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Based on medical record review, policy review, and staff interview it was determined the facility lacked a well organized nursing services department to ensure policy implementation, compliance, and staff training. The hospital failed to ensure the oversight of nursing governance and nursing committees for effective operation of the nursing department, failed to ensure nursing policies and procedures were implemented, and failed to ensure documentation of staff education and training (A386). The hospital also failed to ensure nursing staff were completing reports for possible adverse drug reactions and the appropriate staff and committees were investigating possible occurrences as outlined in hospital policy (A405).
The cumulative effect of these systemic practices resulted in the facility's inability to ensure quality delivery of nursing services.

Based on review of personnel files, job description and staff interview it was determined the facility failed to ensure the Director of Nursing organized and provided oversight for the operation of the nursing departments. This deficient practice has the potential to affect all 39 patients receiving nursing services at this facilty.


Findings include:


On 01/20/16 at 3:34 PM Staff C provided documentation of the RN/LPN Psychopharmacology training packet each nurse receives upon hire. The objective of the training described commonly used medications in the psychiatric setting, allowing the nurse to gain knowledge of side effects including serotonin syndrome and neuroleptic malignant syndrome. On 01/21/16 four registered nurse and two licensed practical nurse personnel files were reviewed and lacked evidence the Psychopharmacological training was completed upon hire.


The 01/21/16 six personnel file review lacked the RN/LPN orientation training check off sheet. Five of the six personnel files reviewed lacked evidence of an RN/LPN job description and performance evaluation when applicable. On 01/21/15 at 12:30 PM Staff C stated in an interview the staff training duties fall under the responsibility of the DON.


On 01/21/16 the job description of the Director of Nursing (DON) was reviewed. Review of the DON job description responsibilities included organizing staff education and training, providing oversight of the nursing departments, and ensuring policies and procedures are implemented according to standards. On 01/19/16 Staff A reported the facility has had an increase in staff turnover. Staff C confirmed there have been four individuals filling the position of Director of Nursing over the past four month period.


A DON qualification variance request was documented on 01/19/16 pending hire of a new DON who does not meet the minimum requirements of holding a bachelor's or master's degree in nursing. The candidate is currently enrolled in an accredited Bachelor of Science in Nursing (BSN) program with a scheduled completion date of December 2016. The new DON candidate is to obtain certification in psychiatric and mental health nursing upon receipt of the BSN degree.

Based on policy review, staff interview, and medical record review the psychiatric hospital failed to ensure nursing staff were completing reports for possible adverse drug reactions under the supervision of the Director of Nursing. The hospital also failed to ensure the Director of Nursing and the Pharmacy and Therapeutics Committee was investigating possible adverse drug reactions as outlined in hospital policy #NUR-2.2. This deficient practice has the potential to affect all 39 patients receiving nursing services at this facility.


Findings include:


Hospital policy #NUR-2.2, Medication Variances, Errors, Near Misses, and Adverse Drug Reactions, revised 03/05/15 was reviewed on 01/19/16. The policy documented medication variances and errors and reactions shall be investigated by the Director of Nursing and information regarding the process shall be shared with the physicians and pharmacist. "Whenever there is an occurrence that could remotely be considered an adverse drug reaction, the nurse should initiate an Adverse Drug Reaction report and forward it to the pharmacy so that the appropriate actions can take place." "The adverse drug reaction reporting does not in itself conclude an adverse drug reaction has occurred." The report is a tool for the Pharmacy and Therapeutics Committee to review for the possibility of an adverse occurrence.

On 01/19/16, 01/20/16 and 01/21/16 ten medical records were reviewed. Three of the records reviewed included patients who were sent out for medical reasons to a community medical hospital. One of the three medical records documented signs and symptoms listed in the NUR-2.2 policy for possible adverse drug reactions, however the record lacked evidence of a possible Adverse Drug Reaction report.

On 01/19/16 at 11:00 AM hospital administration was asked for all possible Adverse Drug Reaction Reports and all Pharmacy and Therapeutics Committee minutes for 2015. The administrator, Staff B, stated the hospital had no Adverse Drug Reaction Reports or Pharmacy and Therapeutic Committee minutes completed for the requested year.

On 01/19/16 at 3:00 PM, Staff B confirmed the requirements of Policy #NUR-2.2 and confirmed the lack of the Director of Nursing and Administration following hospital policy for possible adverse drug reactions.