Boards of nursing are responsible for protecting the public from unsafe nursing care. This mandate is increasingly challenged by impostors and the submission of fraudulent documents to boards of nursing. Some people see the increased need for nursing care combined with the nursing shortage as an opportunity to raise their income by seeking employment without the proper credentials. In today's high-technology world of computers, scanners, photocopiers, and color printers, fraudulent documents can easily be created and may be more difficult to identify.
Forensic document examiners offer services of examining and offering written opinions on a variety of disputed documents. These can range from legal documents (ie, wills, deeds, and contracts) to financial documents (ie, loan applications and income tax records) to medical records and licensure applications. However, these services are not the first line of defense against fraudulent documents. Long before the experts are consulted, questionable documents have to be identified. Much depends on the knowledge, skill, and experience of nursing board staff responsible for reviewing licensure applications. They are expected to identify incomplete and problem applications.
One case in California was initiated when a staff member noticed that some applicants had exactly the same information related to birth dates and school information. A closer review of 20 international applications from the same country revealed that 14 initial applicants had the same number of hours of education, the same handwriting, and what appeared to be the same ink used on the documents. Theoretical instruction and clinical practice hours were identical for different applicants who attended different schools. The same error appeared on 14 of the reviewed applications, an identical error made in adding up the total hours of instruction. The government seals appearing on the documents appeared to have been "cut and pasted" and/or photocopied. Several of the photocopied diplomas appeared to have altered names, dates, diploma numbers, and official seals. All of the questionable applications had been submitted by the same translation service in Los Angeles, California.
The documents were submitted to the Los Angeles Police Department's Questioned Document Section for examination to determine if the documents were from the same source. The forensic examination revealed that a large number of the photocopied nursing school transcripts and diplomas were made on the same copier, despite their being from schools in different cities separated by several hundred miles. The examiner stated that different government seals appearing on these documents were photocopied onto the various documents using several different methods, and there was a similarity in the handwriting and type appearing on many of the documents. The examiner stated that the results of her examination indicated that most of the documents were from one source.
A search warrant was obtained (all investigators in California are peace officers with subpoena and arrest authority), and a search was conducted on the office of the translation service. Items seized as evidence included a kit containing ink pads; notary labels and seals/stamps from several international educational programs; and a folder containing numerous photocopied, altered, or blank documents (including birth certificates, death certificates, marriage certificates, high school transcripts, college transcripts, nursing school transcripts, and various diplomas).
The man who ran the translation service promoted himself as an agent able to help international applicants work through the licensure application process. Some of the applicants were not nurses and knew very well that false information was being submitted on their behalf. Other individuals who worked with this agent were nurses who were just trying to navigate the state's licensure process and were unaware of the agent's subterfuge. They were also victims of the fraud. The agent was convicted of fraud and offering false instruments and was sentenced to 5 years of probation and 180 days in jail.
Anyone who reviews documents supporting high-level decisions needs to be aware of the possibility of fraudulent documents. Visual inspection provides the first level of scrutiny. Is the document on official stationery or form? Is the quality of the paper what would be expected for official documents? Is the print smudged or blurry? Is the print consistent, without any appearance of cut and paste or changed elements or photocopy? If a transcript or a document has a seal, does the seal look genuine? No one point indicates a forgery but can raise suspicions. Multiple points intensify the concern.
A second level of assessment is to consider the content of the application. Are the elements congruent? Do the dates fit with the rest of the document? Does the application make sense?
Finally, there is what might be called the art of document evaluation that comes from experience. Something does not feel right although it might be difficult to identify and articulate. This type of "dis-ease" should be examined. Did that nursing school exist at that time reported for graduation? How does the document compare with other applications from the same school or country? Is there an opportunity to compare the document with similar documents from the same source? It was the board staff's pickup that the same information appeared on several applications that triggered the California investigation. That staff person was observant on all three levels.
Not all states have experienced the same level of impostor activity, but all boards are aware of the potential risk to the public if unqualified individuals attempt to offer nursing services to their citizens. As a response to a growing concern regarding impostors and the use of fraudulent documents in applications for nursing licensure, the National Council of State Boards of Nursing is developing resources to support boards of nursing in the identification of fraudulent documents and in tracking impostor activity.
It is important for the nurse manager to be aware of these possible fraudulent documents when interviewing candidates and dealing with documents produced by those candidates in support of their application. This is especially true in a smaller facility, where the manager may not have a human resources staff available to investigate any discrepancies. The facility has a duty to ensure that the applicant is in fact the holder of any proffered license and the license is legitimate. Failing to do so has potentially dire consequences for both the nurse manager and the facility. The state board of nursing should always be contacted if there is any doubt as to the identity of the applicant or the status of a proffered license, as should the human resources department and the facility's legal counsel.