Weak Oversight Lets Dangerous Nurses Work In New York
by Daniela Porat, Rosalind Adams and Jessica Huseman for ProPublica, April 7, 2016, 4 a.m.
Thomas Maino knew he was going to die. Suffering from serious ailments, the 93-year-old veteran had rejected invasive treatments and asked only that he be made comfortable after he was admitted to a Syracuse nursing home in November 2008.
But on a snowy Saturday morning the following January, his moans could be heard down the hallway.
Over the next eight hours, coworkers reported to the nurse in charge of Maino’s unit that he needed pain medication. That nurse, Maura Quinn, gave him only Tylenol and never alerted the doctor. Other nurses told her Maino was in agony, but she ignored them, even when his moaning turned to yelling, seven staffers at the home later testified in depositions taken during an investigation by the state Attorney General’s office.
“Oh great, now people are going to tell me how to do my freaking job,” Quinn said when a nurse from a nearby wing left a note for her about Maino, according to one deposition.
Maino died that evening.
After an administrator reported the incident to New York nursing home regulators, Quinn was fired and, in December 2010, convicted of a misdemeanor for providing Maino with inadequate care. The state Attorney General’s office reported Quinn to the Office of the Professions, the agency that licenses and disciplines nurses, when she was sentenced two months later.
But it would take another three years for the Office of the Professions to suspend her from nursing. By then, the agency had learned that Quinn lied on her initial licensing application, failing to disclose a 1988 conviction for drug possession, and that she was convicted in 2012 of driving without a license — both grounds for more disciplinary action. The agency finally suspended Quinn’s nursing license for three months in May 2014.
Over the past 15 years, nursing boards across the country have taken steps to tighten oversight of nurses, screening applicants more extensively before issuing licenses and instituting swifter, tougher sanctions for problem licensees.
Not New York.
Unlike many states, New York does not require applicants for nursing licenses to undergo simple background checks or submit fingerprints, tools that can identify those with criminal histories and flag subsequent legal problems. And it often takes years for New York to discipline nurses who provide inept care, steal drugs or physically abuse patients.
A ProPublica review of hundreds of disciplinary records, arrest reports and court filings shows New York’s system for overseeing nurses is deeply flawed. Among our findings:
The Office of the Professions often fails to act when it is informed that other states or even other New York agencies have disciplined New York nurses. One example: The state health department penalized a nurse in early 2014 for administering an overdose of insulin that nearly caused a patient’s death, but the Office of the Professions has taken no action against her license.
Though the Office of the Professions can take immediate action against nurses accused of endangering the public’s health or safety, it has not done so, even in egregious cases. After a nurse in the Bronx was caught sexually assaulting a patient in February 2014, the agency didn’t revoke his license for more than a year and a half, records show.
New York disciplines nurses far less often than other large states. In 2014, the Office of the Professions disciplined fewer than 350 licensees, which works out to 1 in 1,190. In the same year, Ohio disciplined more than 1,600 (1 in 153), and Texas disciplined almost 2,300 (1 in 167). In fiscal 2014, California disciplined over 1,600 nurses, roughly 1 in 325.
“As a professional nurse who is registered in the state of New York, I’m appalled,” said Donna Nickitas, the executive officer of the nursing PhD program at the Graduate Center of the City University of New York. “This is [about] the health and welfare of the general public.”
The Office of the Professions is an arm of the New York Department of Education. In response to these ratios, a spokeswoman for the education department said that New York’s numbers only reflected actions that needed the approval of the Board of Regents. The department did not respond to multiple requests to quantify or elaborate on this.
Even inside the Office of the Professions, concerns have grown so pronounced that one investigator wrote to New York State Sen. Michael Venditto last July about the consequences of not performing background checks on nurses, as well as delays in disciplinary action, letters obtained by ProPublica show. The investigator cited one nurse who was licensed despite a violent criminal history because he never reported it on his application. Another nurse maintained an active license for three years while she awaited trial on charges of selling prescription drugs, the investigator wrote.
In response to a letter from Venditto about the investigator’s concerns, New York State Commissioner of Education MaryEllen Elia said in October 2015 that her agency would support background checks and fingerprinting for nurses if state legislators proposed a measure requiring them. (They have not done so.)
But Elia cited an “extraordinarily high” success rate for the investigations completed by the Office of the Professions. “We are very proud of the work the office does and believe that New York’s licensed professionals are among the safest in the country,” Elia wrote in a second letter in December 2015. She did not clarify how she was defining success, and also declined requests to be interviewed.
Peggy Chase, a member of the New York nursing board, the licensing board for nurses that is part of the Office of the Professions, acknowledged the blind spots in the oversight system. She said she did not remember the issue of background checks being raised at any of the board’s meetings. In a phone interview, she conceded that “people can lie and we will never know,” but said the responsibility for spotting and dealing with problem nurses should not fall exclusively on the Office of the Professions.
In an e-mailed response to ProPublica’s findings, Jeanne Beattie, a spokesperson for the education department, acknowledged that the Office of the Professions had limited ability to discipline nurses.
“We are working with the chairs of the Senate and Assembly Higher Education Committees to improve the disciplinary process to include greater authority and tools for the department,” said Beattie.
Quinn could not be reached by phone and did not respond to a letter sent to her most recent address in Florida. The education department declined to comment on Quinn’s discipline record or the cases of any other individual nurses that ProPublica asked about.
In a handwritten statement three days after Maino died, Quinn said she had left her shift that Saturday afternoon believing Maino was stable and resting. “I was not concerned [with] Thomas’s yelling act because that’s what he had been doing for weeks,” she wrote.
Quinn’s disregard for her patient left a lasting impression on her former colleagues. “Whenever I think about what happened that day I get sick to my stomach,” Veronica Barricella, one of the aides who tended to Maino, said in her February 2009 deposition. “I have also had nightmares.”
There may be no better