Culture of secrecy allowed nurse to keep harming patients

Alice Bandy of Manchester, Iowa, was one of at least 14 patients whose pain killers were stolen by an Iowa nurse who worked at Manchester's Regional Medical Center and two other health care facilities before she was caught. (Hospital photo by Clark Kauffman/Iowa Capital Dispatch; inset photo courtesy of Alice Bandy's family)

Last summer, federal prosecutor Timothy Vavricek stood before a judge and tried to explain how Katie Boll had bounced from one Iowa nursing job to the next, stealing pain killers from hospice patients who had only days to live.

“She was a nurse at UnityPoint, was fired, then she’s up working again at Manchester, doing it all over again,” Vavricek said. “I’m not sure how that’s allowed in the state of Iowa … but she kept being a predator on these poor, elderly people who are dying and in pain.”

According to court records, Boll was fired from one Iowa hospital due to irregularities with narcotics handling, was quickly hired at a larger hospital where she was later suspended and then fired for narcotics handling, and then wound up working at a nursing home where she was fired for the same offense.

At all three health care institutions, Boll later admitted, she repeatedly stole drugs intended to ease the suffering of patients.

“She is a danger to the community,” Vavricek told the judge. “She — on at least 50 occasions — admits she stole hydrocodone from patients of a nursing home over a four-month period … And these elderly hospice patients died, and they died in pain at her hands.”

So how does a nurse fired for mishandling narcotics at one institution wind up working at another and then another?

An Iowa Capital Dispatch review of state and federal records shows that the safety net intended to protect patients from criminal caregivers is riddled with holes. Health facilities don’t share information about past employees’ misconduct; licensing boards don’t tell the public about criminal convictions of the professionals they oversee; and state inspectors don’t always sanction the facilities where the crimes are committed.

‘Mom really trusted everyone’

From October 2016 to August 2017, Boll worked at Manchester’s Regional Medical Center as a nurse. According to court records, she was fired from the hospital for a variety of issues, including inaccurate documentation of narcotics handling. Later, she admitted that while working at the hospital she regularly signed out medications, claiming to have given them to patients, but she was instead pocketing the drugs for her own use. She also admitted stealing injectable narcotics from hospice patients at the medical center.

Within three weeks of being fired from the Manchester hospital, Boll went to work as a nurse at Unity Point-St. Luke’s Hospital in Cedar Rapids. During her time there, she later admitted, she stole narcotic pain medication from hospice patients on numerous occasions. She was fired after an internal investigation found that she failed to follow the protocol for administering pain medications and failed to properly discard excess controlled substances. She had previously been suspended and warned about her failure to follow pain management protocols.

Almost immediately, Boll landed a job at the Good Neighbor nursing home in Manchester. She later admitted that on at least 50 occasions, she took hydrocodone prescribed for residents of the home. She said she stole the drugs by replacing them with over-the-counter pills such as Tylenol.

She also admitted that on Christmas Eve, 2018, she took the liquid morphine that was set up to provide 92-year-old Alice Bandy with pain relief. Using a syringe, she extracted the morphine from the bottle and then, to hide the theft, she replaced the pain killer with mouthwash.

“I knew my mom was in pain,” says Bandy’s daughter, Joyce Becker of Dundee. “So I kept asking the nurses, ‘Can you give her something for the pain?’ And they said, ‘She’s already on morphine.’ Well, then we later came to find out she wasn’t getting any of it. It was quite a shock. Mom really trusted everyone out there.”

Bandy died two weeks after the theft, on Jan. 8, 2019. She had chosen the Good Neighbor Home when she became ill because she had worked there for 16 years as a housekeeping supervisor and had faith in the quality of care at the home.

Boll also admitted stealing morphine from another resident of the home — a 98-year-old World War II veteran who spent 20 years of his retirement delivering Meals on Wheels for his elderly, Linn County neighbors.

During one shift, on Dec. 29, Boll went into the home’s pain-medication room and stole drugs belonging to 10 different patients, replacing them with over-the-counter medications. The patients or their insurers were billed at least $593 for the drugs they never received, according to court records.

In all, 14 residents of the Good Neighbor Home were harmed by Boll. The oldest was 101 years old, but most were in their 80s and 90s, and each was suffering either from significant end-of-life complications or had dementia.

Last July, federal prosecutors charged Boll with one count of tampering with a consumer product and 16 counts of acquiring controlled substances by misrepresentation, fraud, deception and subterfuge.

As part of a plea bargain with prosecutors, Boll agreed last summer to relinquish her nursing license and prosecutors dropped 15 of the 17 charges against her. She was sentenced to four years in prison.

Health facilities don’t share information

Boll wasn’t criminally charged or subjected to any professional discipline until after her conduct at the Good Neighbor home was uncovered. So, prior to that, any background checks and calls to the state licensing board would have turned up nothing.

But had the Regional Medical Center or UnityPoint shared information about Boll’s job performance, she might never have had the opportunity to, in the prosecutor’s words, “prey” on the residents of the Good Neighbor home.

A spokeswoman for Regional Medical Center did not respond to several calls and emails from the Iowa Capital Dispatch, so it’s not clear what the hospital told UnityPoint and Good Neighbor.

However, both UnityPoint and Good Neighbor say they do not share with other employers negative information about past employees’ conduct.

While working at Manchester’s Good Neighbor Home, nurse Katie Boll stole morphine and other pain killers prescribed for dying patients. (Photo by Clark Kauffman, Iowa Capital Dispatch)

When asked what prevents UnityPoint from sharing that sort of information with other medical providers, hospital spokeswoman Sarah Carizzo cited a self-imposed policy — one she described as “standard operating procedure” — that limits disclosure to a worker’s dates of employment, job title and full-time or part-time status.

Good Neighbor’s administrator, Matt Carpenter, said state law prohibits the home from telling other employers about past employees’ bad acts.

But Iowa law doesn’t bar that sort of disclosure. In fact, it encourages employers to share negative information about past employees by providing them with civil immunity. They can’t be sued for relaying negative information about past employees to prospective future employers, as long as the information is shared in good faith.

Iowa’s law, however, doesn’t take the additional step of requiring disclosure, which means employers face no repercussions for establishing policies that limit disclosure to dates of employment and job titles.

Delayed action remains unexplained

UnityPoint officials point out that Boll’s nursing license was in good standing when the hospital hired her. But that doesn’t always mean a licensee has an unblemished record.

For example, it was 29 months ago that Tasha Warnke, a Mason City nurse, was convicted of a series of violent and drug-related crimes — but until last month, when the Board of Nursing took action, she had no history of disciplinary action on her license.

If a patient or the concerned relative of a patient called the board in 2018 or 2019 to check on Warnke’s license, they wouldn’t have been told that in September 2017, Warnke was convicted of unlawful possession of a prescription drug; domestic assault with a dangerous weapon; domestic assault causing bodily injury; possession of methamphetamine; criminal mischief; and felony burglary.

That disclosure wouldn’t have been made until last month, when the Board of Nursing filed its initial public statement of charges against Warnke. By that time, she had already been incarcerated for her crimes and for a subsequent probation violation.

Doug Bartels, the board’s assistant director of enforcement, says he’s not sure why the board took 29 months to file a public statement of disciplinary charges against Warnke after her conviction. But even if he knew the reason, he said, he could not disclose it.

He added that with cases tied to crimes, “sometimes we don’t become aware of things until much later. Unless something is reported to us — and a crime is a good example — we just don’t know about it. We can’t act unless we know about it.”

While the board doesn’t disclose when it initiates an investigation, it does number its cases according to the year in which the cases are opened. Warnke’s case number is 2018-0500, suggesting the board opened the case sometime in 2018 — which would be 14 to 26 months before it notified the public of her crimes through a statement of disciplinary charges.

Bartels acknowledged that the board doesn’t tell members of the public about criminal charges or convictions against nurses unless and until disciplinary action is initiated by the board.

“We would say (they) have an active, unencumbered license and there is no other public information available,” he said. “I don’t know if it’s in statute or if it’s just best practices as recommended by the attorney general’s office, but I know we would not typically say to somebody, ‘We don’t have any public records (on the licensee), but you might want to look at Iowa Courts Online.’ I mean, that is not something we would do. We wouldn’t try to lead inquiries to other sources of information. That’s something they need to do on their own.”

Iowa Board of Nursing Executive Director Kathleen Weinberg agreed, saying even criminal charges, while a matter of public record, have to be treated by the board as confidential. “We have to abide by the law in terms of what we can or cannot say,” she said.

A spokesman for Iowa Attorney General Tom Miller says the office doesn’t discuss the advice it gives to licensing boards. While there’s nothing in state law that expressly prohibits licensing boards from relaying public information, such as a criminal conviction, to the public, the law does say that “all complaint files, investigation files, other investigation reports, and other investigative information in the possession of a licensing board” are confidential.

Iowa’s licensing boards interpret that to mean even public information on a licensee, once it’s in their file, has to be kept confidential by the board itself.

“Once the information is in our hands, we consider it to be part of our confidential investigation,” said Kent M. Nebel, executive director of the Iowa Board of Medicine, which oversees physicians. He says that even if the board was able to release information about crimes, there is no mechanism for the board to collect and share it in the same way it does disciplinary action.

In July 2019, Dr. Joseph Latella of Webster City pleaded guilty to felony charges of Medicaid fraud — but as of March 16, eight months later, his license remained in good standing with the Iowa Board of Medicine, with no history of any disciplinary action.

According to prosecutors, for at least five years Latella billed taxpayers for medical services he falsely claimed to be providing the residents of nursing homes where he worked as medical director. On one particular day, he billed taxpayers for treating nine nursing home residents, but video surveillance showed he was at the home for a total of 14 minutes that day.

In January, Latella was sentenced to two months in prison.

State inspectors don’t disclose crimes

In theory, the public might learn whether a family member has been put at risk by a criminal caregiver by reading the state inspection reports for the facilities where their loved ones have received care. But even there, disclosure is spotty.

Boll’s crimes at the Good Neighbor home involved at least 14 residents and more than 50 instances of theft. But the publicly available inspection reports for the home give no indication any of that ever happened. The reports make no mention of any thefts or tampering with medication.

On March 5, the Iowa Capital Dispatch asked Iowa Department of Inspections and Appeals spokeswoman Stefanie Bond why that is. As of March 16, Bond still had no answer to the question.

It’s possible the inspections department was unaware of the thefts, or that it concluded the crimes didn’t entail any failings by the home itself with regard to quality of care or staff supervision.

The Good Neighbor home isn’t even mentioned in the Board of Nursing’s public statement of charges against Boll. The document says only that Boll was employed at “a long-term care facility” and that on “more than one occasion” she stole medication from more than one resident.

From reading that document, no one would have any idea where Boll committed her crimes, how many people she victimized, or that she had previously committed similar offenses at two Iowa hospitals.

That’s by design. The harm caused to patients, the number of patients affected, and the names of the facilities where the licensees committed their crimes typically aren’t disclosed by Iowa’s Board of Nursing, though such details are often disclosed by boards in other states.

“That has been a long-standing practice − and I think, probably, it comes from an attorney general recommendation,” Bartels said. “Iowa uses more conservative language in their charging documents than some other states. I look at some states’ (public) documents, and they look like our confidential notes. They just put everything out there.”

The manner in which Iowa’s licensing boards dispose of complaints was highlighted in a 2017 report from the Iowa Office of Ombudsman called “A System Unaccountable.” That report focused on the “culture of secrecy” that leads the boards to keep secret virtually all information about the scope of their work and their reasons for dismissing complaints.

“We believe it is imperative that the state’s licensing boards be more accountable to the public they serve,” the report concluded. “More transparency is the only way to instill confidence in the important decisions these boards make.”

In 2019. the Iowa Board of Nursing opened 564 complaint investigations and closed 407 cases with no action taken. In 2018, the Iowa Board of Medicine completed 578 investigations, and doled out public disciplinary action in just 58 cases, while sending out confidential “letters of concern” in 111 others.

(Editor’s note: Reporter Clark Kauffman worked for the Iowa Office of Ombudsman from October 2018 through November 2019.)