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Overdue complaint probes, 60,000 manual IT overrides, missing fingerprints cited in California audit

The California Board of Registered Nursing was the target of a critical review released December 13 by the state auditor, which accused the board of undue delays in its complaint handling and called for an action plan to resolve its deficiencies. The audit recommended that if the board does not develop and implement such an action plan by March 1, 2017, the legislature “should consider transferring BRN’s enforcement responsibilities” to the central Department of Consumer Affairs.

The audit was released under the title: “Significant Delays and Inadequate Oversight of the Complaint Resolution Process Have Allowed Nurses Who May Pose a Risk to Patient Safety to Continue Practicing.” The board, which regulates approximately 430,000 nurses, is the largest RN licensing board in the country.

In conducting the review, the auditor selected 40 investigated complaints resolved between January 1, 2013 and June 30, 2016. Although the state Consumer Affairs department sets a goal for the board to process complaints within 18 months, the auditor said, “BRN has consistently failed to achieve this goal, in large part due to its ineffective oversight of the complaint resolution process and the lack of accurate data regarding complaint status.”

Thirty-one of the 40 complaints failed to meet the 18-month goal, and 15 of those 31 complaints took longer than 36 months to resolve. In seven cases, resolution took longer than 48 months. The assignment of cases to investigative units appeared to be a major bottleneck, as was the categorization of complaints as urgent or high priority subjects of investigation.

In addition, said the auditor, the state’s licensing information system, BreEZe, “lacks adequate controls to ensure that BRN’s staff members accurately enter information into the system regarding the status of complaints. The board’s chief of investigations reported to the auditor that “it is difficult to manage caseloads when the data are not reliable.”

The resulting backlog of complaints included more than 180 that had not been assigned to a board investigator as of July 2016—roughly 70 of those involving urgent or high-priority allegations such as patient death or harm. These were awaiting assignment for an average of nearly 80 days.

A related problem was the board’s failure to assign many urgent complaints to the Department of Investigation, which has sworn peace officers as investigators, rather than the board itself, which has only non-sworn investigators. “One of these complaints alleged that a nurse failed to follow proper procedures after an alarm sounded during a patient’s dialysis procedure, which may have contributed to the patient’s death,” the auditor noted.

In response to the audit’s concerns about the board’s internal handling of urgent complaints, a board official stated that it understood the assignment policy to be a guideline rather than a requirement, and noted that the board could reduce its enforcement costs considerably when non-sworn investigators investigate complaints.

The DOI rate to conduct an investigation in 2014-15 was $235—more than twice the board’s hourly rate of $88. However, the auditor said that cost is not a reasonable justification for failing to use the DOI for the board’s most egregious complaints, especially since sworn peace officers have additional training, skills, and authority that board investigators lack.

A shortage of expert witnesses to help with prosecution of complaints against nurses was another problem cited by the auditor. According to the board’s chief of investigations, the low rate of $75 an hour as payment to expert witnesses is “not very enticing to nurses who have full-time jobs,” the auditor said.

The auditor also faulted the board for lacking sufficient oversight of enforcement. In addition to needing better training procedures for new staff members, the board has not ensured that all nurses as fingerprinted, as the law requires. “As a result, BRN is not always notified by the California Department of Justice when a nurse is arrested or convicted.”

The missing fingerprints were due, in part, to shortcomings of the BreEZe licensing information system, the audit found. Although BreEZe was designed with a control to prevent a nurse from renewing his or her license if fingerprint records were missing, “during the majority of the audit period we reviewed, BRN has been overriding this control by manually removing the hold and approving the nurse’s renewal application.” Between October 2013 and November 2016, the audit found, “BRN overrode BreEZe more than 60,000 times.”

As of November 2016, the board was working with Justice and Consumer Affairs to reconcile the number of nurses the BrEZe system shows as having supplied fingerprints with data provided by Justice.

The board responded to the audit by noting that it agreed with the auditor’s recommendations to improve procedures for tracking and investigating complaints, adhere to complaint guidelines, and implement a formal training program for investigative staff, and that it planned to take several steps to implement the recommendations.