Figure 1 is a flowchart that describes the various steps in the Board of Registered Nursing’s (BRN) complaint resolution process. The description includes boxes describing the process that descends down the page until the complaint is resolved. The process begins when BRN receives a complaint from anyone who believes a registered nurse has acted in an unsafe or unprofessional manner. If the complaint is not related to the Nursing Practice Act (Nursing Act), BRN closes the complaint. If the complaint alleges mental illness or substance abuse, BRN closes the case and refers the nurse to the intervention program. If the nurse successfully completes the program, BRN does not reopen the complaint or pursue disciplinary action; however, if the nurse fails to complete the program BRN continues to process the complaint. After reviewing the investigation report, BRN takes one of four actions: 1) determines the complaint does not warrant discipline and closes the case; 2) issues the nurse a citation and fine because the complaint and supporting evidence do not warrant imposing discipline against the nurse’s license; 3) determines the complaint does not involve patient care but the complaint may warrant discipline against the nurse’s license and forwards the complaint to the Office of the Attorney General (attorney general); or 4) determines the complaint is related to patient care and refers the case to an expert witness who opines on whether the nurse’s actions deviated from the standard of care or constituted gross negligence. Once BRN determines that disciplinary action against a nurse’s license may be warranted, the attorney general reviews the case and either rejects the case because there is insufficient evidence to move forward to a hearing, or prepares an accusation describing the violations it is charging the nurse with. If the nurse does not respond to the charges or appear at the hearing, BRN’s nine-member board may apply its default decision of revoking the nurse’s license. If the nurse responds to the charges, the case may go to the Office of Administrative Hearings (Administrative Hearings) for a hearing, or BRN and the Attorney General negotiate a stipulated settlement agreement with the nurse that outlines the terms of discipline. After either of these steps, the BRN board votes to either adopt, reject, or revise the Administrative Hearings’ decision or the stipulated agreements. The BRN board votes to impose discipline of license revocation, suspension, probation, or public reproval.
Figure 2, a chart describing the four categories of Consumer Affairs’ DOI’s Case Acceptance Guidelines for complaints filed with a healing art boards (health board). Category One complaints identified in burgundy are classified as urgent, and include any case that requires immediate suspension of a nurse’s license, as described in the Penal Code, Section 23, or by an interim suspension order, such as rape, murder, lewd acts, assault with a deadly weapon, or any crime involving children or the elderly; cases that receive media attention or ones that are politically sensitive; unlicensed practice in healing arts professions; and actively practicing under the influence of drugs or alcohol or while impaired. Category Two complaints identified in blue are classified as high and include criminal violations, such as theft of controlled substances or narcotics, prescription forgery, or major financial fraud; high potential for consumer harm, medication tampering; or failure to complete a narcotic rehabilitation program and deemed a public safety risk by the health board. Category three complaints identified in green are classified as routine and include minor injury or harm that is not intentional or not life threatening, related to a nurse’s practice, falsified financial records, misdemeanors related to a nonviolent violation, or multiple incidents of negligence or incompetence without injury. Category Four complaints, also identified in green and classified as routine, include a single incident of negligence or incompetence without injury, minor departure from the standard of care, administrative record-keeping violations, and complaints of “poor-bedside manner.”
Figure 3, a bar graph in succession from left to right that shows BRN’s complaint resolution time, in months, for the selection of 40 complaints that we reviewed. The graph is depicted with the duration of time along the horizontal axis and the number of complaints along the vertical axis. The graph indicates that BRN resolved 9 of the 40 complaints within 18 months or less, which is the goal set by Consumer Affairs’ Consumer Protection Enforcement Initiative for health boards to achieve. The graph also shows that BRN took 19 to 24 months to resolve six complaints, and 25 to 36 months to resolve ten complaints. Finally, the graph shows that for 15 of the 40 complaints we reviewed, BRN took longer more than 36 months to resolve the complaint.
Figure 4, a bar graph in succession from left to right that shows BRN’s complaint resolution time in months for the selection of 40 complaints that we reviewed, with 20 investigated by BRN’s non-sworn investigators and 20 investigated the DOI’s sworn-investigators. The graph is depicted with the duration of time in month along the horizontal axis and the number of investigated complaints along the vertical axis. The investigation stage includes the time it took to assign a complaint to an investigator once received in the applicable investigative unit, as well as the time it took the investigator to complete the investigation. The graph is presented using side-by-side columns of complaints representing the number of complaints investigated by BRN, identified in dark blue, and DOI, identified in light blue. The bars are grouped in periods of monthly increments from those investigations conducted in less than 6 months to more than 24 months. For three of the BRN-investigated complaints we reviewed, the investigation stage took less than six months, and another seven complaints took from six to 12 months to assign and investigate. However, for seven complaints investigated by BRN, BRN took from 13 to 24 months to assign and investigate the complaint, and another three took more than 24 months to assign and investigate. All 20 of the DOI-investigated complaints took from six to 18 months to assign and investigate.
Figure 5, a bar graph in succession from left to right that shows the time it took BRN to assign complaints to either its non-sworn investigators or DOI’s sworn-investigators for investigation. The graph is depicted with the duration of time along the horizontal axis and the number of complaints along the vertical axis. BRN has an informal goal to assign complaints to an investigative unit within 30 to 45 days. The graph shows that of the 40 complaints we reviewed, BRN assigned 16 complaints to an investigative unit in 45 days or less. However, the graph also indicates that it took BRN from 46 to 180 days to assign 13 complaints, from 181 days to one year to assign another two complaints, and from 366 days to 730 days to assign eight complaints. Lastly, BRN took more than 1,000 days to assign one complaint.
Figure 6, a bar graph that compares the time it took BRN to resolve complaints with investigations, indicated in dark blue, against complaints that did not have an investigation, indicated in light blue. The bars are grouped annually and displayed with the year of final disposition from 2013 through 2016 on the horizontal axis and the average number of months from receipt of complaint to final disposition along the vertical axis. The graph demonstrates that it took BRN, on average, 24 months to resolve investigated complaints from 2013 through 2016. The graph also indicates that BRN resolved complaints that do not have an investigation in less than one year, with an average high of 11 months for complaints resolved in 2014 and an average low of 5 months for complaints resolved in 2016.
Figure 7, a bar graph that compares the average time it took BRN to complete each stage of the complaint resolution process for complaints resolved between January 1, 2013 and June 30, 2016. The columns designate the year the stage took place, from 2013 to 2016, and they are grouped along the horizontal axis by the various stages of the process including complaint intake, investigation process, attorney general, adjudication, and board vote. The vertical axis represents the average processing time in months. The shortest stage of the complaint resolution process is the intake stage, which, on average, took less than one month, whereas the longest stage—the investigation stage—took on average between 14 and 20 months. The attorney general processing time averaged roughly six months and the board vote stage averaged more than two months. With the exception of the 2015 year, the adjudication stage has declined, averaging a low of less than 10 months in 2016. The graph includes a sixth category of complaint processing stage referred to as reopened, which consists of the time between the reopening of a complaint and the start of one of the complaint stages. During our testing period, this stage averaged less than two months.