Questioning the system that allowed nurse linked to 17 patient deaths to go undetected for years

PITTSBURGH — More than a year before former nurse Heather Pressdee was arrested and accused of killing her patients, her coworkers called her “The Killer Nurse.”

Pressdee is due in court Thursday on charges related to neglecting, attempting to kill and killing patients she was tasked with caring for. She is expected to enter a guilty plea.

The RN was repeatedly hired by facility after facility, despite leaving previous employers after being fired or resigning, often under investigation or amid concerns she was harming patients.

11 Investigates Jatara McGee has been pushing for answers about how it allegedly happened and if anything is being done to prevent it from happening again.

The alleged victims range in age from 43 to 104. They were grandmothers and grandfathers, sisters, brothers, aunts and uncles. Pressdee is charged with harming 22 patients and killing four of them. But criminal complaints and wrongful death lawsuits connect her to at least 17 deaths.

Investigators said Pressdee has now admitted to administering insulin to nursing home residents who didn’t need it. Most were not diabetic.

Pressdee worked at 11 different hospitals and nursing home facilities in four and a half years.

“I think it’s clear that there are flaws in the system, and there are not enough safeguards in the system to stop a Heather Pressdee,” said Zach Shamberg, president and CEO of the Pennsylvania Health Care Association.

PHCA is an advocacy group that represents residents and care providers.

“There are clearly loopholes in which Heather Pressdee or someone like this could go through and jump from facility to facility, provider to provider and commit these acts,” he said. “We’ve got to as a regulator community act quicker, because lives could have been saved.”

Criminal complaints document concerns beginning in December 2018. Her employee file from her first nursing job at Encompass Health Rehabilitation Hospital of Harmarville said she was counseled “due to error with insulin administration and not following doctor’s orders.”

At several facilities where she worked, coworkers had concerns that Pressdee was harming or killing residents and took those concerns to their superiors.

At Belair Healthcare and Rehabilitation Center in Lower Burrell, Pressdee’s coworkers referred to her as “The Killer Nurse,” according to a lawsuit. She was suspended and investigated by the facility, which later said it found no evidence to support coworkers’ concerns.

A criminal complaint shows an Allegheny Valley Hospital doctor became concerned after treating a second patient from Belair in February 2022. The doctor noticed both appeared to have been treated by Pressdee. The doctor made a referral to the Pennsylvania Department of Health.

The Pennsylvania Department of Health said it could not confirm when the complaint was received. It confirmed that it made a criminal referral to the Office of Attorney General, in conjunction with the Pennsylvania Department of State, in December 2022.

“The Department of Health takes all complaints seriously and follows up on all complaints. The Department is also subject to statutory confidentiality requirements that restrict what the Department can share publicly about its regulatory enforcement actions. Complaints submitted to the Department are not publicly available,” the agency wrote in an email response.

Pressdee was not arrested until May 2023.

“We didn’t have an arrest and charges until a year and a half later. Her license wasn’t pulled until a year and a half later. There is clearly a flaw in that system,” Shamberg said.

From the time of the doctor’s complaint to the state to the state referring the case to law enforcement, at least six residents died.

From the time the Pennsylvania Department of Health and Pennsylvania Department of State referred the case to the AG’s Office to Pressdee’s arrest, at least six more residents died.

11 Investigates asked the Department of State why the nurse licensing board did not move to pull Pressdee’s license.

In a Wednesday evening response nearly a week after 11 Investigates first contacted the Department of State, a spokeswoman declined to answer why the nurse licensing board did not suspend or revoke Pressdee’s license sooner.

The agency repeatedly cited state confidentiality statutes and said it cannot comment on investigatory steps.

A spokeswoman said in part, “As noted, the Department of State properly notified the Office of Attorney General about Pressdee, which is allowable under Pennsylvania law (63 Pa.C.S. § 3109). However, that law generally prohibits the disclosure of information and documents relating to investigations conducted by the Department on behalf of the licensing boards to others beyond law enforcement, professional licensure regulatory boards in other jurisdictions, or in furtherance of an investigation or prosecution.”

The Pennsylvania Department of Health declined a sit-down interview but said it is conducting a review to “identify any potential gaps” and “if appropriate, make recommendations to the General Assembly.”

Not only did Pressdee’s license remain active, none of the red flags were made known. In Pennsylvania, if a healthcare worker is fired or resigns while under investigation, future employers are not privy to that information.

“My concern would be that the welfare of the institution and the facility is being placed above the welfare of the patient,” said Chalon Young, criminal defense attorney and professor of practice at the University of Pittsburgh School of Law.

If found guilty of the crimes law enforcement said she has confessed to, experts believe Pressdee will become one of the most prolific serial killers the state of Pennsylvania has ever seen.

“I think it could happen again. I think it is probably happening a lot more than we know and not just in Pennsylvania,” Young said.

She worries about the lack of safeguards in place and the lack of changes enacted since Pressdee’s arrest one year ago.

Shamberg is now calling on state lawmakers to establish a database where troubling accusations and trends would be visible, as well as displaying a worker’s full employment history.

He said the other issue that needs to be addressed is the lack of protections in place for employers.

“Most employers are told by attorneys don’t inhibit a prospective employee’s ability to go get another job. Well, patient safety has to come first,” Shamberg said.

The families of Pressdee’s alleged victims have declined to speak publicly thus far due to the pending criminal case.

Channel 11 will be in the courtroom for Thursday’s hearing and will provide updates as we learn them.

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