Auditor General Lindsey Perry said the policy of the board, which oversees everything from advanced practice registered nurses to certified nursing assistants, says complaint investigations should be completed within an overall average of 180 days from receipt.
But Perry said of the 25 randomly selected closed complaints the board received in fiscal year 2020, 12 were not finished within that time frame. And of those, four were serious enough to result in nurses surrendering their licenses, two led to consent agreements involving probation and one ended with a letter of censure.
Auditors also looked at 10 open complaints and found none resolved within that 180-day time frame.
“Untimely complaint resolution may negatively impact patient safety when delays allow licensees and certificate holders alleged to have violated board statutes and rules to continue to practice while under investigation even though they may be unfit to do so,” Perry wrote.
She specifically cited one complaint that alleged the nurse failed to recognize and manage postpartum complications, including hemorrhaging. The result was a delay in getting the patient to a higher level of care.
That ultimately resulted in suspension of the nurse’s license until she completed required continuing education care, followed by a 24-month probation.
“Despite this action, the board took 301 days to resolve this complaint, during which time the nurse continued to practice without restriction,” the report states.
Perry said the board said the investigation was delayed because the allegations required an investigator with specialized knowledge, but that the board’s investigator with this knowledge was on extended personal leave for longer than anticipated.
The auditor general noted, however, this isn’t the first time her agency has seen this problem.
As far back as 2001 auditors concluded the board had “excessive investigation time frames and many open investigations.” She said the board implemented some recommendations made at that time.
Yet a decade later Perry said more than half the complaints still were taking more than 180 days to resolve. That, she said, resulted in the nursing board implementing new policies with that 180 goal, including some interim deadlines.
Yet the new report shows problems still exist.
In a formal response, Joey Ridenour, the board’s executive director, said she agrees with the findings of the report.
One issue the board cited is an increase in the number of both complaints and licensure investigations opened each year, with the figure more than doubling between 2011 and 2021. And the number of people holding licenses increased by 20%, to 130,690 in 2021.
The result was that the average caseload was 87 per investigator. That compares with what the board believes would be the ideal number of 60, a number that would allow resolution within that 180-day deadline.
What may help is that the board did seek – and the Legislature granted – an additional 3.5 investigative positions for the current fiscal year.
Perry said her staffers also found that the board and its staff were not good in responding to inquiries from the public.
The staff placed three anonymous phone calls to board offices earlier this year, requesting information about licensees with varying disciplinary histories. And in all three cases, the board “provided some accurate information about the licensees.”
But Perry said the board provided “insufficient information.”
In two of the cases, she said the board staff did not disclose that both nurses had a dismissed complaint or inform the callers that the board could provide general information about the nurse, such as license status and any nondisciplinary actions.
Perry said the board did refer the callers to Nursys, a national database used to verify the licensure, discipline and practice privilege for nurses for states that participate. But state law prohibits the board from including dismissed complaints on that website.
In all three cases, Perry said board staffers referred people to Nursys when callers asked how they can obtain additional information about specific licensees. But here too, she said, they did not tell the callers that the system doesn’t include things like dismissed complaints or nondisciplinary actions.
Perry said that while the audit was pending, the board developed new policies and procedures to address the issues.