Dr. Joely Nelson slumped from a living room chair onto a pillow on the hearth of the fireplace, her face scorched from the heat, her dead body riddled with drugs. A fellow anesthesiologist found her there after Nelson, 44, failed to show up for work at a Vail Valley Medical Center facility. He said she was depressed, upset about having a long-term disease and had killed herself.

Avon police and a medical examiner agreed that she died, probably intentionally, of a drug overdose. The hospital’s safety manager told police she doubted the syringes and pills around her could have come from Vail Valley.

But a hospital report to the state showed Nelson had removed fentanyl, a powerful narcotic, and another drug illegally. The autopsy found cocaine and narcotic drugs in her blood. She died with old and new puncture marks in her legs.

So how did the Vail hospital inform the public about the death of a drug-addicted anesthesiologist in February 2014?

It didn’t. As in hundreds of other drug-theft cases, hospital patients never learn if someone who treated them was involved.

Other hospitals can be left uninformed as well. Colorado hospitals from Craig to Englewood have been duped by applicants with a history of drug addiction.

In Colorado, hospital workers who get caught stealing powerful narcotics often aren’t reported to police or to federal authorities. Unless the state takes formal action against them, their names don’t show up on licensing disciplinary lists. There is little to keep a small but dangerous number of doctors, nurses and surgical technologists from moving from hospital to hospital, taking with them their addictions and risks to patients.

Even when they get fired, they can keep their licenses — and their histories secret — by promising to enter treatment. In a review of state health, licensing board and police records, The Denver Post found cases in which hospital employees worked for years in Colorado despite recurring thefts and even convictions — sometimes while participating in addiction treatment programs.

Almost always, the thief’s identity is protected.

Hospitals have managed to keep secret the names of employees passed out with needles in their arms and blood on bathroom walls, of staffers who stole hundreds of vials of fentanyl, of nurses leaving patients in pain by stealing their medicine.

In August 2010, a drug-addled staffer at Poudre Valley Hospital passed out while a patient was being put onto the operating table, state records show. At Denver Health Medical Center, a nurse resigned in November 2013 after she was seen with needles, syringes and a tourniquet stuffed in her bag, her pupils constricted after she collapsed on an empty patient bed. She was sent home in a taxi.

All of these cases occurred after Kristen Parker, a Colorado surgical technologist, infected hospital patients with hepatitis in 2008 and 2009 by injecting herself with fentanyl and leaving behind dirty needles.

In a review of 416 state reports on missing or stolen drugs from Colorado hospitals during the last six years, The Post found:

• At least two hospital workers, including Nelson, died of drug use. In January 2010, Amanda Cornstubble, 29, also was found dead in her bed by her parents, a syringe and tourniquet at her side. Police found nine empty vials of hydromorphone in her Denver apartment, the same painkiller that Porter Adventist Hospital in Denver later found she likely stole while working there.

• When hospitals report missing or stolen medicines to the Colorado Department of Public Health and Environment, state investigations often show no calls to police or the federal Drug Enforcement Administration. In 222 confirmed drug diversion cases, hospitals referred just 123 to local police, according to state reports listing facility responses. Only 70 showed a referral to the DEA.

• The Post inquired about 24 egregious cases involving employee syringe use and thefts of multiple drugs from hospitals. Police departments were unable to locate reports in 19 cases, in part because health department reports don’t name offenders.

• Dozens of theft cases involved traveling nurses hired from contract agencies to work at multiple hospitals. In some cases, hospitals simply asked the agencies not to send the nurses back to them.

• Nursing board records show people with felony records and histories of drug addiction still manage to get new jobs in Colorado’s health care system.

• The state health department almost never finds fault with hospital responses — except when reports are late.

“Dirty little secret”

On the streets, the opioid epidemic has turned into a subject of national alarm. Opioid-related deaths have tripled since 2000. In February, President Barack Obama requested $1.1 billion to combat the problem. Black-market dealers have heightened the dangers by lacing heroin with fentanyl, creating an extremely potent but deadly high.

At the same time, the very system designed to treat this epidemic has been struggling with its own drug abuse cases.

“It’s kind of a dirty little secret that has gone on around the country. It’s got to stop,” said John Burke, president of the International Health Facility Diversion Association.

“Often the health facilities don’t report it properly. If they don’t, the person may easily go to another facility and continue their ways,”said Burke, a former police commander who investigated drug thefts at Cincinnati hospitals. “It’s not just the people who did this. There’s a breakdown in supervision.”

This year, surgical tech Rocky Allen caused an interstate uproar after Swedish Medical Center in Englewood reported he stole fentanyl, causing the hospital to offer free blood tests to about 2,900 patients. Allen carries an unidentified bloodborne illness. Patients were tested for HIV and hepatitis.

Allen had been court-martialed for fentanyl theft while stationed in Afghanistan, yet managed to find surgical tech jobs and get fired from hospitals in Washington, California and Arizona before Swedish hired him.

Allen was arrested on federal charges in February and has pleaded not guilty. In March, an agency nurse, Kimberly Burgans, was charged with stealing fentanyl from St. Anthony Summit Medical Center.

Those public disclosures are the exception in Colorado, where hospitals that catch employees with narcotic medicines routinely fire them but rarely inform patients or the public.

Hospitals report drug diversions to the health department, which issues one-page public reports that, under state law, never name the employee even if a drug theft is confirmed. Even other hospitals are not entitled to their names.

The state Board of Nursing tracks disciplinary records by name, not by reporting hospital. Police departments say they can’t always confirm that they handled a call from a hospital without a name and case number.

The upshot: It’s difficult to track how police departments and licensing boards treat hospital employees who commit drug thefts on the job.

The privacy of the perpetrators gets protected even when there are massive drug thefts or evidence that employees have risked patients’ health by injecting themselves with narcotics at work.

The Post succeeded in identifying dozens of health care workers who stole drugs, sometimes repeatedly, by matching drug theft reports the hospitals filed with other public records. But even extensive sleuthing yielded no results in many cases.

In March 2015, for example, Denver Health Medical Center found a registered nurse had locked himself in the bathroom of the staff lounge. He was sitting on the toilet with his head between his legs. A bloody syringe lay in the toilet. The nurse was taken to an emergency room.

Afterward, he admitted he had taken fentanyl from a patient’s IV line and that he had a history of drug diversion. He denied contaminating any patients. Denver police provided a copy of its case report, deleting the hospital employee’s name because the district attorney did not file charges.

In the case of Nelson, the anesthesiologist who died of a drug overdose, Dr. Edgar Downs, a retired dentist, became so concerned that he requested a Colorado Board of Pharmacy investigation, its records show. He thinks Nelson, while severely addicted, injured him during his spinal fusion surgery at Vail Valley Medical Center in late 2013, leaving him with acute pain in his neck that required him to be transferred to an emergency room five times, court records show.

But Vail Valley Medical Center succeeded in getting an injunction in Eagle County from District Judge Russell Granger barring Downs from further disseminating his concerns through the media. The hospital claimed his allegations would cause undue “reputational harm.” When The Denver Post asked to review court records in that case, Granger sealed the case. The Colorado Supreme Court rejected Downs’ appeal of the injunction.

Vail Valley Medical Center declined to discuss Nelson’s death.

Hospitals differ in response

Federal regulations require reporting thefts and significant losses of controlled substances to the DEA. They recommend calling local law enforcement and licensing boards as well. While “significant” is not defined, the regulations urge facilities to “err on the side of caution and report it to DEA and local law enforcement authorities.”

The state reports on drug diversions show hospitals differ greatly in their responses.

From March 2013 to the end of 2015, Swedish Medical Center reported to the state that nine staff members had resigned or been fired for drug diversions. State health department reports indicate that just one case was referred to local police and none to the DEA.

Swedish fired Daniel Morrison after he admitted diverting hydromorphone from May through June 2014 from the hospital while working there as a nurse. But the state health department report shows the hospital didn’t report those thefts to the police or DEA. The hospital did notify the board of nursing, which allowed Morrison’s nursing license to remain active after he entered into drug treatment. He also holds a nursing license in Connecticut.

The Denver Post was able to identify Morrison from a lawsuit questioning the hospital’s drug diversion protocols after Rocky Allen’s arrest. He declined comment.

Swedish questioned the completeness of the state reports.

“We are compliant in our documentation and notification of regulatory and investigative agencies,” said Nicole Williams, the hospital’s spokeswoman.

The state requires hospitals to report missing or stolen drugs electronically. They are asked if they notified police and licensing boards and any “other entity or agency.” Mark Salley, a health department spokesman, said its summary reports on drug diversion investigations could fail to mention hospital calls to the DEA because the state does not specifically require that.

Englewood police said no report on Morrison’s theft was made.

In contrast, Presbyterian/St. Luke’s Medical Center in Denver took a much more aggressive stance, reporting even unsubstantiated allegations that included just one missing pill to police. It filed 48 drug diversion reports with the state in the last three years, far more than any other hospital.

The hospital said only five of those investigations confirmed drug diversions. In some cases, the hospital did not confirm a diversion if an employee blood test was negative for unprescribed drugs.

Of the 222 confirmed drug diversions in the state’s hospitals during those six years, hospitals made referrals to all three reporting entities — the DEA, local police and state licensing board — in only 49 cases, according to state health reports.

Hospitals also differed in their approaches to testing employees caught with drugs and needles.

In Fort Collins, Poudre Valley Hospital offered more than 200 patients blood tests in December 2013 when an employee who had been infected with hepatitis C, an infectious liver disease, was suspected of stealing intravenous painkillers.

In Lone Tree, a staff member at Sky Ridge Medical Center in 2013 found a syringe with a needle on a toilet paper roll after a registered nurse left the bathroom.

The nurse tested positive for fentanyl and was fired, but “was not tested for any communicable disease,” according to the state report. Yet the health department found “the facility acted appropriately” and did not question its decision to forgo a disease check.

Treatment over revocation

In 169 of the confirmed drug diversions, hospitals reported the case to the licensing board, which can revoke a nurse’s license to work, state records show.

But the Colorado Board of Nursing gives nurses who steal drugs to feed an addiction a chance at redemption. Nurses addicted to drugs can keep their license if they agree to enter a program that monitors their drug use and treats their addictions.

Shaun Fitzsimmons pleaded with a manager at Denver Health Medical Center to spare his nursing license by letting him enroll in treatment when he admitted to stealing oxycodone during a shift in 2011.

An audit of his drug dispensing at Denver Health determined he removed 485 doses of narcotics, including morphine, over 13 months that could not be accounted for. Hospital officials told police Fitzsimmons likely deprived patients in severe pain of their medications, and he pleaded guilty to a misdemeanor drug possession charge.

Yet he received no adverse licensing action.

After his arrest, he was hired as a nurse at the Medical Center of Aurora and later moved to California, where he holds a nursing license.

Fitzsimmons said he completed drug treatment and submitted to drug testing and monitoring for nearly four years. He said he’s had no relapse.

“It’s a very, very difficult program,” he said.

Davene Riesmeyer was a repeat offender. The state nursing board allowed her to hold a license despite her being found unconscious in 1993 in a call room at Swedish, fentanyl and other controlled substances coursing through her body.

Riesmeyer relinquished her license after she pleaded guilty to a felony charge of obtaining controlled substances by fraud and deceit. She had tested positive for the use of painkillers in 2000 while employed at Rose.

But in 2006, the nursing board reinstated her license with her promise to enter another drug treatment and monitoring program. Her license remained active despite spotty compliance with drug screening she had promised to do.

In June 2013, Riesmeyer was found unconscious in her car in a parking lot of her health care employer in Arapahoe County. She had injected the anesthetic and sedative Propofol through a catheter she inserted in her arm. She was arrested that same day for driving under the influence and unsafe driving, a criminal charge that resulted in probation.

Riesmeyer reached a final agreement with the board to relinquish her license several months later — 20 years after her first drug theft. She declined to comment.

Only about 60 percent of the nearly 250 nurses in Colorado who annually receive addiction help or other counseling from Peer Assistance Services, the group tasked with rehabilitating them, actually complete the program, state data show. About 10 percent don’t comply with the terms of the program and another 30 percent drop out. Those deemed unsafe to practice nursing are referred to the state nursing board for possible revocation.

“He just lied”

Even when cases are reported to police and criminal charges are filed, it can take months, even years, for the nursing board to take final action.

In March 2012, the Memorial Hospital in Craig fired Richard Dickerson Jr., a registered nurse anesthetist who had just arrived from Kansas. Dickerson had been found incoherent in an operating room standing over the anesthesia cart after administering an IV drug to himself, state records show. He had blood on his clothing and shoes. Blood was splattered on the floor, shower and walls of a bathroom, with syringes on the counter.

Hospital officials notified Craig police, who searched Dickerson’s motel room and found vials of painkillers, syringes and a letter from the Kansas Nurse Assistance Program alerting him that he needed to be monitored due to his recent diagnosis of opioid abuse.

Dickerson then returned to Kansas, where he ran afoul of the law again, this time while working at a hospital there. He was sentenced to probation after pleading guilty to drug possession charges. He relinquished his Colorado license in December 2013.

“He just lied on his application,” said Jennifer Riley, a spokeswoman for the Craig hospital.

She suggested that hospitals should be required to notify licensing boards even when an employee agrees to drug abuse treatment because it’s too easy otherwise to conceal the past.

Hospitals often tell employees caught with narcotics that “if you do the treatment, this will not affect your nursing license,” she said.

The Centura Health hospital system has reported at least twice to the state since 2010 that it needed a better way to track drug dispensing by nurses provided by contract agencies at one of its hospitals.

After David Laumeyer, an agency nurse, was busted by police for dealing meth, Centura determined numerous drug dispensing irregularities by him at its St. Anthony North Hospital in Westminster and Parker Adventist Hospital.

Laumeyer’s suspicious drug withdrawals from the hospitals started in 2010. About a year later, after another agency drug theft surfaced at Parker, Centura once again said the tracking of agency nurses still needed to be fixed at that hospital.

Drug diversion remained an issue, though, and Centura promised to the state in June 2015 that it would come up with a comprehensive, standard policy for all of its hospitals for monitoring and reporting drug diversions, which was supposed to take effect that September.

The Burgans case at Centura’s Frisco hospital emerged after that.

In a statement, Centura said its hospitals had separate drug monitoring systems until last year, but they now use the best auditing software on the market.

“We wish we could promise to make diversion attempts go away, but in reality we can promise two things,” Centura said. “Attempts to divert painkillers will continue, and so will the determination of Centura Health to find them and report them.”

Even nurses with felony guilty pleas to drug offenses on their rap sheets continue to find nursing work in Colorado, records show.

Terrala Marie Butler-Perry still had a registered nurse license after pleading guilty twice, in June 2004 and March 2011, to a felony drug charge.

Employed as a director of nursing at Wheatridge Manor Care Center, a nursing home, she showed signs of impairment so severe in October 2012 that her superiors asked her to submit to a drug test. She tested positive for opiates and other controlled substances and was arrested on drug diversion charges again.

The state nursing board revoked her license in February 2014, nearly 10 years after her first guilty plea to a drug charge.

David Olinger: 303-954-1498, dolinger@denverpost.com or @dolingerdp; and Christopher N. Osher: 303-954-1747, cosher@denver- post.com or @chrisosher

How The Post reported this story:

The Denver Post obtained all reports from Colorado hospitals concerning drug diversions since 2010 from the Colorado Department of Public Health and Environment.

The newspaper used these reports to build a database showing how many incidents each hospital reported, how many were confirmed as employee or patient drug diversions and how often the state investigative summaries showed calls to licensing boards, police and the federal Drug Enforcement Administration.

The Post then turned to licensing board, police records and other sources to identify some of the hospital employees who had been fired for drug thefts.