Report 2016-046 Recommendation 16 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 #16 To: Registered Nursing, Board of

To ensure that BRN and DOI consistently conduct adequate investigations and obtain sufficient and appropriate evidence to discipline nurses accused of violating the Nursing Act if warranted, BRN in collaboration with Consumer Affairs should implement a mechanism by March 2017 to track and monitor supplemental investigation requests that result from investigators' failure to obtain required documentation or sufficient evidence and use this information to mitigate the causes of these failures.

Annual Follow-Up Agency Response From October 2018

To ensure that BRN and DOI consistently conduct adequate investigations and obtain sufficient and appropriate evidence to discipline nurses accused of violation the Nursing Practice Act, BRN Subject Matter Experts worked with DCA BreEZe staff to create additional activity codes which identify the source of supplemental investigation (AGO, Expert, Board, Other), and the type of evidence requested (i.e. obtain records, interviews, subpoenas). Reports are run quarterly in BreEZe to track and monitor supplemental investigation requests. BRN Supervising Investigators and the BRN Complaint Intake and Investigations Chief analyze the data to identify trends in order to mitigate the causes of the failures. The BRN Complaint Intake and Investigations Chief communicates trends for DOI investigations at monthly meetings with DOI.

  • Completion Date: March 2017

California State Auditor's Assessment of Annual Follow-Up Status: Partially Implemented

BRN implemented a mechanism to track and monitor supplemental investigation requests that result from investigators' failure to obtain required documentation or sufficient evidence. However, it did not provide adequate documentation to fully demonstrate that it uses this information to mitigate the causes of these failures.

  • Auditee did not address all aspects of the recommendation

1-Year Agency Response

To ensure BRN and DOI consistently conduct adequate investigations and obtain sufficient and appropriate evidence to discipline nurses accused of violating the Nursing Practice Act, the BRN has collaborated with DCA to implement a mechanism to track and monitor supplemental investigation requests that result from investigators' failure to obtain required documentation or sufficient evidence and uses this information to mitigate the causes of these failures.

  • Completion Date: March 2017
  • Response Date: June 2018

California State Auditor's Assessment of 1-Year Status: Pending

Although BRN claims it has fully implemented this recommendation, it did not provide evidence demonstrating that it has. Until it does so, we will continue to assess the status of this recommendation as pending.

  • Auditee did not substantiate its claim of full implementation

6-Month Agency Response

BRN Subject Matter Experts worked with DCA BreEZe staff to create additional activity codes which identify the source of supplemental investigation (AGO, Expert, Board, Other), and the type of evidence requested (i.e. obtain records, interviews, subpoenas). Staff coding procedures that require they document the reason for the supplemental investigation can be found on page 83 of the Complaint Intake Unit Procedure manual.

BRN updated the Complaint Intake Unit procedures for staff to identify the reason why a supplemental investigation is conducted in the activity results text box for the supplemental investigation activity code.

  • Completion Date: June 2017
  • Response Date: June 2017

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

Although BRN's Complaint Intake Unit Procedures direct staff to identify the reason why a supplemental investigation is conducted in BreEZe, it did not provide documentation demonstrating that BreEZe indeed contains this functionality.

  • Auditee did not substantiate its claim of full implementation

60-Day Agency Response

BRN SMEs have submitted SIRs to add additional activity codes to include all reasons why a supplemental investigation would be requested (i.e. obtain records, interviews, subpoenas).

The new/updated BreEZe activity codes, which will capture more detailed information regarding the origin and scope of supplemental investigation requests, have been developed and are scheduled to be implemented in the next BreEZe software release by the end of February 2017.

  • Completion Date: February 2017
  • Response Date: February 2017

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

Although BRN implemented a mechanism in BreEZe on February 21, 2017 to allow it to track who requests a supplemental investigation and whether the request was for an interview, subpoena, or other documentation, this new mechanism does not allow BRN to identify or track whether the reason for the supplemental investigation request was the result of an investigator's failure to obtain required documentation or sufficient evidence during the initial investigation. Without this information, BRN is hindered in its ability to mitigate the causes of investigators' failure to obtain required evidence.

  • Auditee did not address all aspects of the recommendation

All Recommendations in 2016-046

Agency responses received are posted verbatim.