Nursing Boards Failing at NP Oversight?

Change may be necessary to keep patients safe

Published at MedPage Today

https://www.medpagetoday.com/nursing/nursing/82253

Family physician Amy Townsend, MD, first learned of Optimum Family Wellness in January of 2017 when a friend of hers, a physically fit man in his 40s, told her that he was going to be visiting the clinic.

Although the Nederland, Texas clinic was run by nurse practitioners, Townsend was initially unconcerned because her friend had no serious health problems and was simply seeking a refill for his routine thyroid medication.

But Townsend quickly grew skeptical when her friend showed her the slew of lab tests ordered by nurse practitioner Kevin G. Morgan even before an initial office visit -- a panel of nonspecific hormone tests including a C-peptide, growth hormone, prolactin, and a random cortisol level, which added up to a whopping $6,500.

But more worrisome to Townsend were prescriptions that nurse practitioner Morgan had prescribed for her friend: testosterone injections and a higher dose of thyroid medication, despite the fact that the patient's initial labs were completely normal, including a healthy testosterone level of 696.

Worried about the risk of excessive testosterone, which is associated with an increase in heart attacks in men, Townsend called Morgan personally to discuss the treatment plan. "He was contrary and condescending to me, offering to 'send me literature' on testosterone therapy," Townsend recalled.

A family nurse practitioner, Morgan received his master's degree in nursing in 2013 from McNeese State University, a 100% online program. Morgan had neither the training nor experience to treat endocrine problems like thyroid disease or low testosterone. And to Townsend, he seemed unconcerned about the potential side effects of these medications.

Instead of continuing the conversation, Townsend asked for Morgan's supervising physician.

Texas law requires that nurse practitioners be supervised by a physician. Morgan's supervising doctor at the time was Marian Querry, DO. Querry, a general surgeon, did not have the same medical background as the nurse practitioner she supervised, nor was she a specialist in endocrine problems. She practiced at a location 150 miles away from Optimum Wellness.

Townsend contacted Querry to express her concerns over Morgan's care, and threatened to report her to the Board of Medicine for improper supervision of the nurse practitioner. In response, Querry elected to withdraw her supervision of Morgan.

But within days Morgan was back in business, having established a supervisory relationship with a new physician -- obstetrician-gynecologist James Kern, MD. Morgan would later arrange supervision with a third doctor, Dr. George Brown, Jr.

Patient Deaths

About a month later, Townsend learned of the death of Brad Guilbeaux.

Brad Guilbeaux, a 45-year old father of two from Texas, initiated care with nurse practitioner Morgan on March 31, 2015. Over the next year and a half, Morgan prescribed excessively high doses of supplemental testosterone and thyroid medication. On February 23, 2017, Brad Guilbeaux died of cardiac arrest.

Concerned that excessive prescribing of testosterone may have contributed to Guilbeaux's death, Townsend sent a letter to the Board of Nursing on February 28, 2017, asking them to investigate. She included details about her friend's experience with the clinic, including the improper prescribing of dangerous medications.

Within a few weeks, Townsend learned of another death of an Optimum patient. Because she hadn't heard back from the Board of Nursing, Townsend says she called them repeatedly to inquire about the status of their investigation. "I was told, 'we're working on it, we can't give out information due to confidentiality.'"

On June 28, 2017, the Texas Board of Nursing advised Morgan by letter that an investigation had been opened. Morgan vigorously defended himself in multiple media interviews. He claimed that physician accusers were "jealous" of his success, and even shared the letter from the Board of Nursing with a news station for public viewing.

However, Morgan had altered the letter, forging an additional sentence stating that "there were no findings" in the Board's investigation.

Based on this alteration, the Board formally charged Morgan on August 31, 2017 -- but not for patient harm. Rather, the Board cited Morgan for altering a document in conduct "likely to deceive the public." This citation did nothing to restrict Morgan's license, and he continued to treat patients.

Doctor Confronts Nursing Board

Concerned for the safety of other patients, Townsend personally drove to the Board of Nursing office several hours away in Austin, Texas. She says she spent almost an hour there with the Board of Nursing's executive director, general counsel, investigator, and director of enforcement. Townsend says she was told that action had been delayed because the Board was having a difficult time finding an endocrinologist to testify against Morgan.

Feeling stymied by the nursing board, Townsend contacted the Drug Enforcement Administration (DEA), which regulates the use of testosterone, a controlled substance. The DEA raided Optimum in October, removing eight boxes of evidence.

On October 20, 2017, the Texas Board of Nursing finally filed formal charges against Morgan, alleging that his prescriptions for testosterone and thyroid hormone put 12 patients at risk and might have contributed to two deaths.

And on December 1, 2017, nearly a year after Townsend first reported Morgan to the Board of Nursing, his license to practice was temporarily revoked, with the board concluding that "the continued practice of nursing by Kevin Morgan constitutes a continuing and imminent threat to public welfare."

In March 2019, Morgan voluntarily surrendered his license but denied any wrongdoing, arguing that his treatment "did not injure" the 12 patients and that any negative outcomes were caused by "preexisting health conditions." According to a news report, Morgan will be eligible to petition for reinstatement of his license in one year.

Can Nursing Boards Provide Adequate Oversight?

While gratified that Morgan is no longer providing medical care to patients, Townsend is concerned about the efforts that it took to have him removed from practice. "The Texas Board of Nursing seems incapable of dealing with nurses practicing medicine. They don't have a basic foolproof process to deal with nurse practitioners who are dangerous."

Other states have had similar problems. The Tennessee Board of Nursing allowed nurse practitioner Christina Collins to continue to practice even after state attorneys recommended that her license be revoked.

Collins, one of Tennessee's top opioid prescribers, was accused of prescribing "massive" amounts of controlled substances in 2012. According to news reports, Collins defended herself to the board by pleading ignorance, arguing that she was simply refilling prescriptions and that she later learned that the doses were too high. In 2018, state attorneys accused the nursing board of making an error in allowing Collins to keep her license and asked the court to order the nursing board to reconsider the case.

Boards of Nursing are responsible for the licensure and monitoring of nurses, including licensed practical nurses, registered nurses, and nurse practitioners. But with nurse practitioners now providing higher levels of care, with responsibilities that were formally permitted only to physicians, are nursing boards capable of providing proper oversight?

There is also the question of whether nursing boards can monitor the large number of nurses under their jurisdiction. For example, in Texas, a nursing board of only 13 members supervises 452,000 nurses – 26,000 nurse practitioners, 320,000 registered nurses, and 106,000 licensed vocational nurses. Compare that to the Texas Board of Medicine, which has nineteen members to supervise just 79,000 physicians.

Also, nursing boards are often comprised of registered nurses and licensed practical nurses, as well as nurse practitioners. Can a non-nurse practitioner accurately judge care provided by a nurse practitioner, when the scope of practice is vastly different?

With the rapid growth and increasing scope of practice of nurse practitioners across the country, states must ask whether Boards of Nursing can provide proper regulation and oversight to ensure patient safety. The cases of nurse practitioners Kevin G. Morgan and Christina Collins indicate that change may be necessary.

Rebekah Bernard, MD, is a family physician in Fort Myers, Florida, and the president of Physicians for Patient Protection.