Report 2016-046 Recommendation 15 Responses

Report 2016-046: Board of Registered Nursing: Significant Delays and Inadequate Oversight of the Complaint Resolution Process Have Allowed Some Nurses Who May Pose a Risk to Patient Safety to Continue Practicing (Release Date: December 2016)

Recommendation #15 To: Registered Nursing, Board of

BRN should immediately comply with state law and adhere to the revised CPEI guidelines that DOI issued in August 2016. Additionally, BRN should establish and maintain a process for communicating with DOI to discuss any questions that arise in assigning a priority to a complaint or referring a complaint to the proper investigative unit.

6-Month Agency Response

Instructions have been incorporated into the Complaint Intake Unit Procedure manual, which has been implemented into normal staff practice. Data verified in BreEZe shows full compliance with CPEI case referral guidelines as of December 2016.

Staff instructions for the use of CPEI guidelines, resolution of CPEI application questions, and communication with DOI regarding CPEI can be verified on pages 77-79 of the Complaint Intake Unit Procedure manual.

  • Completion Date: December 2016
  • Response Date: June 2017

California State Auditor's Assessment of 6-Month Status: Partially Implemented

BRN developed complaint intake procedures that include a copy of the revised CPEI guidelines DOI issued in August 2016, and that direct staff to adhere to the CPEI guidelines when assigning complaints. However, although these procedures direct staff to assign those complaints with allegations that clearly fall into categories 1 or 2 to DOI, they also instruct staff to assign complaints with vague allegations, or those that do not exactly fall within categories 1 or 2, to BRN's investigative unit without discussing them with DOI. By not communicating with DOI regarding the assignment of these types of complaints, BRN risks not assigning these complaints to the appropriate investigative unit.

  • Auditee did not substantiate its claim of full implementation
  • Auditee did not address all aspects of the recommendation

60-Day Agency Response

Complaint Intake Staff have been trained and provided desk copies of the DCA Case Referral Guidelines for Investigations (Guidelines). Complaint Intake Staff Services Analysts evaluate complaints and refer cases to BRN or DOI investigations as required by the Guidelines.

Complaint Intake Policies and Procedures have been written to formalize the process.

Beginning December 2016, BRN management and DOI have met on several occasions to discuss ongoing case referral and priority issues. Since then, formally scheduled monthly meetings have been conducted to maintain constant communication regarding enforcement matters. Additional meetings will be scheduled as often as needed to ensure that the CPEI case referral guidelines and other matters of concern are being addressed in a timely manner.

  • Completion Date: December 2016
  • Response Date: February 2017

California State Auditor's Assessment of 60-Day Status: Partially Implemented

Although BRN developed complaint intake procedures that include a copy of the revised CPEI guidelines that DOI issued in August 2016, these procedures do not direct staff that they must adhere to the CPEI guidelines. The procedures also do not outline a process for communicating with DOI to discuss any questions that arise in assigning a priority to a complaint or referring a complaint to the proper investigative unit.

  • Auditee did not address all aspects of the recommendation

All Recommendations in 2016-046

Agency responses received are posted verbatim.