Michelle McMahan stole her patients' pain medications so she could take them herself.

Diana Bjorneberg supported her drug habit by tampering with syringes and putting patients at risk for infection.

Catherine Callaway replaced liquid anesthetics with saline, feeding her addiction while leaving patients to suffer.

They are three of the 112 Minnesota nurses who since 2010 are licensed to practice despite having either stolen narcotics on the job, fraudulently obtained prescriptions, or practiced while impaired by drugs or alcohol, a Star Tribune examination of more than 1,000 Minnesota Board of Nursing disciplinary records has found.

Nearly all of those nurses have kept their licenses by taking part in a state program created to protect the public from health professionals who are alcoholics or drug addicts. To avoid further board action, they have to prove they are sober and getting treatment.

Yet records show that nurses have been able to keep practicing while abusing drugs or alcohol, raising questions about whether the program actually works.

Nurses can spend months under state monitoring while missing or failing drug tests, disciplinary records show. If they are kicked out of the program, it can take months more for the Nursing Board to act. Some nurses have been able to use or steal narcotics while enrolled in the program, records show, while others completed the monitoring but later relapsed.

Former nurse Sue Qualick said she stole painkillers from St. Paul's Regions Hospital for a year while under state monitoring. "There should have been a red flag for somebody," Qualick told the Star Tribune. "I don't think I should have gotten away with it for as long as I did."

For at least 67 currently licensed nurses, the state monitoring agency, which is called the Health Professionals Services Program (HPSP), has become a revolving door, Nursing Board records show. They have failed out of the program, only to be sent back by the Nursing Board and allowed to keep practicing.

The HPSP manager, Monica Feider, acknowledged that the state program isn't "foolproof."

But she said health care professionals with addictions are safer to the public if they are in the program.

"Being monitored, then you know that they're sober," Feider said. "There are cases where individuals are using, but I like to believe that those are few and far between."

When asked if nurses should lose their license if they take medication meant for patients, Nursing Board executive director Shirley Brekken replied: "Substance use disorders are an illness."

"The concern has to be for the safety of the public, but for the future of the individual as well," she said.

Giving nurses who are addicts repeated chances puts Minnesota patients at risk, said Dr. Marvin Seppala, the chief medical officer at the drug treatment center Hazelden.

If nurses flout the rules of the state monitoring program, "I think they should have their licenses revoked," Seppala said. The only way these nurses should get their licenses back is permanent monitoring, Seppala said. That isn't available in Minnesota.

When told of the Star Tribune's findings about the state monitoring program, Gov. Mark Dayton said the system sounded "very wrong."

"There should be consequences," the governor said. "Somebody who's using illegal drugs or abusing alcohol or engaging in misconduct or malpractice should understand there's no place for them in the health care professions."

Patients in pain

The consequences for patients can be devastating when nurses steal drugs from their workplaces.

In 2011, 25 St. Cloud Hospital patients came down with a bacterial infection after nurse Blake Zenner replaced their liquid hydromorphone with tainted saline, according to the U.S. Department of Justice. A Minnesota Department of Health report said that within two days of becoming infected, one patient died, three required surgeries and six needed intensive care. In 2010, nurse Sarah Casareto was accused of telling her surgery patient at Abbott Northwestern Hospital to "man up" instead of giving him pain medication she had kept for herself.

Those cases represent some of the most extreme examples of a growing problem both for employers of nurses and the Nursing Board.

Reports of Minnesota health care professionals who have diverted — the industry's term for drug theft — jumped 325 percent from 2006 to 2010, the most recent data available from the Drug Enforcement Administration and state health department.

Health care facilities across the state have responded by tightening their protocols to keep track of narcotics. Yet addicted nurses figure out ways to get them, records show. They override dispensing machines, tamper with medications, get fake prescriptions, falsify records to hide their thefts, give small doses to themselves that are meant for patients, or take excess medication that's supposed to be destroyed.

"Nurses have much more access to prescription medications and diversion of those substances than physicians do," Seppala said. "It's a major part of their job. They are really are at the highest risk for such diversion."

The Nursing Board estimates that about 85 percent of nurses who admit to diverting have at some point lost their licenses. That's what happened to Zenner and Casareto.

Most are given the opportunity to regain those licenses if they prove their sobriety and meet other conditions. Since 2010, the Nursing Board has licensed 94 nurses accused of diversion or illegally getting prescription drugs, the Star Tribune found. Of those, 71 have no limitations on working with narcotics. Those include nurses like Elizabeth J. Foss, who has a history of drug abuse, being impaired on the job, and allegations that she stole Vicodin for herself and her boyfriend, who was also one of her patients, according to a Nursing Board record.

Foss said in an interview that she has completed treatment and that "everybody makes mistakes. I've learned from them and moved forward."

When presented with the Star Tribune's findings, Deb Holtz, the state's long-term care ombudsman, responded, "that's horrific to me."

Holtz said nurses who have stolen medications from patients should permanently lose their licenses due to the harm they have caused.

"We need to take a look at the language in our state and federal law that enable us to give people second chances, and determine if those are actually working to the best benefit for the patients, clients and residents," she said.

Prescription drug abuse isn't the only addiction that results in referrals for state monitoring. Twice convicted of DWI, Jane Conroy was a school nurse for South Washington County schools when in 2011, she drank eight to 10 shots of liquor one day, then went to work the next day and provided care to students while under the influence of alcohol, according to the Nursing Board. She enrolled in the HPSP in March 2012 but was kicked out after submitting three problem screens, failing to provide three others and failing to respond to the program's attempt to contact her.

The Nursing Board allowed Conroy to keep her license and ordered her to go back to the monitoring program in April 2013. Conroy's license was suspended in August after she started drinking again, the board report said.

High rate of failure

More than 600 health care professionals are enrolled in the state monitoring program. That number has grown by 15 percent in the last five years. About half of them are nurses, making them the largest group of professionals under monitoring.

Compared with doctors, nurses are more than twice as likely to fail the requirements of state monitoring, a Star Tribune analysis shows. Feider, the HPSP manager, said that's probably due to two reasons: nurses work directly with narcotics and make less money.

"Nurses don't have the same financial resources as physicians to seek treatment, to pay for treatment, to pay for screens," Feider said.

Even after successful completion of monitoring, typically a three-year term, some nurses who handle narcotics can't resist the temptation and relapse.

"It was like being a kid in a candy store," said former nurse Melissa Anne Moir.

Moir said she entered the HPSP in 2006 after stealing powerful painkillers like morphine, Fentanyl and Dilaudid from Unity Hospital in Fridley. She successfully completed the program after three years but began diverting again in 2010 while working as a traveling nurse for a dialysis company.

According to the Nursing Board report, she took pain patches off her patients for her own use, abused medication that was supposed to be destroyed, and volunteered to give medications for other nurses, only to use them herself. She diverted from seven hospitals in two years before being caught, according to the report.

Moir's license was suspended in February, about 10 months after she said she stopped stealing drugs. She said the HPSP was a good program, but added, "If it had worked, maybe I wouldn't have reoffended."

Another nurse, Ann Fleisch­man, took pain medications from hospital patients three years after completing state monitoring. Fleischman already had a history of diverting in 1990 when she worked at a Seattle hospital but was able to obtain a license in Minnesota in 1994. She stole morphine, Demerol and Fentanyl from intensive care patients while working at a St. Louis Park hospital in 2002 and 2003, used while on duty, and was charged with a felony drug crime, according to the Nursing Board report. Instead of imposing discipline, the board sent Fleischman to the HPSP, which she completed in 2006.

Three years later, Fleisch­man's supervisors at a hospital in Robbinsdale noticed discrepancies in her documentation regarding pain medication. Patients said they never got the medication that Fleischman claimed she had given them. She admitted that she had taken the medications for herself, according to the Nursing Board report. This time, the board suspended Fleischman's license. The board reinstated her license in 2011, then suspended it again two months later after Fleischman failed to contact the monitoring program.

Protecting the public?

Former nurse Jerold Mullins underwent three rounds of state monitoring but still managed to divert narcotics from his workplaces for 15 years before the board took his license away. Because Mullins self-reported to the HPSP, rather than being ordered to do so by the Nursing Board, nothing in the law required the monitoring program to tell the board about his dangerous conduct.

That case prompted a Nursing Board task force to examine the HPSP last year. The task force identified more than 30 issues it had with the monitoring program.

During one task force meeting, Judy Reeve, a nursing practice specialist for the board, said the monitoring protocols the HPSP uses are identified as "draft" and noted that "no study of the HPSP has ever been completed and we do not know if the protocols effectively protect the public," according to meeting minutes.

Another issue identified: The HPSP has to trust what participants, treatment providers and employers tell it, because it doesn't have the resources or authority to do its own investigation.

"For example," a report said, "licensee may disclose diversion, but no investigation is undertaken to determine whether there was patient harm."

One Nursing Board member, Deborah Meyer, said during a task force meeting that the HPSP didn't "have the ability or the authority to protect the public from practice violations."

Another concern: the HPSP doesn't report to the board until after three to four problem drug screens, and participants are allowed to skip drug screens too often.

One nurse, Dayton D. Carlson, gave three unusable screens, missed seven others and then tested positive for narcotics in January 2013.

He told the Nursing Board the skipped or unusable screens were intentional because he was using drugs, according to the Nursing Board report. Carlson remains licensed after completing treatment and telling the board he would stay sober.

Feider said claims that the HPSP isn't protecting the public are "inaccurate." While no study has been done of the HPSP, Feider said studies of similar monitoring programs in other states showed the programs are effective.

She said steps can be taken to improve state monitoring, including adding another case manager to the program. The five case managers handle about 100 to 120 cases, "higher than we'd like," Feider said.

Feider said the HPSP doesn't just rely on drug screens to determine whether nurses are still using, but also tries to learn that information through reports by nurses' employers and treatment providers.

And, she added, "even though it may seem absolutely crazy, sometimes when a nurse who has diverted reports to our program, and I talk with their supervisor, the supervisor will say 'They were my best nurse.' … Being chemically dependent does not necessarily mean being impaired."

Still, the Nursing Board wants to ensure that it's notified when nurses divert drugs. Next year, the Legislature is expected to take up a bill that would require employers to tell the licensing boards about diversion cases. The Nursing Board supports the measure.

'Addicted to the excitement'

Even if that bill passes, it does nothing to help the HPSP stop nurses like Qualick, who stole and used drugs on the job while under state monitoring.

"It was really easy to get away with," she said.

Qualick, 59, of North St. Paul, got her license in 1986 and a year later began working at hospitals in St. Paul. But she struggled with alcoholism and underwent treatment in 1995.

In 2000, while working at Regions Hospital, she said she took Percocet from a patient who didn't want it. Qualick knew it was wrong, but she did it "just too see what would happen." The theft went undetected.

Eventually, "I became addicted to the excitement of it," she said.

She would use daily and sometimes during her shifts. She left Regions Hospital and went to work for United Hospital, stole drugs and got caught. She realized she had a problem and entered drug treatment and reported to the HPSP. She was hired again at Regions, which she said didn't know her drug history.

Qualick successfully completed drug treatment and state monitoring by 2004.

She went back to the HPSP in 2007 after she was worried she would start diverting again while battling pain from a broken arm. It didn't help. A few months later the pain drove her to take extra narcotics out of a dispensing machine.

Qualick said she could fool the monitoring program by stopping her drug use before doing the tests, because she always had a few days' notice. The HPSP requested that she not work with pain medications, but she said her supervisor at work never heeded that request.

The HPSP required updates from her, her supervisor and her doctors, but Qualick called them "Mickey Mouse stuff." She said an HPSP case manager never called her while she was being monitored.

"The people in HPSP ought to do more to make personal contact with their clients," Qualick said. "As long as I kept sending in reports, they didn't bother me."

After a year of diverting and sometimes daily use, Qualick was caught by the hospital's pharmacy. The HPSP was notified, which referred her to the Nursing Board. In 2010, the board restricted her from working with narcotics but allowed her to keep practicing. She retired in 2012.

Though Qualick didn't think she was harming patients because she was stealing from the hospital's supplies, she realizes now she was wrong.

"If you're thinking about diverting drugs, maybe I wasn't thinking about my patients as much as I could," she said. "The thought that I could be harming my patients bothers me a lot."

Brandon Stahl • 612-673-4626