Report 2016-046 Recommendation 18 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 #18 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 use this training program to develop a procedural guide that specifies proper evidence-gathering techniques, including a description of what constitutes sufficient evidence, for investigators to follow when investigating complaints. They should then distribute this guide to all investigators, including DOI's investigators, by December 2017, and jointly instruct them to adhere to the guide when conducting investigations.

6-Month Agency Response

The manual developed for Investigator Training as required in Auditor Recommendation #17, specifies proper evidence-gathering techniques, including a description of what constitutes sufficient evidence, for investigators to follow when investigating complaints. The manual was disseminated at the trainings held in March 2017. The training manual has been digitized and is available via the BRN Investigation shared network.

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

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

BRN did not provide evidence demonstrating that it has specified proper evidence-gathering techniques in its procedures and did not submit documentation indicating it had provided such direction to staff in its March 2017 training. Further, it did not provide documentation demonstrating that it distributed direction regarding proper evidence-gathering techniques to all investigators, including DOI's investigators. Until it does so, we will continue to report this recommendation as not fully implemented.

  • Auditee did not substantiate its claim of full implementation

60-Day Agency Response

Once the two training sessions for BRN and DOI investigators have concluded, BRN will meet with DOI, SOLID, and AG to assess effectiveness of training materials and convert the training manual into a procedural guide manual that will be distributed to all BRN and DOI investigators with instructions to adhere when conducting investigations. This completion and distribution of this guide to staff is scheduled on or before December 2017.

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

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


All Recommendations in 2016-046

Agency responses received are posted verbatim.