a year after the first articles were published, Gov. Ted Kulongoski ordered an outside investigation of the agency and its oversight board. The investigators’ report was issued Wednesday; while it confirms the Tribune’s findings, it reveals additional disturbing shortcomings, including: • The failure of the agency to routinely report to criminal authorities alleged cases of nurses engaged in sexual abuse of patients, theft, forgery, commission of assisted suicide, tampering with drug records and attempted rape. • The failure of the agency in about 73 percent of all complaint cases to complete investigations within the 120-day period prescribed by state law. • The agency’s practice of appearing to favor the protection of nurses’ licenses more than public safety. • The oversight board’s practice of meeting only five times a year — or by phone when needed — not in monthly session, as is the case with most state boards and commissions. The report led to the resignation of the nursing board’s longtime executive director, Joan Bouchard, and the termination of Kimberly Cobrain, the agency’s second in command. Much of this action occurred at a special session of the agency’s oversight board attended by only one of its nine members. Such mass absences are a dereliction of duty and should result in the board’s termination. The public should appreciate Kulongoski’s intervention but ask why it took so long for the governor to become involved. And while state Rep. Mitch Greenlick, D-Portland, has been holding hearings to investigate the performance of all state health-licensing agencies, we ask Kulongoski and legislative leaders to address the big picture and tell the public exactly who is overseeing the overseers of all state agencies. Looking ahead, we think the governor must act quickly to reform the nursing board and replace its entire membership. Some of that rebuilding is under way with the naming of Suzanne Nelson as the nursing board’s interim executive director. We suspect that the public’s trust has been seriously damaged by the nursing board’s poor practices. It is reasonable to question whether other state oversight boards — such as those watching doctors, pharmacists and other professionals — are equally slipshod. Kulongoski, legislative leaders and the secretary of state’s office, which performs audits of state agencies, must take immediate steps to assure the public that the violations of the nursing board are not being repeated anywhere else in state government — and that such neglect will never be tolerated again.