JOHNSON CITY, Tenn. (WJHL) — Despite a warrant and a grand jury presentment against her five months ago, a travel nurse fired by Ballad Health last July for stealing narcotics intended for patients got another job out of state and allegedly did the same thing — and questions remain about the case that put dozens at risk.

Ballad acted on evidence Jacqueline Brewster had stolen narcotics from Johnson City Medical Center (JCMC) — firing her, reporting her and sending about 100 patients letters telling them to test for blood-borne diseases due to Brewster’s alleged actions.

Ballad also sent a news release that said the hospital system had fired a travel nurse for “improperly handling controlled substances. But Brewster’s name wasn’t made public until a similar case against her last month in West Virginia.

News Channel 11 is piecing together the limited information it’s gotten access to so far, while trying to get more documents and speak to law enforcement and state nursing board officials.

So far, only an attorney representing eight people potentially exposed to illness at JCMC has spoken, along with a CEO whose company maintains disciplinary action databases for health care clients.

Attorney Robert Bates said the lack of information is both highly concerning and, in the case of Ballad Health’s failure to divulge Brewster’s name to him — a potential violation of Tennessee law. John Benson of Verisys, meanwhile, said it’s common for nurses and other practitioners to slip through the cracks of a system that involves 50 different state bureaucracies, many of them thin on staff and swamped with a variety of regulatory chores.

‘The health care system is so overly burdened by administrative requirements today that for there to be any kind of improvement around this, it would really take a quantum leap in applying automation and technology to the system, which is not happening.’

John Benson, CEO, Verisys

“This nurse is not an outlier,” Benson said. With drug abuse common nationwide and 15 million people employed in health care, the access to drugs it provides in many settings creates opportunities that people with abuse issues tend to seize upon, he said.

Bates, an attorney based in Kingsport, wants to know how Brewster managed to get another job and allegedly commit a similar violation. His clients were potentially exposed to HIV and hepatitis because Brewster’s medication tampering affected vials their own meds could have been drawn from.

“Each time they get a test, they’re scared to death as to what the results are going to be,” Bates said Monday. “Why is this happening again to someone else? Shouldn’t this have been prevented? It’s sad.”

Now that he knows Brewster’s name, Bates said she and the Florida agency that employed her as a travel nurse will become part of any suit he might file in the case.

News Channel 11 asked the Tennessee Department of Health (TDH) whether it could have summarily suspended Brewster’s license to practice in the Volunteer state last year when the case arose. As of late last week, the board had only scheduled a full disciplinary hearing for August and not until after the West Virginia case.

“The board does have the authority to take summary action against a licensee,” TDH spokesman Bill Christian told News Channel 11 in an email.

“Given the additional information that has recently come to light in this case, the board will hold a public meeting on April 29 to consider suspending Ms. Brewster’s multistate privilege to practice nursing in Tennessee,” Christian wrote. “Since she is a nurse licensed in Kentucky, the Tennessee Board of Nursing cannot discipline her license, but it can restrict her ability to work in Tennessee on her multistate privilege.”  

The patients Bates represents have undergone the continued stress of periodic testing since last summer, Bates said. And though Brewster’s name is on a presentment and bench warrant dated Nov. 4 and signed by First Judicial District District Attorney Ken Baldwin, it wasn’t until her arrest in Kentucky last week and the news of the similar incident in West Virginia that Brewster’s name came to the surface in Johnson City.

That delay wasn’t for lack of Bates trying, he said. He began by contacting a Ballad attorney to ask for the nurse’s identity and who they were working for, a request that was denied.

Bates then sent Ballad a certified letter notifying it of a potential lawsuit. Bates said Tennessee law required Ballad, as a potential defendant, to provide his office — as the potential claimant — “written notice … of any other person, entity or health care provider who may be a properly named defendant” within 30 days. Brewster, he said, would certainly have been a potential defendant.

Bates said he thinks Ballad was protecting Brewster and he was concerned about similar incidents. “If you don’t tell us who she is, this kind of thing is going to happen again,” he said. “Lo and behold, it did.”

Protection, maybe not — slipping through the cracks, definitely

John Benson said Verisys’s “secret sauce” is its daily scouring of disciplinary reports and other actions like sanctions, exclusions and debarments that could be red flags for hospital systems, pharmacies and other health care-related companies who are hiring.

Verisys CEO John Benson

“Our client can actually make a decision whether they want that person to show up for work and be in front of a patient again,” Benson said.

Those providers pay for that sauce and it contains as many ingredients as Verisys can find, but Benson said it still has its limits.

State health boards operate on thin budgets and have to expend lots of time on things like continuing education credit verification. They don’t necessarily have time to pursue every case quickly, and people who are accused of violations like Brewster’s still have a right to due process.

Benson said many of the accused lawyer up quickly and those lawyers often say the action resulted from a medical issue (addiction), “and they’ll typically try to seal it due to HIPAA (the federal health care privacy act).”

Layer on top of that the fact that state’s systems don’t all connect and the two main electronic health record systems in the country, Epic and Cerner, aren’t interoperable and the cracks in the system begin to emerge.

One federal system does exist. It’s called the National Practitioner Data Bank (NPDB) and it’s overseen by the Health Resources and Services Administration, the same Department of Health and Human Services agency that helps fund healthcare in poor, rural and underserved areas.

Hospitals and malpractice insurers are mandated to report.

“In theory when something like this happens that information should be reported to NPDB, and if you are properly querying NPDB … you would be notified so you could take action,” Benson said.

But that’s a tall order. The requirement is difficult to enforce on already overburdened state boards of nursing, physicians and other practitioners, Benson said.

“If as a state you’re not reporting routinely because you don’t have the staff, the feds are powerless to really take any action,” Benson said.

Added together, the lack of resources, myriad of states, agencies and systems and the sheer workload on top of trying to run hospitals or state health departments leaves definite flaws in the system.

“The health care system is so overly burdened by administrative requirements today that for there to be any kind of improvement around this it would really take a quantum leap in applying automation and technology to the system, which is not happening,” Benson said.

In cases like Brewster’s, more patients can wind up at risk, Bates said.

“Nurses trust doctors, doctors trust nurses, patients trust nurses and doctors,” he said. “There has to be that trust. When that trust is betrayed, it makes them all look bad.

“This case hurts the good nurses just as much as it does the patients. There have to be systems in place to prevent this from happening.”

Seeing that this happened once again, he said breaking that news to his clients was heartbreaking. He said his clients are still living with the damage caused by Brewster and this just opens back up wounds that never truly healed in the first place.

Benson said the answer isn’t simple. Debate still rages even over whether drug abuse is a criminal problem or a medical problem, he said. Some states use amnesty programs that allow practitioners who come forward the opportunity to get help without losing their licenses immediately.

“I applaud that because it helps some people, and if it can protect patients, that’s great,” Benson said.

Patients, he added, are most affected.

“The person who’s harmed at the end of the day is the patient, and we should be doing everything we can to protect the patient from harm,” he said.

Asked to comment, Ballad Health declined, saying the case is still pending. News Channel 11 also reached out multiple times to District Attorney Ken Baldwin’s Office regarding this case and he has yet to return our calls. Emails were also sent to the West Virginia Board of Nursing as well as the company responsible for issuing interstate nurse licensure compacts and News Channel 11 has still yet to hear back from any of these agencies.