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 In California alone, a months-long review of its 350,000 active nurses found at least 177 whose licenses had been revoked, surrendered, suspended or denied elsewhere.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.
Even when states share borders, they sometimes fail to heed each other's disciplinary actions. At least 10 nurses, for example, hold clear licenses in Massachusetts despite being disciplined next door in Rhode Island, including suspensions for drug thefts and violence.
Nurse Karen Rheuame's Rhode Island license was suspended in 2007 after she was arrested on suspicion of assaulting a woman in a wheelchair in a hospital emergency room and trying to steal her pocketbook, according to state disciplinary records. She also had numerous other convictions and, records show, had once brought two beers to work, which she explained to her boss were for "the ride home."
But she's free to practice in Massachusetts. A health department official there said regulators are reviewing Rheuame's case and others to see if action is warranted, but they haven't received any complaints about the nurses in Massachusetts.
Rheuame said she'd made mistakes but has completed rehabilitation for addiction. "I'm not going to minimize what I did," she said. "I've really turned my life around since then."
There is ample information available for states to identify nurses disciplined by other jurisdictions. Two separate databases attempt to track disciplinary actions from every state. States are required to report to one, run by the federal government, within 30 days of taking an action. Reporting to the other, operated by the National Council of State Boards of Nursing, is voluntary.
Each database can be programmed to alert a state whenever a nurse it has licensed runs into trouble in another state.
When checking a nurse's record, nursing officials say they almost uniformly use the council's database; it's free and the government's is not. In fact, federal statistics show that nursing boards accessed the government database fewer than 300 times total in 2007 and 2008.
In addition, ProPublica and The Times found that the federal database is incomplete, despite the requirement that all states report discipline to it. Many actions appeared to be missing when reporters tried to match known cases by date of discipline to a version of the database in which confidential information had been removed.
Some regulators are vigilant, while others are not.
Louisiana, for example, checks the council database every day for discipline involving its nurses, its board director said. Rhode Island does it once a month, an official said.
New York, by contrast, uses it primarily to look into the backgrounds of people applying for nursing licenses. It typically does not check it for problems involving the 266,000 registered nurses already licensed to practice in New York.
Barbara Zittel, head of the New York board, said she relies on other states to notify her if one of her nurses has been disciplined and she counts on the nurses themselves to honestly disclose their problems. It works, she says, "unless someone is lying to us."
Officials at the National Council of State Boards of Nursing said they don't tell nursing boards how often to consult their database. But tools are there to help them. State boards imposing discipline, for instance, can send out warnings known as "speed memos" to flag other states.
But the council's database continues to have significant weaknesses. Nearly all states report their disciplinary information to the council, according to its website. Yet only 37 states and the District of Columbia supply it with the names of all their licensees.
As a result, it's difficult for regulators to know who is licensed in the 13 other states, including California, and when to alert them about discipline. Those states account for more than 40% of the nation's approximately 3.5 million registered nursing licenses.
The council cannot force states to submit names, and states have a financial incentive not to: They make money by charging nurses to verify their licenses, test scores and training to authorities in other states. For example, a nurse licensed in California who wants credentials to practice in Arizona must pay California $60 to confirm her background. Those sorts of checks netted California nearly $1 million in fiscal 2009. New York, which charges $20 a check, earns more than $250,000 a year.
When states turn over their lists of licensed nurses to the national council, that group earns such verification fees. "The decision to join is a revenue loss for them," said Kathy Apple, the council's chief executive officer. "That's difficult for some states."
Barbara Morvant, executive director of Louisiana's board, said the trade-off was worth it. After the board submitted the names of all its licensees last year, it saw an immediate upswing in the number of disciplinary actions it discovered.
"While it was a loss of revenue to our state, it was a benefit to the public," she said.
To estimate the scope of the problem nationwide, ProPublica and The Times searched the records of the nation's largest state, looking for examples of nurses licensed in California who had been disciplined elsewhere.
California's Board of Registered Nursing has historically done little on its own to ferret out such problems. Until last year, the state did not even ask nurses renewing their licenses whether they had been disciplined by another state.
Moreover, the board only checked nurses' records against the council's database of disciplinary actions when they applied for a California license. Since August, California also has been checking the database when the board begins an investigation of a nurse.
Reporters went further, checking the full roster of 350,000 licensed nurses against a public version of the council database. They found that at least 643 California nurses had sanctions elsewhere, including the 177 whose licenses had been revoked, suspended, denied or surrendered.
Among them are:
* Jose Martinez, who surrendered his license in Texas in July 2008 after being accused of performing a rectal exam on an 11-year-old girl without a doctor's order or a witness present. In a letter to the Texas board, Martinez acknowledged his misconduct. "Yes, I made a mistake and, yes, I am guilty. After 4 years as a tech and 12 years as a nurse I slip and fall. . . . I guess I deserve what is coming to me."
His California license is active, without restrictions, and does not expire until July 2010.
* Jeffrey Strong, whose license was indefinitely suspended in Virginia in September 2008 after he allegedly left his post at a hospital psychiatric ward with the medication cart unattended. He had previously been disciplined for medical errors at another hospital in the state, including failing to monitor a patient who fell and as a result required emergency surgery.
"I was not providing safe care on that unit at that time and could not now," he wrote the Virginia nursing board in December 2007 about that earlier discipline. Strong has a clear license in Florida as well as California.
* Randy Hopp, who was convicted in 2004 of assaulting a nursing home resident in Minnesota. It was the fourth facility since 1998 at which he had been accused of mistreating a resident, records show. The nursing boards in Minnesota and Missouri placed him on probation, and Kansas imposed restrictions on his practice. Hopp surrendered his license in Texas. In California, his license remains clear.
Martinez and Strong could not be reached for comment. Hopp declined to comment, saying the discipline was in the past. Reporters could not determine if or where they and others in this article were working, because this information is not collected by most states.
Asked about this article's findings, California officials said regulators will now check for out-of-state discipline for every licensee by the end of March. At its February meeting, the nursing board plans to discuss additional steps to better use the council's database.
California is also working to speed up the pace of discipline.
In the past, the board took a median of 13 months to file public accusations against nurses after their licenses were first revoked, surrendered, denied or suspended by another state, according to a review of 258 such cases since 2002.
Three of these nurses got work and stole drugs from California hospitals after they had surrendered their licenses across the border in Nevada for previous wrongdoing there.
Experts and regulators say the patchwork nature of nursing regulation in the country underscores the importance of a complete national database. State regulators should be required not just to submit their licensees, they said, but to routinely check to see if their nurses have been disciplined elsewhere.
Currently, only information about completed sanctions is available. Some experts say formal accusations, detailing charges against nurses, should be included too. "The more information that's available as quickly as possible and shared as fully as possible . . . the better off you are," said Oshel, the former federal official.
Such efforts might have kept Orphia Wilson from moving easily from Florida to Connecticut. Within days after Florida regulators revoked her license in October 2004, they reported the action to the federal government's database. Sometime later, the information was put into the council database.
As is their practice, however, Florida officials didn't report their action to other states. Connecticut, as is its practice, did not regularly check the national databases.
The next year, Wilson once again renewed her Connecticut license, checking "no" when asked if she had been disciplined elsewhere.
Wilson, who did not respond to requests for comment, wrote in a sworn statement to investigators later: "I am very sorry about the deaths of the babys I cared for. Believe me I went through my share of guilt."
The month after Jexier's May 2005 death, she was back at work, as a supervisor in a Connecticut nursing home.
Connecticut suspended Wilson's license in June 2006 and revoked it several months later. The nurse was sentenced to jail last year for reckless endangerment and hiding her Florida discipline from Connecticut.
In an e-mail response to questions, a Connecticut health department spokesman blamed Wilson for hiding her past, and said communication among states has improved.
Christopher T. Godialis, who prosecuted Wilson for the Connecticut chief state attorney's office, said a system that relies chiefly on the honesty of such nurses does so at its peril.
"The way the situation is set up now, there's no way for Connecticut to have known about what happened in Florida unless Orphia had told them," he said. "The state didn't check anything."
Ornstein and Weber are senior reporters at ProPublica. Moore is a Times researcher.
Lisa Schwartz, ProPublica's director of research, contributed to this report.