On the same day a team of state investigators issued a scathing report about the operations of the Oregon State Board of Nursing, Joan Bouchard, the agency's executive director, tendered her resignation and Gov. Ted Kulongoski appointed an interim executive director to replace her.
The report, Bouchard's resignation and her replacement's appointment were the principle agenda items at a strange Aug. 29th afternoon special session of the nursing board attended by six people sent by the governor and only one of the board's nine members.
Six of the other eight board members checked in by conference call as the governor's staff presented investigators' findings to a room nearly devoid of nursing board staff.
The moves were followed last Thursday by the firing of the nursing board's No. 2 staff person by the board's new executive director. Last week's actions came 17 months after a series of stories in the Portland Tribune first brought to light problems in the way the board oversees the state's 65,000 nurses and nursing assistants.
Among the most serious allegations in the stories were that the board routinely hid the actions of nurses who had committed crimes from criminal justice authorities.
Also, the stories highlighted abuses in the board's monitoring program, which allows nurses with drug and alcohol addictions to continue working while they receive treatment.
In some cases, nurses in the monitoring program were allowed to continue in their jobs even after multiple instances of stealing medications from patients.
The state report issued Aug. 29 supported the Tribune's stories and found even more problems. According to the report, even cases of alleged sex abuse and attempted rape that came before the nursing board were not referred to criminal authorities.
And, the report found, the nurse monitoring program 'does not protect the public as effectively as it protects a participant's license to practice.'
Stories detailed abuse
The state report came from a two-month investigation by the state's Department of Administrative Services ordered by the governor. Kulongoski's order came in June, after the Portland Tribune published two stories relating to questionable oversight by the nursing board.
The first story detailed the case of a nurse alleged to have abused a nursing home patient. That nurse was practicing with an unencumbered license, even though she had been found to have abused another patient at another nursing home.
The second detailed the case of two nurses who assisted a cancer patient in ending her life. The nursing board learned of the case but did not revoke the nurses' licenses, and never alerted criminal justice authorities about the case, though Oregon's assisted suicide law allows only physicians, and not nurses, to assist patients in dying.
Last week's report said the Oregon State Board of Nursing's 'deliberations and practices appear to lack an acute sense of urgency to protect the public.'
The report says that sometimes years pass before action is taken against nurses who have been the subjects of complaints, and that nurses' licenses were not suspended 'even though the licensee may appear to endanger the public.'
The report calls the board's criminal background checks of nurses 'inadequate.'
Administrative Services investigators were given access to nursing board files and found, as the Tribune had reported, that the board often did not report suspected crimes by nurses to the police. 'These potential violations have included suspected instances of theft, forgery, aiding commission of (suicide), sex abuse, reckless endangering, attempted rape and tampering with drug records.'
The report was especially harsh on the controversial nurse monitoring program. In a letter to the nursing board that accompanied the Aug. 29th report, the governor called for the program to be 'overhauled.'
The report also noted that board spending on furniture and refreshments were 'extravagant and excessive.'
Report suggests steps
Alycia Juber, a McMinnville resident who has been harshly critical of the nursing board, said she was speechless at news of the governor's report and actions.
Juber's father was one of four residents of a Sheridan nursing home who died allegedly at the hands of a nurse who overdosed them with morphine in 1998. That nurse previously had been found to have endangered patients at a previous job but had been allowed by the nursing board to keep practicing.
'I believe this shows that hard work by private citizens, not being afraid to come forward, though it can take a lot of time, can get things done,' Juber said.
Juber said she has been talking with legislators and staff members at the governor's office since 2004, and 'no one seemed to care until it made the paper.'
The report makes 34 specific recommendations for revamping the nursing board, ranging from reducing the number of staff members that directly report to the executive director to suspending nurses' licenses while they participate in the nurse monitoring program.
It also recommends the agency consider removing the program from the agency's control. Nursing boards in many states have their addicted licensees monitored by outside contractors who specialize in running such programs.
All of which may not be enough, according to state Rep. Mitch Greenlick, D-Portland. Greenlick, chairman of the Oregon House Health Care Committee, has been holding hearings looking into all health licensing agencies, and whether they serve licensees at the expense of public safety.
Greenlick said Bouchard's replacement with Interim Executive Director Suzanne Nelson, the deputy chief administrative officer in the state Department of Human Services, is far from the last step in reforming the nursing board.
'I think it's total chaos at the nursing board,' Greenlick said. 'That's what the report said.'
Asked on Aug. 29 whether replacing Bouchard with Nelson would be sufficient in reforming the nursing board, Greenlick said, 'I think it's a first step. … It's absolutely not over. My guess is there will be a pretty major housecleaning.'
Personnel changes uncertain
Greenlick called the lack of attendance by board members at the Aug. 29th meeting 'appalling. It's my guess this is not accidental that they didn't show up. Eight members not showing up, I bet that's the first time in history that's happened.'
He said board members' absences could suggest that not all board members agree with the governor's actions.
Some of the nursing board housecleaning, Greenlick said, might take place among the nine members of the nursing board. He added that he had been 'in close contact with the governor's staff all through this.'
Board members are appointed by the governor, and can be removed by the governor.
But Tim Nesbitt, Kulongoski's deputy chief of staff, denied that the governor had plans to remove any nursing board members.
'At this point, no other changes are planned,' Nesbitt said. 'We have confidence in the board and the new interim executive director.'
According to Nesbitt, 'as a practical matter the boards follow the lead of the person who is here day to day. The feedback we're getting from this board is they weren't aware of some of these problems.'
Critics, however, have said that the board has known details of many of the most questionable cases before voting for light disciplines for the nurses.
As for Bouchard, Nesbitt said, the governor did not ask her to resign, but simply asked his staff to meet with her and 'talk with her about his concerns.' Bouchard, he said, chose to resign on her own.
Director promises change
Phil Fleury, a nurse practitioner and reserve Portland police officer who worked as an investigator for the nursing board in 2005, was interviewed extensively by Administrative Services investigators.
Fleury said changing the executive director and firing her No. 2 - Kimberly Cobrain, the board's program executive for compliance and investigations - was a good start, but it won't be enough to significantly change the agency.
'It's the entire culture of the board of nursing,' Fleury said. 'Their priority seems to be protecting the nurses, not protecting the public.'
And that attitude begins with the board, Fleury said. 'The board members are ultimately responsible for the regulation of the nursing practice act and protection of the public. The buck stops with them,' he said.
Before Cobrain's firing, Nelson said she intended to first try to work on the prevailing culture at the board before making recommendations to the governor about significant staff or board changes.
A letter from the governor to the nursing board requests monthly reports from the board on progress in instituting changes.
The Portland Tribune attempted to interview Bouchard but telephone calls were not returned.