A new report exposes gaps in nurse accountability
The Beltrami County Jail in Bemidji, Minn.
Dan Gunderson | MPR News
You may recall the story of a Beltrami County inmate who died after medical staff ignored his pleas for help. That was back in 2018 and since, almost everyone involved in his care and confinement has been held accountable, except for the nurse who failed to check his vitals while he lay in anguish on his cell floor.
Despite a complaint being lodged against her and a judge’s opinion that she was negligent in her duties, her nursing license remains unblemished. And she isn’t the only one.
ProPublica Reporter Emily Hopkins joined MPR News host Cathy Wurzer to talk about her story published Monday that shows how the Minnesota Board of Nursing is falling short when it comes to nurse discipline.
Use the audio player above to listen to the full conversation.
Subscribe to the Minnesota Now podcast on Apple Podcasts, Google Podcasts, Spotify or wherever you get your podcasts.
Create a More Connected Minnesota
MPR News is your trusted resource for the news you need. With your support, MPR News brings accessible, courageous journalism and authentic conversation to everyone - free of paywalls and barriers. Your gift makes a difference.
Audio transcript
INTERVIEWER: You may recall the story of a Beltrami County inmate who died after medical staff ignored his pleas for help. Now, this was back in 2018. And since, almost everyone involved in his care and confinement has been held accountable except for the nurse who failed to check his vitals while he lay in anguish on his cell floor.
Despite a complaint being lodged against her, and a judge's opinion that she was negligent in her duties, her nursing license remains unblemished. And she's not the only one. Reporting from ProPublica out today shows how the Minnesota Board of Nursing is falling short when it comes to nurse discipline. Here to tell us more about it is reporter Emily Hopkins. Emily, welcome to the program.
EMILY HOPKINS: Thank you for having me.
INTERVIEWER: You wrote this story with your colleague, Jeremy Kohler, I understand. Complaints against nurses can sit for weeks or even months, simply because they weren't forwarded in a timely manner. There's a hefty backlog of cases. What's going on?
EMILY HOPKINS: Yeah, so the really difficult part of the story is that there's no one clear driver that we can point to, except to say from our reporting that there's sort of a culture of inefficiency and dysfunction. But that several board-- former board employees have reported to us. And the result of that has-- comes out in the numbers.
It takes an average 11 months for complaints to be resolved. And that's even when state law says they should take less than a year. So if it's taken on average 11 months, many, many cases are taking longer than that. So unfortunately, no clear answers on that front.
INTERVIEWER: Has the backlog and the delays led to nurses being able to continue to work even in other facilities while their case languishes?
EMILY HOPKINS: Yes. Precisely. So when an investigation against the nurse takes this long, they keep their license while the investigation has happened. And that's perhaps for good reason because some complaints are false. And some complaints do-- many, many complaints do get dismissed against nurses.
But we've found that in some cases, where nurses are accused of serious misconduct, and that misconduct has been even substantiated through investigations by other state agency, the Board of Nursing still takes a very long time to act. As you know, we feature another-- two other stories of nurses who kept their licenses as they were being investigated. And ultimately did get new jobs, based on the fact that their license was completely clean, and were able to actually go on to hurt additional patients.
INTERVIEWER: One of those stories deals with a nurse at a nursing home in greater Minnesota. Let's look to this story in Beltrami County, as an example. Tell us what happened there, and what has and has not happened as a result.
EMILY HOPKINS: Yeah, so I am sure that many, many, many people in Minnesota are familiar with this man, Hardel Sherrell, who died over the course of many days, ultimately, in a Beltrami County jail. He died of a treatable neurological issue. But in the final days of his life, a nurse did not even enter his cell to check his vitals, according to an administrative law judge who found evidence that the medical board should suspend indefinitely the license of the doctor.
This doctor, of course, was monitoring the situation by phone. Was not even in the facility. So it leaves-- it leaves people, including Sherrell's mother, kind of scratching their head, as to why the person who is sort of most directly responsible for his care would still be able to go out and practice nursing.
We have-- in the wake of that incident, there have been state reforms on medical care for inmates. There's been investigations into the jail by the Department of Corrections. The FBI is involved. The attorney general recently said they may be pursuing criminal charges. Yet, you know, nothing-- at least publicly-- has happened to this particular nurse's ability to practice. So I think-- and for the mother of Hardel Sherrell, that is something that is deeply upsetting.
INTERVIEWER: So you mentioned at the beginning of our conversation, inefficiencies and dysfunction at the nursing board. What does that do, or what does that point to?
EMILY HOPKINS: What we've seen is there's an email-- it can be something as simple as an email, inbox. Complaints that are emailed to the board get lost in the general inbox. It seems like are-- there's been a large amount of turnover. People who have told us that they just didn't feel like they could do their jobs well because there was just not a clear sort of management style that allowed them to deal with cases with the urgency that they believe that they were owed.
I mean, one thing-- one of the major-- it seems really simple. One of the major things that the board pointed out to the public after that 2015 audit, and previously a 2013 investigation by the "Star Tribune," they said, hey, we're going to start meeting every other month. 12 times a year, rather than six times a year.
And this is going to really allow us to move these discipline cases more quickly, get the final sign off. And for nurses who are having their licenses suspended, get those licenses suspended more quickly.
INTERVIEWER: It hasn't happened.
EMILY HOPKINS: Around 2018 or so, they stopped. They did that, and then they stopped. And we don't really-- we have no real, clear reason why.
INTERVIEWER: Final question here. What does the board tell you about this?
EMILY HOPKINS: You know, the board acknowledged the backlog. The executive director, Kimberly Miller, has said that she has, since her appointment in 2021, is trying to right the boat. She points to a new case management system-- as that's been difficult to work with-- as one of the reasons that these numbers have grown in the past several years.
But many questions, especially from former-- based on former staff members talking about dysfunction and mismanagement, have gone unanswered. She has not responded to those questions.
INTERVIEWER: All right. Emily, thank you so much for your reporting.
EMILY HOPKINS: Thank you for having me. Thank you so much.
INTERVIEWER: That was Emily Hopkins of ProPublica. ProPublica is a nonprofit newsroom that investigates abuses of power. They have a newsletter called "The Dispatch." It spotlights wrongdoing around the country. You can sign up for it at propublica.org.
Despite a complaint being lodged against her, and a judge's opinion that she was negligent in her duties, her nursing license remains unblemished. And she's not the only one. Reporting from ProPublica out today shows how the Minnesota Board of Nursing is falling short when it comes to nurse discipline. Here to tell us more about it is reporter Emily Hopkins. Emily, welcome to the program.
EMILY HOPKINS: Thank you for having me.
INTERVIEWER: You wrote this story with your colleague, Jeremy Kohler, I understand. Complaints against nurses can sit for weeks or even months, simply because they weren't forwarded in a timely manner. There's a hefty backlog of cases. What's going on?
EMILY HOPKINS: Yeah, so the really difficult part of the story is that there's no one clear driver that we can point to, except to say from our reporting that there's sort of a culture of inefficiency and dysfunction. But that several board-- former board employees have reported to us. And the result of that has-- comes out in the numbers.
It takes an average 11 months for complaints to be resolved. And that's even when state law says they should take less than a year. So if it's taken on average 11 months, many, many cases are taking longer than that. So unfortunately, no clear answers on that front.
INTERVIEWER: Has the backlog and the delays led to nurses being able to continue to work even in other facilities while their case languishes?
EMILY HOPKINS: Yes. Precisely. So when an investigation against the nurse takes this long, they keep their license while the investigation has happened. And that's perhaps for good reason because some complaints are false. And some complaints do-- many, many complaints do get dismissed against nurses.
But we've found that in some cases, where nurses are accused of serious misconduct, and that misconduct has been even substantiated through investigations by other state agency, the Board of Nursing still takes a very long time to act. As you know, we feature another-- two other stories of nurses who kept their licenses as they were being investigated. And ultimately did get new jobs, based on the fact that their license was completely clean, and were able to actually go on to hurt additional patients.
INTERVIEWER: One of those stories deals with a nurse at a nursing home in greater Minnesota. Let's look to this story in Beltrami County, as an example. Tell us what happened there, and what has and has not happened as a result.
EMILY HOPKINS: Yeah, so I am sure that many, many, many people in Minnesota are familiar with this man, Hardel Sherrell, who died over the course of many days, ultimately, in a Beltrami County jail. He died of a treatable neurological issue. But in the final days of his life, a nurse did not even enter his cell to check his vitals, according to an administrative law judge who found evidence that the medical board should suspend indefinitely the license of the doctor.
This doctor, of course, was monitoring the situation by phone. Was not even in the facility. So it leaves-- it leaves people, including Sherrell's mother, kind of scratching their head, as to why the person who is sort of most directly responsible for his care would still be able to go out and practice nursing.
We have-- in the wake of that incident, there have been state reforms on medical care for inmates. There's been investigations into the jail by the Department of Corrections. The FBI is involved. The attorney general recently said they may be pursuing criminal charges. Yet, you know, nothing-- at least publicly-- has happened to this particular nurse's ability to practice. So I think-- and for the mother of Hardel Sherrell, that is something that is deeply upsetting.
INTERVIEWER: So you mentioned at the beginning of our conversation, inefficiencies and dysfunction at the nursing board. What does that do, or what does that point to?
EMILY HOPKINS: What we've seen is there's an email-- it can be something as simple as an email, inbox. Complaints that are emailed to the board get lost in the general inbox. It seems like are-- there's been a large amount of turnover. People who have told us that they just didn't feel like they could do their jobs well because there was just not a clear sort of management style that allowed them to deal with cases with the urgency that they believe that they were owed.
I mean, one thing-- one of the major-- it seems really simple. One of the major things that the board pointed out to the public after that 2015 audit, and previously a 2013 investigation by the "Star Tribune," they said, hey, we're going to start meeting every other month. 12 times a year, rather than six times a year.
And this is going to really allow us to move these discipline cases more quickly, get the final sign off. And for nurses who are having their licenses suspended, get those licenses suspended more quickly.
INTERVIEWER: It hasn't happened.
EMILY HOPKINS: Around 2018 or so, they stopped. They did that, and then they stopped. And we don't really-- we have no real, clear reason why.
INTERVIEWER: Final question here. What does the board tell you about this?
EMILY HOPKINS: You know, the board acknowledged the backlog. The executive director, Kimberly Miller, has said that she has, since her appointment in 2021, is trying to right the boat. She points to a new case management system-- as that's been difficult to work with-- as one of the reasons that these numbers have grown in the past several years.
But many questions, especially from former-- based on former staff members talking about dysfunction and mismanagement, have gone unanswered. She has not responded to those questions.
INTERVIEWER: All right. Emily, thank you so much for your reporting.
EMILY HOPKINS: Thank you for having me. Thank you so much.
INTERVIEWER: That was Emily Hopkins of ProPublica. ProPublica is a nonprofit newsroom that investigates abuses of power. They have a newsletter called "The Dispatch." It spotlights wrongdoing around the country. You can sign up for it at propublica.org.
Download transcript (PDF)
Transcription services provided by 3Play Media.