Thierry LaMarque, Helen Brown

Helen Brown holds a photo of grandson Thierry LaMarque Jr., left, and one of his mother, Glenda Brown. (Phelan M. Ebenhack / For The Times / December 23, 2009)

The frantic knocking of home health nurse Orphia Wilson startled the boy's parents awake just after dawn.

Their 3-year-old son, who suffered from chronic respiratory failure and muscular dystrophy, had stopped breathing.

The boy's mother raced to his side and began performing CPR as Wilson stood by. It was too late. Jexier Otero-Cardona died at a Hartford, Conn., hospital the next day.

In the months that followed Jexier's May 2005 death, Connecticut health officials discovered that Wilson had fallen asleep, then ignored -- or possibly turned off -- ventilator alarms that signaled the boy was not getting enough oxygen, state records show.

And Jexier, they learned, was not the first child to die under Wilson's care. Seven months earlier, she had lost her registered nursing license in Florida for similar lapses in the death of another boy in 2002. In that case, 21-month-old Thierry LaMarque Jr. had stopped breathing while Wilson was caring for him at her Orlando home. Instead of calling 911, she tried CPR, then drove the boy's limp body three miles to his parents' house.

"She said she panicked," recalled the boy's mother, Glenda Brown, who was summoned home and found her dead son still strapped into his car seat. "Why would you bring him to my house if he passed at your house?"

Wilson's case highlights a dangerous gap in the way states regulate nurses: They fail to effectively tell each other what they know. As a result, caregivers with troubled records can cross state lines and work without restriction, an investigation by the nonprofit news organization ProPublica and The Times found.

Using public databases and state disciplinary reports, reporters found hundreds of cases in which registered nurses held clear licenses in some states after they'd been sanctioned in others, often for serious misdeeds. In California alone, a months-long review of its 350,000 active nurses found at least 177 whose licenses had been revoked, surrendered, suspended or denied elsewhere.

Such breakdowns are readily fixable. Yet state regulators aren't using their powers to seek out this information, or act on what they find, the investigation found.

Florida officials, for instance, didn't notify Connecticut authorities when they sanctioned Wilson -- even though she'd told them that she also held a Connecticut license. And Connecticut's nursing board renewed Wilson's license three times after Thierry's death, relying on her pledge that she hadn't been disciplined or investigated elsewhere.

By simply typing a nurse's name into a national database, state officials can often find out within seconds whether the nurse has been sanctioned anywhere in the country and why. But some states don't check regularly or at all.

The failure to act quickly in such cases has grave implications: Hospitals and other healthcare employers depend on state nursing boards to vouch for nurses' fitness to practice.

"It only takes one outlier to end up killing a bunch of patients," said Robert E. Oshel, who retired last year as an associate director at the federal agency that runs discipline databases on health providers. "The fact that the vast majority of nurses don't cause problems and are fine professionals . . . doesn't mean you shouldn't be very vigilant against the few who aren't."

State practices vary

Because there is no federal licensing of nurses, each state sets its own standards on punishable behavior.

In general, states can discipline a nurse based solely on the actions taken by another state. But they vary widely in how quickly -- or harshly -- they act on this information, according to interviews with regulators in 14 states.

Under the law in Virginia and Louisiana, for instance, officials must immediately suspend nurses' licenses for serious misconduct in another state. Nurses are barred from practicing unless they successfully appeal.

Missouri, on the other hand, must personally serve all accused nurses with written charges and offer hearings to contest them. If nurses can't be found, their licenses remain clear and they are free to continue practicing, said Lori Scheidt, executive director of Missouri's nursing board.

Delays in several states left Craig Smart free to practice. In 2000, he surrendered his license in Florida after testing positive for cocaine and flunking a treatment program. It took eight years for five other states in which he was licensed to respond to Florida's action. California was the last to revoke his license, in 2008, after he had practiced here for several years, apparently without incident.