Figure 1
Timeline of Events Leading Up to Submission of Falsified Caseload Report
Figure 1 displays a timeline of events starting in December 2016 and leading up to the case reassignments, the submission of the falsified caseload report, and the subsequent reassignments in November 2018.
On December 13, 2016, the State Auditor issues report 2016-046—Board of Registered Nursing: Significant Delays and Inadequate Oversight of the Complaint Resolution Process Have Allowed Some Nurses Who May Pose a Risk to Patient Safety to Continue Practicing. The report includes several recommendations, including that BRN establish a plan to eliminate its backlog of complaints awaiting assignment to an investigator. During the audit, BRN's chief of investigations states that a full caseload for BRN investigators is 20 cases.
Between February 2017 through October 2018... BRN submits follow-up responses to the State Auditor; auditors review
responses showing average caseload of 24 and determine that the recommendation is not fully implemented.
On or around November 27, 2018... Executives A, B, & C meet and discuss plan to manipulate caseload data to convince the State Auditor that BRN has fully implemented the recommendation.
On November 27, 2018 at 11 am... Executive A informs Executive B of State Auditor's current assessment on caseload recommendations and states via email, "[The auditor] said she needs us to provide any additional supporting documentation TODAY if we want to get the responses to Fully Implemented. Looks like we need to get busy ... "
At 1:30 pm...Executive B meets with managers.
At 4:05 pm...Executive B meets again with managers.
At 5:05 pm...Managers begin reassigning cases.
At 5:21 pm...Executive B sends draft caseload report to Executive C.
At 5:24 pm...Managers finish reassigning 38 cases.
At 5:31 pm...Executive B sends final caseload report to Executives A and C showing all investigators with an assigned caseload of 20 or fewer.
At 6:29 pm...Executive C sends final caseload report to the State Auditor.
The next day, November 28, 2018... State Auditor reviews the falsified caseload report and, trusting its legitimacy, informs the executives that BRN has fully implemented the recommendation.
Finally, from November 27, 2018 through December 7, 2018... Managers reassign 38 cases back to the original investigators.
Figure 2
Comparison of Caseload Report Manipulation
Figure 2 demonstrates how managers shifted cases to manipulate caseloads of 11 employees during the 10-day span in question. Before reassignments occurred on November 27, 2018, nine investigators had caseloads ranging from 21 to 26 cases. One remaining investigator who was on extended leave and one manager had 0 cases.
The report BRN submitted to the State Auditor later that same day on November 27, 2018, showed the same nine investigators with exactly 20 cases. The remaining investigator who earlier had 0 cases, now has 20 assigned. The manager who had 0 cases, now has 18 cases.
By December 7, 2018, after all cases were reassigned back, the same nine investigators all have caseloads ranging from 21 to 26 cases. The remaining investigator and the manager are both back to 0 cases.