In 2005, Los Angeles County officials fired Abbie Dickerson, a nurse at the publicly owned Olive View-UCLA Medical Center in Sylmar.
It wasn't Dickerson's first alleged lapse. She'd been written up four times for medication errors, according to the letter, which is on file with the county Civil Service Commission.
"Your unsatisfactory job performance and medical errors are no longer tolerable," the letter said. Dickerson's appeal to the commission was thrown out because she failed to show up for a hearing. She declined to comment.
California nursing regulators either didn't know about the allegations or didn't do anything about them -- they wouldn't say. Anyone looking Dickerson up on the board's website would find a clean record. She is free to work anywhere in the state.
Hers is one of the 120 cases in which the board hasn't acted despite sanctions imposed by other agencies or employers that were based on clear evidence. Reporters easily found the cases through public records, and nothing prevents the board from getting the same information and acting on it.
Cases like these "should be dealt with immediately," said Agoura Hills nurse Tricia West, an authority on healthcare quality who has been an expert witness both for the board and for nurses accused of wrongdoing.
Even when a registered nurse loses a license with another of California's professional boards, the nursing board does not always act promptly.
In more than a dozen cases, individuals were able to care for patients as registered nurses after they had been severely sanctioned -- or even had their license revoked -- by the Board of Vocational Nursing and Psychiatric Technicians.
Both boards use the same pool of investigators and fall under the Department of Consumer Affairs. But the department has no central database that can be searched for all the licenses belonging to an individual.
Lynn Teehee lost her LVN license in 2006 following allegations that she had improperly inserted a feeding tube into a patient, then ignored his cries of pain as his abdomen was flooded. The man died two days later of septic shock, records show. Her license was revoked after she failed to respond to the allegations.
The registered nursing board filed its charges two years after the LVN board acted -- and later put Teehee on probation.
Percy Randall Wade surrendered his vocational nursing license in 2003 after being accused of failing to account for missing narcotics. Then, while working under his registered nursing license, he billed San Quentin State Prison $161,000 for work he didn't do. He was convicted of felony grand theft in 2006.
A year and a half later, the registered nursing board filed an accusation against him, citing both incidents. He was given four years' probation in March.
The problem extends beyond the vocational nursing board. Dorothy Wilson (also known as Dorothy Bauer) is licensed as both a registered nurse anesthetist and a podiatrist. In 1999, the California Board of Podiatric Medicine put her on five years' probation for repeated acts of negligence.
The following year, as a nurse handling anesthesia during a breast enlargement operation, Wilson did not notice that the patient had stopped breathing, according to filings in a subsequent malpractice suit against Wilson and the surgeon.
Mary Lopez, then 32, was deprived of oxygen, went into a coma and suffered brain damage, according to the pleadings. Lopez's attorney filed a complaint with the nursing board in April 2002, alleging that Wilson had over-sedated Lopez, then altered records to cover up the error.
A judge found Wilson at fault and ordered her in August 2002 to pay Lopez $779,000, although the case was settled for a lower, undisclosed amount on appeal, said Wilson's attorney, Michael Khouri.
The nursing board did not file an accusation against Wilson until December 2007. Wilson's lawyer said in court papers that any injury to Lopez resulted from wrongdoing by the surgeon, not his client. (The surgeon was dropped from the case.)