California State Auditor Report Number : 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

Audit Results

The Board of Registered Nursing Has Failed to Resolve Consumer Complaints in a Timely and Adequate Manner

The Board of Registered Nursing’s (BRN) lack of sufficient oversight has led to delays in resolving consumer complaints. The California Department of Consumer Affairs (Consumer Affairs) expects the healing arts boards (health boards) to resolve complaints within 18 months.³ However, for the majority of the complaints we reviewed, all of which underwent an investigation, BRN failed to ensure that it met this 18‑month goal. Specifically, BRN did not ensure that it promptly moved complaints through the various stages of the complaint resolution process, such as assigning complaints to an investigative unit and referring complaints to an expert witness, within a reasonable time frame. We determined that BRN management did not set formal goals for staff to achieve when processing complaints, nor did it monitor the status of complaints as they were moving through key stages of the process. As a result, it has missed the opportunity to identify steps in the complaint resolution process that need improvement. Unnecessary delays in the complaint resolution process enable nurses who are the subject of allegations to continue practicing, which could risk patient safety.

Insufficient Oversight Has Contributed to BRN’s Failure to Resolve Complaints Within a Reasonable Time Frame

BRN’s lack of oversight has led to delays in resolving consumer complaints. In 2010 Consumer Affairs established a goal in accordance with its CPEI, setting the expectation that all health boards resolve complaints within 18 months. However, for the majority of the investigated complaints that we reviewed, which were resolved between January 1, 2013, and June 30, 2016, BRN failed to ensure that it met this 18‑month goal. According to BRN’s chief of complaint intake and investigations (chief of investigations), inadequate staffing and inefficiencies caused by its information system, BreEZe, were the primary causes for delays. During that time frame, BRN’s enforcement staff grew considerably, by more than 60 positions. Nevertheless, we found that BRN’s failure to set goals for how long key stages in the complaint resolution process should take, coupled with a lack of monitoring of complaint status by management, contributed to lengthy complaint resolution time frames.

During our review of 40 complaints that underwent an investigation, we found that BRN struggled to resolve complaints in a timely manner, which potentially placed additional patients at risk. As shown in Figure 3, BRN failed to resolve 31 of the 40 complaints within the 18‑month goal, and for 15 of those 31 complaints BRN took longer than 36 months—more than twice as long as the CPEI goal—to resolve the complaints.⁴ Further, we found that BRN took longer than 48 months to resolve seven of those 15 complaints, six of which included allegations of patient harm resulting from a nurse’s actions. Delays such as these could have potentially serious consequences for patients these nurses subsequently cared for. With the exception of certain circumstances that we describe in the Introduction—in which BRN’s nine‑member board (BRN board) takes immediate action on a nurse’s license—a nurse who has allegedly committed a violation or crime may continue to have direct involvement with patients while his or her case is being resolved. Therefore, the longer it takes BRN to resolve complaints, the greater the number of patients who may receive treatment from a nurse who could expose them to harm. For example, we reviewed one complaint alleging that the nurse inappropriately left medication near patients’ bedsides, inappropriately administered medication without following physicians’ orders, forged prescriptions, and stole medications.  While BRN was investigating this complaint, it received an additional complaint against the nurse alleging similar misconduct. Although the nurse ultimately surrendered her license, she was able to practice for more than three years, potentially risking patient safety.

We found that a primary reason for the delays in BRN’s processing of these complaints was its failure to ensure complaints moved through the various stages of the complaint resolution process in a timely manner, a concern we describe in more detail in the next section. For example, in one instance in which a nurse allegedly overmedicated a patient and did not accurately document the medication administered and times delivered, BRN took roughly 15 months to assign the complaint to Consumer Affairs’ DOI. Interestingly, we noted that the complainant sent a letter to BRN stating her belief that it had been over a year since she filed the complaint and, to her knowledge, no disciplinary action had been taken. It is reasonable to conclude that this letter caused BRN to finally take action, because it assigned the complaint to DOI for investigation about three weeks after receiving the letter. Further, nearly another year later, BRN referred the complaint to an expert witness, who requested additional evidence before she could opine on the case. However, because BRN, which processes supplemental investigation requests, repeatedly failed to respond to the expert witness’s numerous requests for this supplemental information in a timely manner, it ultimately took more than 30 months for BRN to receive the expert witness’s final report regarding the complaint. Although BRN’s board ultimately revoked the nurse’s license, the nurse remained licensed to practice for nearly 70 months, or almost six years, while BRN attempted to resolve the complaint. In another example, we found that BRN took more than eight months to assign to an investigator a complaint alleging that a nurse administered chemotherapeutic medication to a patient at an excessively fast rate. BRN’s significant delay in assigning the complaint to one of its non‑sworn investigators, in part, allowed the nurse’s license to remain active for 28 months while BRN investigated the complaint. The expert witness concluded that the nurse was grossly negligent and incompetent in treating the patient and, ultimately, this nurse surrendered her license.

Figure 3
Complaint Resolution Times for a Selection of Investigated Complaints Resolved Between January 1, 2013, and June 30, 2016

In addition, although Consumer Affairs has established a formal overall goal for the time frame within which BRN and other health boards should resolve complaints, BRN has not established formal goals for key stages of the complaint resolution process. The chief of investigations stated that although BRN has informal goals for certain stages, it has not developed formal goals. For example, as shown in the text box, BRN has an informal goal for how long it should take its staff to assign a complaint to an investigative unit. However, this goal is limited in value without a corresponding goal for how long it should take to actually assign the complaint to a specific investigator. Further, BRN’s management does not routinely monitor or track staff members’ progress in achieving even these informal goals. Without meaningful and formal goals for its staff to achieve, BRN risks that staff members will not prioritize their work to ensure that they process complaints as efficiently and quickly as possible. Further, without formal goals, BRN is hindered from tracking its progress in processing complaints, identifying areas where delays occur, and implementing mitigating measures to reduce delays.

A lengthy investigation stage, which includes the time it takes either BRN or DOI to assign a complaint to an investigator and complete the investigation, contributed to the time it took BRN to resolve complaints. As shown in Figure 1 in the Introduction, either BRN’s non‑sworn investigators or DOI’s sworn peace officers investigate complaints against nurses. Of the 40 complaints we reviewed, 20 were investigated by BRN and 20 were investigated by DOI. As shown in Figure 4, of the 20 complaints that BRN referred to its investigative unit for review, 10 were not assigned to an investigator and the investigations completed for more than one year, with three of the 10 taking more than two years to be assigned and the investigations completed. For example, we reviewed one complaint alleging that a nurse failed to remove a suction catheter before closing the surgical site, necessitating a surgical reopening that resulted in the patient developing pneumonia and requiring subsequent surgeries. Although the complaint alleges patient harm, BRN took seven months to assign the complaint to an investigator and another nearly 18 months to complete the investigation. Further, BRN took more than 12 months to assign the complaint to its investigative unit. Another complaint alleged that a supervising nurse failed to take sufficient action against a subordinate nurse whose conduct may have endangered patients. In this case, BRN took more than 22 months to assign the complaint to a non‑sworn investigator and another 24 months to finish investigating the complaint. Although these complaints were ultimately closed without BRN taking action on the nurses’ respective licenses, BRN could not have foreseen this outcome during the early stages of the complaints. With allegations of potential harm or danger to patients, we expected to see BRN processing the complaints with a sense of urgency. However, according to the chief of investigations, BRN did not have the resources to quickly process complaints through each stage, and it did not consistently monitor the complaint resolution process.

Similarly, Figure 4 shows that for six of the 20 complaints we reviewed that DOI investigated, DOI took longer than one year to assign the complaints to a sworn investigator and complete the investigations. For example, one complaint alleged that a nurse falsified physicians’ signatures on patient transportation order forms. Although DOI assigned the complaint to a sworn investigator relatively quickly—within nine days—the investigation itself took 17 months. The complaint was eventually closed without BRN taking action against the nurse. According to DOI’s supervising investigator, most investigations take between nine months and one year to conduct, and she acknowledged that some may take longer to finalize because of investigator workloads, the prioritization of urgent cases, and the ability to obtain records from a health facility. She indicated that DOI monitors the time it takes to complete investigations but does not routinely analyze the data to identify trends causing delays in investigation processing.

Figure 4
Time Frame for Completing the Investigation Stage for a Selection of Complaints Resolved Between January 1, 2013, and June 30, 2016

When a substantial portion of the complaint resolution process is consumed by the time it takes to assign a complaint to an investigator and investigate the complaint, BRN is hindered from processing the complaint in a timely manner. Specifically, other entities, such as expert witnesses, the Office of the Attorney General (Attorney General), and, for those cases that are adjudicated, the Office of Administrative Hearings, often also have to act on the complaint. Thus, long time frames for assigning and investigating complaints jeopardize BRN’s and DOI’s ability to achieve the 18‑month goal for overall complaint resolution. These delays emphasize the need for BRN and DOI to establish a formal goal for completing each key stage of the complaint resolution process and to consistently meet those goals.

According to the chief of investigations, many factors can contribute to the length of an investigation, including the complexity and severity of a complaint, the availability of key witnesses, and the ability to access key documents that may be necessary to complete an investigation. Although we recognize these factors, without establishing formal goals for investigators to work toward and tracking the reasons for delays in the investigation stage, investigators may miss opportunities to focus their evidence gathering and to better organize both time and resources to finalize investigations as efficiently as possible. Formal goals for investigators will also aid supervising investigators’ efforts to monitor whether investigations are being conducted at an effective pace and to identify the reasons for any delays.

BRN has pointed to a lack of resources as one of the reasons for the delays we identified in its processing of complaints. Specifically, the chief of investigations stated that from 2010 through 2015 BRN was expanding its enforcement division staff, but did not have enough staff to meet the demands of its complaint caseload. During that time frame, BRN ultimately requested and received 65 positions in its enforcement division. Although BRN indicated that it continues to believe it could use additional enforcement staff, it has not attempted to request additional resources from the Department of Finance given that it recently received these positions. However, as we describe later in the Audit Results, BRN has not adhered to specific direction from Consumer Affairs, as well as recent state law, regarding the types of complaints it must forward to DOI for its investigation. Essentially, because BRN is investigating more complex complaints that it should forward to DOI for its sworn peace officers to investigate, BRN’s non‑sworn investigators’ caseloads are at maximum capacity, which affects their ability to complete investigations in a timelier manner.

Further, BRN has pointed to inadequate monitoring of the complaint resolution process and issues it has faced in obtaining information regarding complaint status from BreEZe. Specifically, the chief of investigations stated that, until recently, BRN could only run reports that provided information on overall complaint processing time frames, rather than how long specific phases in the complaint resolution process took, such as how long it took to refer complaints to an investigative unit or to an expert witness.  Instead, she explained that BRN’s managers would have to periodically check in with staff to determine their caseloads or manually enter specific information about individual complaints into BreEZe to identify aging status.  She explained that the coding and data in BreEZe was, and still is to an extent, not always accurate and this made tracking and evaluating the status of the large volume of complaints in BreEZe nearly impossible. Without the ability to produce reliable reports, the chief of investigations explained that BRN management did not have an effective way to track how quickly staff members were processing complaints during each stage of the resolution process, nor could they strategically identify those stages that may be contributing to a backlog in its process. She stated that, as a result, BRN failed to meet the 18‑month goal for resolving complaints.

According to the chief of investigations, BRN recently began using a software product to more effectively produce reports using BreEZe data, which has improved BRN’s ability to monitor the complaint resolution process. She explained that, as of April 2016, BRN management can generate reports using BreEZe data to run specific workload and complaint aging reports. For instance, she provided examples of reports generated by the new software product that she stated BRN managers can use to review the time it takes for support staff to enter complaints into BreEZe once they are received, whether staff members enter the complexity of the complaint accurately into BreEZe, and how long complaints have been pending. According to the chief of investigations, BRN managers use these reports to track the progress of complaint processing in an effort to shorten overall complaint resolution time frames. However, she stated that because BRN’s use of this software product is a new capability, as of October 2016, it has not begun to evaluate this data to identify trends or deficiencies during key phases in the complaint resolution process.  Although this is an important step toward ensuring that the complaint resolution process is more efficient, without formal goals and routine monitoring by managers to determine whether staff members are achieving the established goals and to understand the reasons for any delays, BRN risks that it is not mitigating the factors that cause delays and not processing complaints as promptly as it should, which may place the public at risk of harm. In addition, although BRN can now generate some reports regarding complaints, as we discuss later in the Audit Results , the data in BreEZe is not always accurate, calling into question the reliability of the data in these new reports.

BRN Has Not Ensured That Complaints Move to the Next Stage of the Resolution Process When Ready, Which Has Contributed to a Backlog of Complaints Awaiting Investigation

Our review of 40 complaint files found that BRN took excessive amounts of time to assign more than half of them to either BRN’s investigative unit or DOI’s investigative unit. When we asked whether BRN had established a goal for how long it should take to assign a complaint to an investigative unit after receiving it, the chief of investigations stated that BRN’s informal goal is 30 to 45 days. However, as shown in Figure 5, BRN took more than 45 days—the high end of its goal—to assign 24 of the 40 complaints we reviewed to an investigative unit, the stage that precedes assignment of the complaint to an investigator. Further, the figure shows that BRN took more than a year to assign nine of the 24 complaints to an investigative unit—clearly exceeding BRN’s informal goal of assigning a complaint within 45 days of receipt.

Such delays not only prolong the length of time it takes BRN to resolve complaints, but they also allow nurses who may have committed serious violations to continue caring for patients. For example, one of the complaints we reviewed alleged that a nurse midwife failed to consult with an obstetrician during a patient’s labor and that, as a result, the patient’s baby was born with neurological damage. Although BRN initially assigned the complaint to its investigative unit, the chief of investigations acknowledged that BRN did not take any action on the complaint for more than two and a half years before assigning it to DOI for investigation, well beyond BRN’s informal goal of assigning a complaint to an investigative unit within 45 days. The nurse who was the subject of the complaint was allowed to continue practicing during the more than four years BRN took to decide to close the complaint, until the expert witness concluded there was no evidence that early intervention in the patient’s labor would have improved the outcome. Nonetheless, because of the severity of the allegation and the fact that BRN did not yet know what the outcome of an investigation would conclude, we expected BRN to quickly assign the case for investigation to ensure it was resolved in a timely manner and that the nurse did not cause any harm to the public by continuing to practice. When we asked BRN’s chief of investigations why this particular delay occurred, she acknowledged that at the time BRN was processing this complaint, BRN had very few complaint intake staff, the analyst did not effectively move the complaint forward, and BRN’s management was not effectively monitoring complaints or staff caseloads.

Figure 5
Timeliness of the Board of Registered Nursing’s Assignment of Complaints to an Investigative Unit for a Selection of Complaints Resolved Between January 1, 2013, and June 30, 2016

In another example, we found that BRN delayed assigning to DOI’s investigative unit a complaint alleging that a nurse caused a toddler’s death by administering the incorrect dosage of medication. According to the complaint file, BRN initially assigned the complaint to its investigative unit, and BRN’s chief of investigations acknowledged that BRN did nothing with the complaint for roughly 18 months. She indicated that the complaint should have been prioritized due to its sensitivity and referred to DOI faster. This nurse was allowed to continue practicing for 39 months while BRN processed the complaint. Ultimately, the complaint was referred to an expert witness who determined, based in part on autopsy results, that the evidence was inconclusive as to whether the nurse’s conduct resulted in the child’s death. However, BRN’s board concluded that the nurse violated the Nursing Practice Act (Nursing Act) by inaccurately recording the dosage of medication administered to the toddler, and the board placed the nurse on three years of probation. Essentially, this discipline allowed the nurse to continue practicing with a restricted license under the terms and conditions of probation established by BRN’s board. BRN’s chief of investigations acknowledged that BRN should never have allowed the delay to occur, which she attributed to a lack of monitoring processes and staffing issues at the time. Such delays unnecessarily prolong the complaint resolution process, while the subject of the allegation may continue to practice, which potentially poses a safety risk to patients.

In addition to the deficiencies and time delays described previously, BRN accumulated a notable backlog of complaints awaiting assignment to one of its non‑sworn investigators. As of July 27, 2016, according to a BreEZe report provided by BRN, at least 184 complaints were pending assignment to a BRN non‑sworn investigator. Of these, 138 were pending assignment for more than 10 days and, on average, had been awaiting assignment to a BRN non‑sworn investigator for 77 days, with the oldest complaints pending assignment for more than 180 days, or more than six months. Table 2 shows these complaints, broken down by allegation type. Of most concern is that 71 of these complaints, or 51 percent, involved allegations that, according to Consumer Affairs’ complaint prioritization guidelines (complaint guidelines), should have been categorized as urgent or high priority and been promptly referred to DOI for investigation. However, BRN instead forwarded these complaints to its investigative unit. As an example of the severity of these complaints, one complainant alleging patient harm stated that a nurse failed to provide proper care to a patient with an infected wound, which eventually led to the patient developing an infection that caused kidney failure and the patient being placed on life support. As of July 27, 2016, this complaint had been pending assignment to a BRN non‑sworn investigator for 105 days. In another example, a complainant alleged that a nurse who operates an assisted living facility was practicing with an expired license and was overmedicating patients during the night shift due to low staff support. As of July 27, 2016, this complaint had been awaiting assignment to a BRN non‑sworn investigator for nearly 70 days. These examples underscore the importance of BRN taking steps to ensure that it assigns complaints promptly and, in particular, that it assigns complaints of urgent or high priority to DOI.

Table 2
Length of Time Complaints, by Allegation Type, Had Been Pending Assignment to a Board of Registered Nursing Non‑Sworn Investigator, as of July 27, 2016

Allegation Type	Number of Complaints Unassigned for More Than 10 Days	Average Days Pending assignment	Highest Number Of Days a Complaint has been unassigned
Urgent or High Priority
Actual/potential patient harm	15	65	135
Conviction	1	127	127
Drug theft/drug abuse	10	62	139
Fraud/theft	6	96	183
Gross negligence	11	78	170
Incompetence	3	47	56
Patient death	5	106	162
Unlicensed activity	9	58	140
Unprofessional conduct	11	74	181
Subtotals	71	79
Routine Priority
Actual/potential patient harm	11	78	156
Conviction	3	64	107
Drug theft/drug abuse	1	75	75
Gross negligence	2	52	76
Incompetence	26	98	174
Unprofessional conduct	24	81	198
Subtotals	67	75
Totals	138	77

When we asked BRN’s chief of investigations about the significant delays we identified, she acknowledged that the complaints should have been assigned more quickly and explained that, although BRN has an informal goal of assigning a complaint to an investigative unit within 45 days, it lacks a goal specifying the time frame within which complaints should be assigned to an investigator. She also pointed to a lack of resources as one reason for the delays, explaining that all of BRN’s existing non‑sworn investigators already had a full caseload of 20 complaints, a workload that we describe later. The chief of investigations stated that increased functionality that was added to BreEZe in April 2016 will increase her ability to monitor the aging of complaints. Although this may be an improvement, without having an action plan that specifies how BRN will ensure it promptly prioritizes and forwards complaints to an investigator, BRN risks that it will continue to face a backlog of complaints pending assignment to an investigator.

Additionally, we found that BRN frequently exceeded its informal goal for referring complaints to an expert witness for review after either DOI or BRN completed its investigation. As described in the previous section, BRN’s chief of investigations stated BRN did not have a goal for assigning complaints to an expert witness until July 2014, and the goal at that time was 11 days and remained the goal until July 2016, when it was increased to the current goal of 25 days. The current goal was established subsequent to the period we tested. Of the 40 complaints we reviewed, 27 required an opinion from an expert witness. We found that BRN took longer than 11 days to assign the complaint to an expert witness for 25 of the 27 complaints that required an expert witness review. For these 25 complaints, the time frame for assignment to an expert witness ranged from 16 days to 254 days. Six of these cases took more than 100 days to be assigned. Further, in one instance BRN assigned the case to an expert witness who did not have the appropriate expertise to review the complaint. The complaint alleged that the nurse gave a patient an injection in her elbow that resulted in an injury to the patient’s arm. In the administrative law judge’s formal decision regarding the complaint, the judge stated that BRN’s expert witness had never personally performed the procedure in question, even though the expert witness was being asked to give an opinion about the nurse’s competence in performing the procedure.

When we asked BRN’s chief of investigations about the delays we identified in BRN’s assigning of complaints to expert witnesses, she stated that one reason is that BRN has too few expert witnesses for the volume of complaints it receives. However, because BRN knows only how many expert witnesses it currently has, it was unable to provide us with the number of expert witnesses it had available during the time period we reviewed. Thus, we could not determine the extent to which this reason contributed to the delays we identified.

Despite being aware that it has too few expert witnesses, BRN has taken limited steps to increase this pool. BRN’s chief of investigations explained that as of September 2, 2016, BRN had 195 active expert witnesses. However, BRN lacks historical data on how many expert witnesses it has had during a given year or at a certain point in time, which hinders its ability to assess how many expert witnesses would be sufficient to meet its needs. The chief of investigations stated that one of the largest obstacles BRN faces in recruiting expert witnesses is the low hourly pay rate nurses receive for these services. She explained that the hourly pay rate of $75 is not very enticing for a nurse that works a full‑time job. When we asked BRN if it has taken steps to increase the hourly pay rate, its assistant executive officer explained that once its fund condition improves and BRN is able to support the additional costs, it will seek to increase the expert witness hourly pay rate.  Further, in terms of BRN’s recruiting efforts to increase its pool of expert witnesses, BRN’s chief of investigations stated that it currently posts openings on its website, on Consumer Affairs’ Facebook page, and on nurse association websites, and has distributed information at its board meetings for roughly the last four years. In addition, she stated that BRN receives referrals from the Attorney General and from other expert witnesses. Although these are all positive efforts, we believe there are other steps BRN could take to expand its pool of expert witnesses. For instance, BRN could include a question on its nurse license renewal application about whether the nurse is interested in becoming an expert witness. The chief of investigations stated that this would be possible, but pointed out a concern regarding available resources to process the applications. However, as described in a later section, BRN has not completed an analysis demonstrating its staffing needs. Further, BRN does not track the effectiveness of its recruiting efforts by identifying how applicants learned of the expert witness opportunity, according to the chief of investigations. As a result, BRN is missing the opportunity to identify which methods are most effective for recruiting expert witnesses. By focusing on these methods in the future, BRN could increase its pool of expert witnesses and better ensure that complaints are not unnecessarily delayed due to a lack of expert witnesses.

In conducting our review of complaints for which BRN requested an expert witness review, we identified that BRN failed to protect the confidential details—including specific information about the allegation and the nurse involved—surrounding its ongoing reviews of complaints when corresponding with expert witnesses. The State Administrative Manual requires end‑to‑end encryption or approved compensating security controls to protect confidential, sensitive, or personal information that is transmitted or accessed outside a secure network, such as email. Although BRN is subject to this requirement, we found that it communicated confidential information regarding active complaints via email without using encryption. Specifically, we identified several instances where BRN sent to expert witnesses’ private email accounts information that listed the nurse’s name and details surrounding the allegation for which BRN was conducting an investigation. We question how BRN ensured the protection of this confidential information since it does not know the security and privacy protection that exist on the expert witnesses’ personal email accounts. As a result, BRN risks compromising private and confidential information. Further, if this information were to be compromised, it could discourage complainants who wish to remain anonymous from filing complaints for fear of retaliation from the respective nurse.

BRN Lacks Accurate Data Critical to Assessing Its Efficiency and Effectiveness in Resolving Complaints

BRN lacks reliable data to monitor the performance of its complaint resolution process because the system it uses to track complaints, BreEZe, has weaknesses in the controls used to validate data at the time of entry into the system (input controls). We found that BreEZe does not require staff members to enter activities in a manner that follows BRN’s established business processes. For example, BRN staff members using BreEZe can assign a complaint to an investigator when the current status of the complaint is closed. For such complaints, BRN cannot easily determine from the BreEZe data whether the complaint was inappropriately closed at some point before it was assigned to the investigator or whether an appropriately closed complaint should have been reopened before it was assigned, as required by BRN’s business process. Further, BreEZe does not capture information that identifies the order in which activities occurred when two or more activities occur on the same day. For example, staff members may assign a complaint to an investigator and then close the complaint on the same day. However, if the activities are not entered in the correct order, it may appear as if the complaint was closed and subsequently assigned to an investigator. Entries such as these can introduce errors into management reports or other analyses that depend on accurate data.

As a result of these control weaknesses, we identified errors in the data when we analyzed the nearly 550,000 complaint resolution activities for the population of more than 28,000 complaints in BreEZe. Specifically, because BRN staff members can enter new activities for complaints that are closed and can enter other activities that deviate from the normal sequence established by the business processes, we were unable to calculate the length of each stage of the complaint resolution process for 17 percent of the complaints. Ultimately, we had to remove 4,778 complaints from our analysis for these reasons. For the remaining data, we compared selected dates in the system for 34 complaints to available documentation in the complaint files. Of the 85 date fields we reviewed, we identified five errors. We also found that BRN’s staff members were inconsistent in the date they chose to enter into BreEZe to reflect when BRN received 11 of the 34 complaints. Specifically, we found that BRN’s staff members used dates other than the date BRN received the complaint, such as the date a staff member began processing the complaint, which could be several days after BRN received the complaint. Without data that accurately reflects when it received the complaint, BRN is hindered in determining whether it is adhering to state law, which we describe in a later section in the Audit Results, that requires BRN to notify complainants of the initial action taken on a complaint within 10 days of its receipt. Therefore, the remaining data could contain additional inaccurate dates that we cannot anticipate, which could cause other complaint resolution activities to appear in the incorrect order. Using the remaining data, we calculated the average processing times for complaints, as shown in Figure 6. Specifically, we found that complaints that included an investigation averaged about 24 months, while all other complaints averaged between five and 11 months.⁵

Figure 6
Board of Registered Nursing’s Average Processing Time for All Complaints Resolved Between January 1, 2013, and June 30, 2016

Additionally, we calculated the average length of each stage of the complaint resolution process for complaints that included an investigation. Figure 7 shows that the investigative process took the longest amount of time, averaging between 15 and 19 months. We also identified 729 complaints that were open for 18 months or more. However, because staff members can enter activities out of sequence, such as by assigning a complaint to an investigator when the current status of the complaint is closed, as described earlier, some of these 729 complaints may actually be closed. Further, the results in Figure 7 may also be inaccurate because of the control weaknesses and data entry errors described previously.

Figure 7
Board of Registered Nursing’s Average Time to Resolve Complaints by Stage and Year for Investigated Complaints Resolved Between January 1, 2013, and June 30, 2016

When we inquired about the BreEZe data errors, BRN stated that it had identified similar errors when examining the results of its management reports. Until recently, these reports presented the time between the date that a complaint was received and a specific milestone, such as referral to the Attorney General. BRN is now measuring its performance on additional activities, such as the length of investigations for complaints that are subsequently forwarded to the Attorney General. BRN stated that it found inaccuracies in these more detailed measures, such as complaints with negative processing times and other complaints with very lengthy processing times. BRN’s chief of investigations acknowledged that it has become difficult to manage caseloads because the BreEZe data are not reliable. Consequently, BRN cannot accurately assess its performance, and these errors have also left it without accurate data to assess its workload or staffing needs. Despite these issues, BRN currently takes a reactive approach to addressing errors in the BreEZe data by making manual adjustments to individual complaints when it identifies an error. However, BRN has not implemented preventive measures to help ensure that similar errors do not occur in the future. To overcome the problems we identified with data discussed in this section and to get an accurate measure of how long BRN takes to resolve complaints with an investigation, we tested the 40 complaints discussed throughout this report.

BRN could improve the accuracy of its data by requesting that Consumer Affairs make system modifications to BreEZe. These modifications could include input controls that restrict the type and sequence of activities that staff members can enter in a complaint record based on the complaint’s resolution status and BRN’s business processes, and would also capture information to accurately identify the order in which activities occurred. BRN’s chief of investigations stated that it is open to requesting that Consumer Affairs modify BreEZe to include additional input controls and is working with Consumer Affairs to better understand the feasibility and complexity of adding such controls, as well as the cost associated with implementing them.

BRN Did Not Always Assign Complaints to the Appropriate Professional for Investigation

BRN has not adhered to Consumer Affairs’ direction or state law requiring that it assign complaints categorized as urgent or high priority to DOI for investigation. As described in the Introduction, since 2009 Consumer Affairs has maintained complaint guidelines for the health boards to refer to when determining the priorities to assign to complaints. The complaint guidelines were revised in July 2014 and again in August 2016 and currently establish four categories for complaints, based on priority—urgent, high, and two levels that are considered routine. Although not specified in these complaint guidelines until August 2016, Consumer Affairs and DOI officials maintain that they have consistently verbally communicated to the health boards, including BRN, that complaints categorized as urgent and high priority must be referred to DOI for investigation. However, during the course of our review, we found that BRN chose to have its non‑sworn investigators investigate numerous urgent‑ and high‑priority complaints internally, rather than referring them to DOI. BRN attributes its continued use of its non‑sworn investigators to investigate these complaints to the complaint guidelines’ lack of a specific, written requirement prior to January 2016 that urgent‑ and high‑priority complaints be referred to DOI. Because of a lack of adherence by some health boards to Consumer Affairs’ verbal direction regarding the referral of complaints, state law effective January 2016 requires the health boards to use the complaint guidelines to prioritize their complaints and investigative workloads and, once complaints are determined to be either urgent or high priority, to refer those complaints to DOI.

The director of Consumer Affairs indicated that DOI’s investigators, who are sworn peace officers, are better suited to investigate complaints of urgent or high priority than BRN’s investigators, who are not sworn. Table 3 compares the responsibilities and duties, as well as the required education and training, of BRN’s and DOI’s investigators. Both types of investigators can conduct independent criminal, civil, and administrative investigations. However, state law designates DOI’s investigators as peace officers, which allows them to carry out certain duties non‑sworn investigators cannot. For example, DOI’s investigators can make arrests and serve search warrants. These investigators are also required to complete specific training prescribed by the Commission on Peace Officer Standards and Training, whereas BRN investigators are not required to complete any training specific to their enforcement duties.⁶

Despite Consumer Affairs’ previous direction and the passage of a state law effective January 2016 requiring that BRN refer cases of urgent or high priority to DOI for investigation, we found that BRN continued to investigate many complaints internally. Specifically, we selected and reviewed 10 complaints alleging patient harm, unlicensed practice, substance abuse, or a drug‑related offense—all allegations requiring an urgent‑ or high‑priority designation—that were received between January 1, 2016, and June 30, 2016 subsequent to the change in law, and found that BRN did not always assign the complaint to DOI when required or accurately prioritize complaints. In fact, based on our review of the complaint files, BRN should have referred all of these complaints to DOI, but failed to refer seven of the 10 complaints. Although it referred two of these complaints to DOI after initially assigning them to a BRN non‑sworn investigator, it chose to investigate five complaints that we determined were of urgent or high priority because they involved patient death or unlicensed practice. For example, one complaint alleged that a nurse failed to follow proper procedures by leaving the room and not checking an alarm that sounded during a patient’s dialysis procedure, which may have contributed to the patient’s death. In another example, the complaint alleged that a nurse failed to assess a patient in the neurological intensive care unit for over two hours, which may have led to the death of the patient.

Table 3
Comparison of the Duties and the Education and Training Requirements for Non‑Sworn and Sworn Investigators

Selected Duties and Responsibilities*	Non‑sworn Investigators (Board of Registered Nursing)	Sworn Investigators (Division of Investigation)
Conduct criminal, civil, and administrative investigations	Yes	Yes
Obtain and verify evidence to support administrative action, conferences, or prosecution	Yes	Yes
Serve subpoenas	Yes	Yes
Perform undercover assignments and surveillance operations	No	Yes
Serve search warrants	No	Yes
Make arrests	No	Yes
Education and/or Training
Introductory training course prescribed by the Commission on Peace Officer Standards and Training†	No	Yes
Equivalent to graduation from an accredited college or university with a major in criminal justice, law enforcement, administration of justice, criminology, or a comparable field of study	Yes	Yes

In fact, in the years prior to the change in law—when BRN had been verbally directed by Consumer Affairs to refer all urgent‑ and high‑priority complaints to DOI for investigation—it apparently did not. According to Consumer Affairs’ deputy director of board and bureau relations (deputy director of relations), in July 2016 DOI evaluated its overall workload and identified that the number of complaints BRN referred to DOI for its investigation significantly decreased over the last six fiscal years. Specifically, the deputy director of relations stated that the number of complaints BRN referred to DOI decreased from a high of 846 complaints in fiscal year 2010–11 to a low of 334 complaints in fiscal year 2015–16, representing more than a 60 percent decrease. As a result, DOI conducted an initial review of complaints assigned to BRN’s non‑sworn investigators. The deputy director of relations explained that this review covered 515 open complaints for the period December 2014 through June 2016, and DOI identified that 171 were possibly of urgent or high priority and should have been referred to DOI. As shown in Table 4, based on our review of DOI’s listing of the 171 complaints, which included a description of the allegations, we identified that 111 should have been prioritized as urgent and that the remaining 60 should have been categorized as high priority. In all instances, based on the information in the report, BRN was required to refer these complaints to DOI, but chose instead to have its non‑sworn investigators investigate them. As an example of the severity of the complaints shown in Table 4, one alleged that the nurse was found to be under the influence of a controlled substance at work after being observed having difficulty with starting intravenous therapy on a patient after multiple attempts. After a drug test was administered, the hospital conducted an investigation and subsequently terminated the nurse. Another complaint alleged that the nurse failed to order the appropriate test on a patient who had complications with her pregnancy and sent the patient home. The patient later returned by ambulance, and doctors had to deliver the baby by cesarean section. The baby died shortly after birth due to complications.

Table 4
Types of Complaints the Board of Registered Nursing Investigated That It Should Have Referred to the Division of Investigation December 22, 2014, Through June 24, 2016

Type of Allegation	Number of Cases Investigated by the Board of Registered Nursing
Urgent Priority
Conviction	1
Drug theft/drug abuse	9
Fraud/theft	3
Incompetence/negligence	47
Patient death	27
Unlicensed practice	4
Sexual misconduct	6
Unprofessional conduct	14
Subtotal	111
High Priority
Conviction	1
Drug theft/drug abuse	40
Fraud/theft	2
Incompetence/negligence	5
Unprofessional conduct	12
Subtotal	60
Total	171

According to the deputy director of relations, DOI reported its preliminary findings to Consumer Affairs’ director, who requested that DOI conduct further review of BRN’s complaint referral practices for compliance with the complaint guidelines and state law. In August 2016, according to the deputy director of relations, DOI began a review of the nearly 1,600 complaints BRN’s non‑sworn investigators either opened or closed during July 2014 through September 2016. As of November 2016, the review was ongoing and Consumer Affairs’ chief of DOI stated that he anticipated completing the review in December 2016.

Additionally, in our review of 20 complaints that BRN investigated and resolved between January 1, 2013, and June 30, 2016, we found that it failed to refer two complaints to DOI as directed. One complaint alleged that although an unlicensed nurse was instructed not to do so, she had direct contact with a patient and did not use proper infection control measures when treating the patient’s blisters. According to the complaint guidelines, a complaint alleging unlicensed practice must be prioritized as urgent, and Consumer Affairs told us that it verbally directed BRN to refer this type of complaint to DOI for its investigation. The other complaint involved a patient death at a hospital where the complaint alleged that the nurse did not communicate the doctor’s order for constant monitoring of the patient and did not develop a care plan for the patient’s mental status. Consequently, the complaint alleged that the patient went missing and was found deceased in an emergency exit stairwell 18 days later. In addition to involving a patient’s death, this complaint was sensitive because it was reported in the media before BRN received the complaint, both of which are factors that place this complaint in the urgent category. When we asked why BRN had failed to adhere to Consumer Affairs’ verbal direction, the chief of investigations stated that BRN assigns complaints to DOI that involve patient death related to direct patient care where harm is considered intentional. If the nurse’s culpability is not considered intentional or criminal, she explained this complaint could be investigated by BRN. She also explained that in order to be cost‑effective, the complaint was assigned to BRN. However, we disagree because the fact that the complaint involved a patient death and was media‑sensitive placed it into the urgent category, and BRN should have referred the complaint to DOI for investigation as directed by Consumer Affairs. Further, as we describe later in this section, BRN’s mission is to protect and advocate for the health and safety of the public—not to minimize costs.

When we asked BRN’s assistant executive officer and chief of investigations about the numerous complaints we identified that BRN chose not to refer to DOI, they explained that the primary reason they did not refer them was that the complaint guidelines were unclear. These officials stated that until recently, although the complaint guidelines specified the priority a complaint should be assigned, they did not state which entity—BRN or DOI—should investigate the complaints. The assistant executive officer acknowledged that although Consumer Affairs may have verbally communicated to BRN that it should refer complaints it categorized as urgent and high priority to DOI, BRN had understood this direction as being a guideline and not a requirement. According to the chief of investigations, because of this understanding, BRN considered several factors in making the decision as to when to refer a case to DOI. She explained that these factors included consideration of which entity can complete the investigation in a timely manner, allowing for public awareness sooner; the possible cost associated with the investigation compared to the potential outcome; and whether the investigator will encounter any danger, given the nature of the complaint. However, regardless of its rationale, before January 1, 2016, BRN defied Consumer Affairs’ direction that it refer complaints categorized as urgent or high priority to DOI, and subsequent to that date it failed to follow the law.
When we asked the director of Consumer Affairs whether he believes Consumer Affairs clearly directed BRN to refer urgent‑ and high‑priority complaints to DOI, he stated definitively that Consumer Affairs clearly communicated this direction to BRN. He described several meetings he attended or knew of between Consumer Affairs and BRN’s former executive officer and her deputies during which this direction was clearly provided. In fact, he stated that BRN has been very resistant to complying with Consumer Affairs’ direction and the complaint guidelines since the CPEI was implemented several years ago. The director explained that the reason behind the CPEI and the complaint guidelines is to maximize enforcement staff by freeing up non‑sworn investigators to conduct more routine, less complex cases, thus leaving the more complex and serious cases for DOI’s sworn investigators. The desired effect, he stated, is to reduce processing timelines and improve the quality of the investigations.

Another reason BRN gave for not complying with Consumer Affairs’ direction and state law is the hourly cost of conducting investigations. The chief of investigations stated that BRN can reduce its enforcement costs considerably when its non‑sworn investigators investigate the complaints because the cost per hour is lower. In the most recent fiscal year for which actual cost information was available for both investigative units, fiscal year 2014–15, DOI’s hourly rate to conduct an investigation was $235, more than twice BRN’s hourly rate of $88. The costs of investigations can be passed on to the nurse if he or she is found to have violated the Nursing Act and, if paid back, are deposited into a fund, but BRN may not spend the money without appropriation by the Legislature. According to the chief of investigations, cost recovery is usually the first thing that the Attorney General tends to negotiate down during settlements. Because BRN’s lower hourly rate makes it less costly for BRN to conduct an investigation, the chief of investigations stated that having BRN’s non‑sworn investigators conduct investigations means that BRN can use the savings to commit additional resources to training staff or increasing hourly pay in an effort to recruit additional expert witnesses, which BRN does not have the budget for otherwise. BRN’s assistant executive officer stated that she and other BRN officials have communicated concerns about DOI’s costs to Consumer Affairs in the past; however, she indicated that Consumer Affairs did not take any action to address these concerns. Nevertheless, cost is not a reasonable justification for choosing not to comply with requirements. BRN’s mission is to protect and advocate for the health and safety of the public by ensuring the highest quality registered nurses in the State—not to minimize costs. Further, state law specifies that the protection of the public is the highest priority for BRN and whenever the protection of the public is inconsistent with other interests—such as achieving cost savings—the protection of the public shall be paramount.

Due in part to the fact that BRN was not referring cases to DOI as state law requires or as Consumer Affairs directed, DOI issued revised complaint prioritization guidelines in August 2016 to clearly indicate in writing that the health boards must refer urgent and high priority complaints to DOI for investigation. Nevertheless, BRN still has concerns about adhering to this requirement. According to the chief of investigations and the assistant executive officer, the new complaint guidelines would require BRN to refer the vast majority of its complaints to DOI for investigation, which they believe will result in an insufficient workload for BRN’s investigators. However, when we asked these officials whether BRN had conducted a review to determine how many complaints it typically processes that would need to be referred to DOI, they responded that they had not conducted such an analysis, but were working with DOI to identify the number.

As we describe earlier, our analysis of 138 complaints that had been pending assignment to a BRN non‑sworn investigator as of July 27, 2016, found more than 50 percent should have been referred to DOI if BRN had adhered to the CPEI guidelines as state law requires. Further, according to the chief of investigations, one reason for its backlog of complaints pending assignment to an investigator was because all of its investigators already had a full caseload of 20 complaints—a number we were able to confirm through supporting documentation BRN supplied—and therefore could not handle any more. BRN’s assistant executive officer explained that BRN plans to ask Consumer Affairs to revise the complaint guidelines to allow BRN discretion in deciding when to refer complaints to DOI.

However, it is unclear to what extent BRN’s investigators’ workload would be negatively affected if BRN adhered to the CPEI guidelines and BRN’s non‑sworn investigators worked on the two less severe priorities of complaints, had more manageable caseloads, and were able to more quickly resolve complaints. When BRN chooses not to follow the complaint guidelines, not only is it breaking the law, but it is risking that the appropriate attention and resources are not being directed toward urgent‑ and high‑priority complaints. As a result, it could be prolonging its complaint processing timelines and, more importantly, placing the public at a greater risk of potential harm.

Incomplete Investigations Contributed to Unnecessary Delays

BRN and DOI did not consistently gather sufficient evidence when conducting some investigations, extending the time it took BRN to resolve some complaints. According to its Recommended Guidelines for Disciplinary Orders and Conditions of Probation (discipline guidelines), BRN must consider the totality of the facts that enable BRN’s board to determine whether these facts prove that a nurse violated the Nursing Act. When the Attorney General or expert witnesses need additional information before making a decision on a complaint, they can return the case to BRN to request a supplemental investigation. In fact, we found that during their initial investigation, BRN and DOI did not always acquire all the information pertinent to taking action against a nurse’s license.

During our testing of 40 investigated complaints, we identified five that BRN investigated and three that DOI investigated in which supplemental investigations were requested because the investigator did not acquire sufficient evidence during the initial investigation. For example, we reviewed a complaint alleging that a nurse administered chemotherapeutic medication to a patient at an excessively fast rate, in which the deputy attorney general assigned to the case requested BRN to conduct a supplemental investigation to obtain the perspective of the main witnesses, which were the patient and his wife. According to the chief of investigations, the non‑sworn investigator did not gather the information and conduct the interviews during the initial investigation due to inexperience. She explained that the BRN analyst responsible for referring this case to the Attorney General should have identified this missing information as well before forwarding the complaint to the Attorney General. Ultimately, the BRN investigator took more than three months to obtain this missing information, which unnecessarily prolonged the amount of time BRN took to resolve this complaint.

Another complaint, investigated by a sworn DOI investigator, alleged that a nurse overmedicated a patient and did not accurately document the medication administered and times it was delivered. The expert witness requested a supplemental investigation to identify the type of medication delivered and the time it was delivered. According to a supervising investigator for DOI, the investigator could have been more thorough when collecting the evidence. By not obtaining evidence critical to pursuing action against a nurse during the initial investigation, BRN’s and DOI’s investigators are unnecessarily prolonging the complaint resolution time frame. A senior assistant attorney general for the Attorney General’s licensing section, which is responsible for prosecuting cases against nurses for BRN, indicated that both BRN non‑sworn investigators and DOI’s sworn investigators would benefit from training regarding what constitutes sufficient evidence to substantiate that a nurse has violated the Nursing Act.

When we asked BRN to provide the total number of complaints for which supplemental investigations were requested because of insufficient evidence during the period from January 1, 2013, through June 30, 2016, we learned that BRN did not track this information. However, BRN’s management created a report containing 21 complaints for which supplemental investigations were requested due to insufficient evidence during the six‑month period from January 1, 2016, through June 30, 2016. From this list we selected 10 complaints to review, and we identified similar instances of investigators not gathering sufficient evidence. For example, one complaint alleged that a managing nurse inappropriately denied medical attention to a patient who fell or threw himself off of a third‑story balcony at a medical facility. However, the BRN investigator did not interview the nurse who was the subject of the allegation and the additional evidence the investigator gathered was not sufficient enough to directly link the nurse to the incident. Nevertheless, BRN submitted the case to an expert witness to review. After the expert rendered an opinion, available documentation indicates that BRN executive management decided that the nurse’s testimony was crucial to processing the complaint and requested a supplemental investigation to obtain this testimony. By not gathering sufficient evidence during the initial investigation and then sending the investigation to an expert witness, BRN spent more time and resources than necessary to process the complaint and reach a resolution.

DOI’s list of complaints requiring supplemental investigations raised similar concerns. Specifically, DOI provided us with a list of 56 complaints for which it had to conduct supplemental investigations due to insufficient evidence from January 1, 2013, through mid‑April 2016. One complaint from our original selection of 20 complaints for which DOI performed the initial investigation was mistakenly miscoded in DOI’s information system and was thus not included on the list, although it had required a supplemental investigation due to insufficient evidence. Nevertheless, we selected 10 of these complaints for further review to determine the nature of instances in which sworn investigators did not collect sufficient evidence. For example, one complaint investigated by DOI alleged that a nurse placed a patient in wrist and leg restraints without a doctor’s orders or the proper consent from the patient or the patient’s family. Following the investigation, BRN forwarded the complaint to an expert witness who found that the nurse had violated provisions of the Nursing Act. However, the Attorney General rejected the case, noting that the expert witness report was deficient because the DOI sworn investigator did not obtain the medical facility’s policies on using restraints and did not interview all relevant personnel. As a result, DOI had to perform a supplemental investigation to acquire the additional information, thereby extending the complaint resolution timeline.

Although BRN receives and coordinates requests for supplemental investigations, it does not routinely track the number of complaints for which supplemental investigations are requested due to insufficient evidence and the reasons why these supplemental investigations are necessary. As a result, BRN is hindered from identifying and addressing common problems in investigators’ evidence‑gathering practices. Because supplemental investigations increase the time required to resolve a complaint, BRN is missing an opportunity to improve its overall timeliness. Further, BRN’s failure to track issues with investigators’ evidence‑gathering practices limits its ability to work with other entities, such as the Attorney General or expert witnesses, to improve the evidence‑gathering process, reduce the need for additional investigation work, and help shorten complaint resolution timelines.

BRN Lacks a Formal Training Program for Its Enforcement Staff, Risking Inconsistent and Inefficient Processing and Resolving of Complaints

Although BRN makes various training‑related resources available to its staff and provides training indirectly related to activities that BRN performs, it does not have a comprehensive training program that seeks to identify overall training needs and provide such instruction to its staff. The U.S. Government Accountability Office considers employee training an important part of an agency’s commitment to competence, stating that agencies should establish a training program that includes orientation programs for new employees and ongoing training for all employees. Further, having a comprehensive training program is a sound business practice. However, according to the managers in BRN’s enforcement unit, rather than having its staff attend formal training sessions, BRN uses a checklist process to familiarize staff with work tasks and to monitor staff experience. This checklist is used in conjunction with a shadowing process during which new staff members learn their jobs by reviewing complaints in collaboration with existing staff. In contrast, DOI’s investigators are sworn peace officers and are required to complete an investigative training course as prescribed by the Commission on Peace Officer Standards and Training. This training covers topics such as criminal law, presentation of evidence, and investigative report writing. Although these courses are available to BRN investigators as well, they are not a requirement. The limited required training resources that BRN offers its enforcement staff are one explanation for some of the inefficiencies and inconsistencies we describe throughout the Audit Results.

Consumer Affairs provides training resources to its boards through its enforcement academy, leadership academy, and other training programs. According to Consumer Affairs, these programs support the development of its employees by providing a well‑grounded, standard baseline of knowledge and practices for new and existing employees who perform enforcement functions, such as complaint intake and investigations. However, in general these training resources are not specific to the activities that BRN’s staff performs in the field of nursing, and therefore they do not directly address the enforcement activities that BRN staff members specifically perform and the types of complaints they may process and investigate.

Further, BRN does not track when enforcement personnel take the trainings previously described, nor does it track when staff members take training conducted external to Consumer Affairs that are related to enforcement. We asked the management of BRN’s complaint intake unit, investigative unit, and discipline unit for a comprehensive list of the trainings that enforcement division staff members have attended, and they were unable to provide such a listing. The managers stated that BRN does not centrally track trainings that staff members have attended. Instead, the managers said that BRN handles training on an as‑needed basis to address employee requests or deficiencies it has identified during its general management activities or through the discipline process. For example, the chief of investigations explained that the complaint intake unit has case management meetings every two weeks that also function as trainings. At these meetings, analysts can ask questions, discuss cases, and work through “gray areas” of their cases with management. Although some staff members we interviewed indicated that they did not receive adequate training, BRN managers expressed their belief that staff members have adequate resources available to them to perform their jobs, such as procedure documents, BRN’s orientation process, Consumer Affairs’ training resources, and select external trainings. This disconnect likely results from BRN’s lack of a formal training program that would identify training needs and provide those resources to staff in order for BRN to more effectively achieve its mission of protecting the public.

The chief of investigations explained that limited funding and resources for training have led the enforcement unit to limit training that requires course fees or reimbursement of travel expenses. Because of these limitations, a supervising investigator stated that it is difficult to send BRN investigators who work in Southern California to trainings, as Consumer Affairs provides the majority of its trainings in Sacramento. She provided us with a list of training classes that include a cost, but which she believes would help her investigative staff members, such as classes regarding witness interview techniques, testimony, report writing, and evidence. We found that BRN has approved staff attendance at only two external trainings between January 1, 2013, and June 30, 2016, which some investigators attended in person, while others attended via webcast. The two approved external trainings were developed by the California District Attorneys Association and the Attorney General. One was related to investigating cases involving elder abuse and the other was related to privacy laws and interacting with the California Department of Justice (Justice). Regardless, without detailed tracking of training attendance and a comprehensive training plan to meet the needs of the enforcement staff, BRN risks that some of its staff members may not be fully competent in completing crucial tasks related to their jobs. This lack of training could have contributed to the numerous issues we found in our review of BRN’s processing of complaints, as described throughout the Audit Results.

BRN Has Failed to Ensure That All Nurses Have Fingerprint Records on File as Required and May Not Be Notified When a Nurse Is Arrested or Convicted of a Crime

Although state law requires nurses to do so, BRN has not ensured that all nurses are fingerprinted.⁷ As of March 2009, state law requires the submission of fingerprints upon license renewal for licensed nurses who were not previously fingerprinted or who do not have a fingerprint record with BRN. According to BRN’s chief of licensing and administrative services (chief of licensing), fingerprint records allow Justice to notify BRN when a nurse is arrested or convicted of a crime. If the reason for conviction or arrest is egregious enough, she stated that BRN can seek to discipline the nurse, including potentially suspending the nurse’s license. However, she explained that if a nurse does not have fingerprints on file, Justice may not be aware that the individual is a nurse and will not notify BRN of the arrest or conviction of a crime. Further, although state law requires a nurse to self‑report his or her conviction for a crime directly to BRN, the chief of licensing stated that some individuals may fail to do so for various reasons, such as not wanting to lose their license. Thus, the most reliable and consistent means of ensuring that BRN is promptly informed of nurses who may be involved in criminal activity is to ensure that all active nurses have fingerprints on file with Justice.

Although Consumer Affairs designed BreEZe with a control to prevent a nurse from renewing his or her license if BreEZe did not contain any fingerprint records on file for that individual, we found that BRN had been circumventing that control from the time it implemented BreEZe in October 2013 until we raised it as a concern in November 2016. 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. BRN’s chief of licensing stated that when BRN began using BreEZe in October 2013, some fingerprint data in one of its legacy systems was not converted into BreEZe until May 2014. Because of this, she explained that when BreEZe would place a hold on license renewal applications for nurses who did not have a fingerprint record in the system, BRN would override the hold after verifying that the legacy system indicated the nurse had submitted fingerprints previously. We question this approach given that the legacy system may have contained inaccurate information regarding the status of a nurse’s fingerprints, and instead we would expect BRN to confirm the status of the fingerprints directly with Justice.

Of further concern, we found that BRN continued to override the system, even after the fingerprint data was converted into BreEZe in May 2014. Specifically, Consumer Affairs provided a report showing that, from October 10, 2013, through November 1, 2016, BRN overrode BreEZe more than 60,000 times. The assistant executive officer of BRN explained that if the licensee fails to answer the fingerprint submission question on the license renewal form but provides BRN with proof that fingerprints have been submitted to Justice for which the results of the background check have not yet been received, BRN would override BreEZe and renew the license. As a result, a nurse who has committed an egregious crime could continue practicing until BRN is notified by Justice, potentially placing patients at risk. When BRN approves a license renewal before receiving results from Justice’s criminal background check, it runs the risk of failing to achieve its mission of ensuring consumer protection.

Nurses are required to renew their licenses with BRN every two years, indicating that BRN could have ensured Justice received all nurses’ fingerprint records as of November 2016, since state law requiring fingerprints became effective in 2009. However, we found that this is not the case. According to BRN’s chief of licensing, from 2009 through 2015 BRN focused its efforts on ensuring fingerprints were obtained for those nurses who its records indicated did not have any fingerprints on file with Justice. However, it was not until recently that BRN began working with the results of a reconciliation Consumer Affairs conducted between its records and those provided by Justice.

According to the reconciliation Consumer Affairs conducted at the end of October 2016 of fingerprint data in BreEZe and data provided by Justice, Consumer Affairs identified approximately 24,000 active licensed nurses who did not have fingerprint records on file with Justice and another 4,700 active licensed nurses who did not have fingerprint records in either BreEZe or with Justice. These results indicate that BRN would not potentially be notified by Justice of any subsequent arrests or convictions for these approximately 29,000 nurses. The chief of data governance at Consumer Affairs stated that, for the population of approximately 24,000 nurses for which the data in the BreEZe system and Justice’s system is out of alignment, while a subset of those licensees may indeed need to be refingerprinted in order to ensure BRN receives subsequent arrest notifications from Justice, some of these nurses may be showing up on the reconciliation due to either timing issues between BRN’s and Justice’s systems or minor data errors between the systems. He explained that Consumer Affairs and BRN are working on analyzing this population to determine how many nurses actually need to be fingerprinted. Regarding the approximate 4,700 nurses for which fingerprint data does not exist in BreEZe or with Justice, the chief of data governance at Consumer Affairs indicated that these individuals most likely have not been fingerprinted and therefore BRN would not receive subsequent arrest notifications for these individuals from Justice. According to Consumer Affairs’ officials, as of November 2016 this reconciliation is still ongoing, and BRN and Consumer Affairs are working with Justice to determine the cause of Justice not having records of these nurses’ fingerprints. Consumer Affairs indicated that its goal is to complete this review as soon as possible.

BRN Should Improve Its Collaboration With Other State Agencies and Health Boards to Ensure Effective Enforcement

BRN’s relationship and sharing of information with other entities involved in the enforcement of complaints against nurses could be improved. The chief of investigations explained that although BRN collaborates with other health boards regarding complaints or investigations related to registered nurses, it has no formal agreements outlining the circumstances under which this type of collaboration should occur to ensure that it happens consistently. She explained that BRN interacts primarily with the Medical Board of California, the Board of Vocational Nursing and Psychiatric Technicians, and the Board of Pharmacy, all of which are within Consumer Affairs. She further stated that BRN and the health boards are expected to notify one another if a health care provider with multiple types of licenses, such as a nurse with a chiropractic or pharmacist license, is under investigation by any of these health boards and, if warranted, to share information pertaining to their ongoing investigations. However, the chief of investigations stated that the interactions among the health boards are governed primarily through mutual, informal agreements. As a result, BRN lacks assurance regarding whether other health boards consistently notify it when they receive complaints regarding nurses, or when they undertake an investigation related to a nurse who has multiple licenses.

BRN also collaborates with various state and local agencies regarding its enforcement of the Nursing Act. The chief of investigations indicated that BRN primarily interacts with county courthouses, the California Department of Public Health (Public Health), the California Department of Corrections and Rehabilitation, the California Department of Social Services, the California Department of Health Care Services, and other local and state government law enforcement agencies. She explained that these agencies sometimes forward complaints to BRN. For example, if one of these agencies has concerns with a nurse in the course of its own investigation, it is expected to file a complaint with BRN.

BRN management believes it could improve its relationships with other state agencies through formal agreements. The assistant executive officer stated that BRN and the other agencies and health boards have a mutual understanding of complaint referrals and notifications. She further explained that no major problems have arisen that would have required the creation of formal agreements. Nevertheless, management confirmed that BRN could improve its collaboration with other agencies and health boards by entering into formal agreements with them to ensure that the expectations regarding the sharing of information are solidified and consistently followed. For example, the chief of investigations told us that complaints BRN receives from Public Health sometimes have little information. Additionally, the process for requesting documents from specific field offices of Public Health can vary greatly—some readily share documents and information with a BRN investigator, while others require a subpoena. She concurred that establishing formal agreements that clearly describe the types of information each agency is required to share and the information necessary to include in a complaint would help create more effective and efficient complaint processing and investigations.

We believe BRN management should also take steps to improve collaboration among the health boards by way of BreEZe. According to the assistant executive officer, BreEZe currently does not allow for automatic notifications among the various health boards when, for example, a nurse with multiple licenses has a complaint filed against him or her. Rather, she stated that the management of the health boards has a mutual understanding to notify the other health boards of complaints against their licensees. She explained that BRN management was informed in fiscal year 2009–10 by the contractor that developed BreEZe, that the system would be able to notify BRN automatically if nurses who are licensed with other health boards had complaints filed against them or were disciplined by other health boards. However, when BreEZe was implemented, it was not able to perform this function. She explained that after BreEZe was implemented, BRN made Consumer Affairs aware that the automatic notification capability was missing. However, according to Consumer Affairs’ chief of data governance, Consumer Affairs has no record of BRN bringing this concern to its attention. He also stated that in May 2016, based in part on a legislative request, Consumer Affairs began running monthly reports tracking the discipline of nurses with multiple licenses. However, these reports do not track complaints, only disciplinary actions. Due to the ad hoc nature of this approach, BRN risks that it will not be notified of potential violations of the Nursing Act by its licensed nurses. Automatic notifications of complaints about nurses with multiple licenses that are filed with other health boards would inform BRN of complaints against nurses in which no disciplinary action is taken. Until BRN seeks changes to BreEZe to require the automatic notification of any complaints received or disciplinary actions taken against nurses by other health boards, nurses who warrant disciplinary action may continue to practice.

Additionally, state law does not require employers of nurses to report complaints or discipline to BRN. For instance, current state law requires the employer of a licensed vocational nurse to report to the Board of Vocational Nursing and Psychiatric Technicians any licensed vocational nurse who resigns, is suspended, or is terminated for cause. The assistant executive officer stated that she does not know why BRN was excluded from this law, but she believes BRN would benefit greatly if employers were required to report to it nurses who violate the Nursing Act.

BRN Does Not Consistently Notify Complainants as State Law Requires

BRN does not always adhere to state law requiring it to promptly notify complainants that it has received their complaint. State law requires BRN to notify complainants of the initial action taken on a complaint, for every case in which the complainant is known, within 10 days of receiving a complaint. Of the 40 complaints we reviewed, 25 met this condition of having known complainants. For 14 of the 25 complaints, BRN did not provide this notification within the required 10‑day time frame. In seven of the 14 complaints, BRN took more than 20 days to notify the complainant. For example, a former patient submitted a complaint alleging that one of the nurses who cared for her during a five‑day hospital stay overmedicated her and did not properly document the medications and times they were administered. BRN took 28 days to notify this complainant that it had received the complaint after receiving it. Similarly, BRN took 30 days to notify a patient who is also a licensed vocational nurse after she submitted a complaint alleging that during her hospital stay one of the nurses attempted to administer an incorrect dose of medication to her. According to BRN’s chief of investigations, BRN failed to notify complainants within the 10‑day requirement because it did not have enough staff to manage the number of complaints and also because it lacked management oversight to review the complaint files and verify that the letters were sent on time. When BRN fails to notify complainants within 10 days as the law requires, it is not acting with the urgency state law intended by creating the 10‑day deadline.

Additionally, BRN failed to notify some complainants of the final action it took on the complaint. State law requires BRN to notify complainants of the final action taken on a complaint for every case in which the complainant is known. For four of the 25 complaints that we reviewed for which the complainant was known, BRN did not have evidence to demonstrate that it notified the complainant of the final action it took on the complaint. According to BRN’s chief of investigations, BRN’s failure to comply with the law in two of these instances—neither of which resulted in disciplinary action—was due to oversight on the part of staff members. However, these omissions clearly point to a lack of management supervision, since management is ultimately responsible for ensuring that staff members process complaints effectively and in accordance with applicable laws.

In the other two instances in which BRN did not send notifications to complainants of the final action it took on the complaints, the chief of investigations stated that the reason was because the BRN board imposed discipline in these two instances and BRN posts all disciplinary actions on its website. She said that since the website posting informs the public of the final action taken on a complaint, the posting also informs the complainant. However, we disagree. The complainant cannot know when BRN will post the information to its website. Thus, for a complaint that may remain open for years, the complainant must spend significant time and effort checking BRN’s website repeatedly to see if it has taken disciplinary action against the nurse involved in the complaint. When BRN fails to consistently notify complainants of its final action as required, not only does it not comply with state law, but it also fails to provide transparency and closure for complainants. One of these two complaints involved an allegation that the nurse administered a fatal dosage of antibiotics to a toddler and BRN imposed a final disciplinary action of license revocation stayed with three years of probation, but never notified the complainant. The other complaint involved the allegation discussed previously in which a nurse attempted to administer an incorrect dose of medication to a patient who is a licensed vocational nurse. BRN imposed a final disciplinary action of public reproval more than four years after receiving the complaint, but never notified the complainant.

State Law That Establishes BRN’s Intervention Program Restricts Its Ability to Investigate Certain Complaints

State law requires BRN to close the investigation of certain types of complaints against a nurse if and when the nurse is determined to be eligible for, and chooses to participate in, the voluntary intervention program that we described in the Introduction. The investigation remains closed unless the nurse exits the program early or he or she fails to successfully complete it. This requirement applies to the investigation of complaints primarily alleging substance abuse, and it does not apply to allegations that involve actual or direct harm to the public. Additionally, although it has the authority to do so, BRN’s assistant executive officer explained that BRN does not investigate complaints alleging that a nurse is impaired due to mental illness, as long as the allegation does not involve actual or direct harm to the public, and the nurse chooses to enter and successfully complete the intervention program. If the nurse chooses not to participate in the intervention program or fails to successfully complete it, BRN refers the complaint to the appropriate unit for investigation, the results of which could lead to disciplinary action on the nurse’s license. As a result of the law’s requirement and BRN’s practice that it suspend the investigation during the nurse’s participation in the intervention program, an investigation may not occur or be completed until several years after BRN receives the complaint, restricting BRN’s ability to access evidence and potentially impose discipline when warranted.

BRN’s assistant executive officer acknowledges that it is problematic when a nurse fails to successfully complete the intervention program after several years. The assistant executive officer explained that BRN must then attempt to investigate the years‑old complaint when it is extremely difficult for investigators to locate witnesses or evidence because hospitals and health care facilities have records retention policies and often destroy records after a certain amount of time. To the extent BRN finds that evidence is no longer available, it will close the complaint without taking action against the nurse’s license.

The entity with whom Consumer Affairs contracts with to oversee the intervention program provided information confirming that nurses can spend years working to complete the intervention program. This information illustrated that about 57 percent of nurses who exited the intervention program from January 1, 2013, through June 30, 2016, successfully completed it. According to this information, a successful exit from the program took an average of nearly five years, whereas the information shows that those who did not successfully complete the program left it an average of eight months after they began.

The circumstances described in this section underscore the need for a change in state law to require BRN to investigate all complaints against nurses while they are participating in the intervention program. Timely investigations are critical to ensuring that BRN has access to witnesses or information that may be central to its disciplinary decisions. If state law required BRN to conduct investigations of all complaints against nurses while they participate in the intervention program, it would increase the likelihood that investigators have access to the necessary evidence. Therefore, if a nurse fails to successfully complete the program, BRN would already have collected the necessary evidence to pursue disciplinary action. This approach would also allow BRN to defer any disciplinary decision until it knows whether the nurse successfully completed the program. Essentially, this means that as long as the nurse participates in the program and successfully completes it, BRN would not pursue any disciplinary action related to the original complaint.

BRN Adequately and Consistently Imposed Discipline on Nurses in Accordance With Its Discipline Guidelines for the Complaints We Reviewed

We found that BRN’s discipline decisions for selected cases we reviewed were adequate, within its authority, and were made in accordance with BRN’s discipline guidelines. As we described in the Introduction, BRN is required to take disciplinary action against nurses who it determines have violated the Nursing Act, and the discipline guidelines contain recommended and minimum discipline terms. State law allows BRN’s board to deviate from the discipline guidelines if it determines that the facts of the case warrant such deviation.

We reviewed 20 complaint files, all of which involved similar violations of gross negligence, incompetence, or unprofessional conduct, and found that BRN consistently imposed discipline in accordance with its discipline guidelines. Although BRN’s board has the authority to revise stipulated settlement agreements, for 13 of the 20 complaints we reviewed, its board agreed to adopt the proposed stipulated settlement agreements in those instances. Stipulated settlement agreements are settlements negotiated between the nurse, BRN, and the Attorney General, and are similar to out‑of‑court settlements in civil suits. For another two complaints we reviewed, the nurses defaulted, or failed to provide a notice of defense, after an accusation had been served, and BRN’s board followed the guidelines’ recommended discipline, which called for it to revoke the nurses’ licenses. For the remaining five complaints, BRN’s board similarly adhered to the discipline guidelines and acted within its authority when it voted to either adopt or reject and revise the respective administrative law judge’s proposed decision.

Finally, for five of the 20 complaints discussed in the last paragraph, they not only contained similar violations, but also contained similar allegations. For these cases, we also found BRN’s board’s disciplinary decisions to have been consistent. Specifically, two of the complaints, which were related to separate incidents, alleged that the nurses failed to appropriately interpret a fetal heart rate during the patients’ labor and delivery, resulting in the infants’ deaths. In both of these cases, BRN’s board imposed the same discipline on these nurses—license revocation stayed with three years of probation. For the remaining three complaints, which were related to separate incidents, the complaints alleged that the nurses failed to appropriately respond to patients’ changes in condition and failed to notify the physician about the changes, and the patients later died. For each of these nurses, BRN’s board imposed license revocation stayed with three years of probation.

Recommendations

Legislature

To ensure that BRN receives timely and consistent notification of nurses’ alleged violations of the Nursing Act, the Legislature should require the employers of registered nurses to report to BRN the suspension, termination, or resignation of any registered nurse due to alleged violations of the Nursing Act.

If BRN does not develop and implement an action plan by March 1, 2017, to prioritize and resolve its deficiencies, as mentioned in the first recommendation to BRN, the Legislature should consider transferring BRN’s enforcement responsibilities to Consumer Affairs.
The Legislature should amend state law to require BRN to conduct investigations of complaints alleging substance abuse or mental illness against nurses who choose to enter the intervention program.

BRN

To ensure that it promptly addresses this report’s findings, BRN should work with Consumer Affairs to develop an action plan by March 1, 2017, to prioritize and resolve the deficiencies we identified.

To ensure that BRN resolves complaints regarding nurses in a timely manner, it should do the following by March 1, 2017:

• Develop and implement formal policies that specify required time frames for each key stage of the complaint resolution process, including time frames for how quickly complaints should be assigned to the proper investigative unit or expert witness, and how long the investigation process should take. BRN should also work with DOI to establish a reasonable goal for the length of time DOI’s investigators take to conduct investigations of complaints referred to it by BRN.
• Establish a formal, routine process for management to monitor each key stage of the complaint resolution process to determine whether the time frames are being met, the reasons for any delays, and any areas in the process that it can improve.
• Establish a plan to eliminate its backlog of complaints awaiting assignment to an investigator.

To increase its pool of expert witnesses, BRN should do the following by June 2017:

• Develop and implement a process to track the effectiveness of the methods it uses to recruit expert witnesses, and then focus its efforts on those methods that prove to be the most successful.
• Modify its renewal application process for nurses’ licenses to include a question regarding whether they would be interested in serving as an expert witness, and then develop a process to promptly follow‑up with those nurses.
• Take the steps necessary to increase the hourly wage it pays expert witnesses.

To ensure it does not risk compromising private and confidential information related to ongoing investigations of complaints, BRN should immediately ensure that any email correspondence it has with expert witnesses is transmitted securely.

To ensure that it is able to accurately monitor the performance of its complaint resolution process and that it has accurate data to address its staffing needs, BRN should do the following:

• Immediately begin working with Consumer Affairs to implement cost‑effective input controls for BreEZe that will require BRN staff members to enter information into a complaint record in a way that is consistent with BRN’s business processes, as well as to implement changes that would cause BreEZe to accurately identify the order in which activities occur.
• Once it has implemented these controls and accumulated six months of data, BRN should analyze these data to determine whether its staffing is sufficient to meet its workload.
• Develop and implement training for all BRN complaint processing staff that instructs them on how to accurately enter information in complaint records that are contained in BreEZe, including the date BRN received the complaint, in a manner that is consistent with BRN’s business processes.

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.

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 do the following:

• 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.
• Coordinate with the Attorney General to develop a biennial training program that includes techniques for gathering appropriate evidence and ensure that all investigators, including DOI’s investigators, participate in this training.
• 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.

To ensure that its enforcement unit employees appropriately address and process complaints in a consistent and efficient manner, BRN should do the following:

• By March 2017, develop a process to centrally track the internal and external trainings its staff participate in. On a regular basis, managers should review this information to ensure enforcement staff are participating in a timely manner in appropriate trainings that address the enforcement activities they specifically perform and the types of complaints they may investigate.
• Implement a formal training program no later than December 2017. In developing this program, BRN should consult with DOI and the Attorney General to identify training that could benefit its enforcement staff, and also solicit input of its enforcement staff on areas of their job duties where they believe they need additional training.

BRN should immediately stop overriding fingerprint holds in BreEZe based solely on the fact that fingerprint data is present in BRN’s legacy system and, for those cases where it believes it is necessary to override the system, BRN should receive its executive officer’s approval to do so and document both the reason for the override and evidence of the executive officer’s approval.

BRN should continue working with Justice and Consumer Affairs and finalize its reconciliation, by March 1, 2017, of Justice’s fingerprint data with its data in BreEZe to identify any nurses who are missing fingerprint records. Once this reconciliation is performed, BRN must take the steps necessary to immediately obtain fingerprints from those nurses for which Justice has no fingerprint records.

To ensure that it has prompt access to adequate information that could affect the status of a nurse’s license, BRN should do the following by June 2017:

• Establish formal agreements with other agencies and other health boards that have information pertaining to a nurse’s misconduct.
• Work with Consumer Affairs and other health boards to determine whether modifying BreEZe to include a capability that would allow it to promptly notify BRN when another health board receives a complaint or takes disciplinary action against a licensed nurse is cost‑effective. If it is, add this functionality to BreEZe.

To ensure that it promptly and appropriately sends notifications to complainants as state law requires, BRN should do the following by March 2017:

• Develop desk procedures that describe the actions enforcement staff members should take when processing incoming complaints and when BRN reaches a final disposition on a case.
• Establish formal procedures, such as managers performing routine audits of complaint files, to monitor incoming complaints and final dispositions.

We conducted this audit under the authority vested in the California State Auditor by section 8543 et seq. of the California Government Code and according to generally accepted government auditing standards. Those standards require that we plan and perform the audit to obtain sufficient, appropriate evidence to provide a reasonable basis for our findings and conclusions based on our audit objectives specified in the Scope and Methodology section of the report. We believe that the evidence obtained provides a reasonable basis for our findings and conclusions based on our audit objectives.

Respectfully submitted,

ELAINE M. HOWLE, CPA
State Auditor

Date:
December 13, 2016

Staff:
Laura G. Kearney, Audit Principal
Katrina Solorio
Jim Adams, MPP
Fahad Ali, CFE
Ryan Grossi, JD
Bridget Peri, MBA

IT Audits: Michelle J. Baur, CISA, Audit Principal
Ben Ward, CISA, ACDA
Derek J. Sinutko, PhD

Legal Counsel:
Scott A. Baxter, Sr. Staff Counsel

For questions regarding the contents of this report, please contact Margarita Fernández, Chief of Public Affairs, at 916.445.0255.

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Footnotes

³ Consumer Affairs’ 2010 Consumer Protection Enforcement Initiative (CPEI) specifies that the health boards should resolve complaints within 12 to 18 months. For purposes of this report, we assessed BRN’s timeliness of resolving complaints by comparing it to the high end of the goal, 18 months..  Go back to text

⁴ Although Consumer Affairs’ Division of Investigation (DOI) investigates some of the complaints BRN receives as we describe later, BRN is responsible for the entire complaint resolution process, including steps that come before and after the investigation.  Go back to text

⁵ Complaints that do not include an investigation may take several months to complete because, for example, they involve a nurse’s arrest and require BRN to contact relevant law enforcement and court officials to obtain documentation regarding the arrest and the court’s decision.  Go back to text

⁶ The Commission on Peace Officer Standards and Training is a legislatively established state commission whose responsibilities include setting training standards for law enforcement in California.  Go back to text

⁷ According to the assistant bureau chief of the Bureau of Criminal Information and Analysis within Justice, BRN will be notified of a subsequent arrest or disposition as long as the fingerprints are submitted to Justice, regardless of whether the fingerprints are submitted via hard copy or electronically.  Go back to text

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