TUALATIN, Ore. - A change in leadership at the Oregon State Nursing Board has led to revelations showing the regulatory agency failed to investigate or follow up on complaints against nurses and nursing assistants for issues ranging from substance and patient abuse to probation violations.

Executive Director Holly Mercer started her new job in January. A few days later, compliance and investigations manager Linda Fisher-Lewis joined the staff.

Fisher-Lewis immediately started examining the status of the board's investigations. Her results startled Mercer to the point that she fired off a letter to the State Legislature and Gov. Ted Kulongoski, acknowledging the board had not been doing its job.

In the Feb. 28 letter, Mercer outlined a "critical situation" involving "alarming discrepancies in agency probation files, Nurse Monitoring Program cases and other investigatory files."

Her memo included the following observations and actions:

• 56 out of 90 nurses on probation are "out-of-compliance." Board investigators have contacted three-quarters of those individuals "and brought them into compliance or are pursuing further discipline (suspension or revocation)."
• About 100 complaint files dating as far back as 2003 have gone without investigation. The most serious files have been handed over to investigators.
• About half of 331 cases closed in early 2006 "were closed without being investigated." Mercer said those cases will be re-examined.
• A sample analysis of working nurses being monitored for issues like substance abuse and fraud-- shows 75 percent are "out of compliance with their contract requirements." This includes missing appointment and phone calls or poor reports from employers. The board has "rectified" the situation by sending notices to all nurses in the program, warning them about stricter guidelines. They are also working the the Justice Department to strengthen contracts and provide more resources to employers.

KATU News asked Mercer how hard it was for her to admit her agency overlooked these cases.

"You know, I don't think it's been a board problem whatsoever," Mercer responded. "I think the (person in the) position I'm in and the leadership that was here had a responsibility to keep this board informed. And I do not feel they kept them informed."

The Board of Nursing has been plagued with issues throughout the last year.

In September 2007, McMinnville resident Alycia Juber joined a choir of critics - including the Dept. Of Administration - in telling the state board their lack of oversight was posing a risk to public safety.

Juber testified before the board, telling them a nurse with a criminal history injected her father with a lethal dose of morphine.

"Members of this board knew about it and did nothing," she said.

The Oregon Nurses Association (ONA) says it agrees with the board's crack-down, but they are also mindful of the fact the nature of complaints can vary.

"There are many complaints that are made to the board that turn out to be unfounded. And some are serious. So we believe the standards of due process need to be met," said ONA Executive Director Susan King.

So what happens now, especially for those who filed complaints against problem nurses?

"We say to them we are starting to triage the most serious cases first and we will assure them that we are following up and taking appropriate action," Mercer told KATU News. "And we're trying to make that happens as fast as possible."

Mercer says the board plans to hire additional investigators. She said they are dealing with about 1,000 cases - a small percentage of the state's 65,000 nurses and nursing assistants.

The agency reports the top complaints against nurses and nursing assistants involve substance abuse, patient abuse or neglect and fraud. Other issues may be as minor as turning in the wrong paperwork.