HospitalInspections.org

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Based on record review and interview the facility failed to ensure a Behavioral Health Unit (BHU) Nurse Manager was qualified by training, experience and/or education to provide staff leadership and clinical direction for staff providing services to this unit. The failure to ensure the unit be managed by a qualified registered nurse (RN) with experience in the care of the mentally ill had the potential to prohibit those patients from achieving their maximum potential outcomes in a safe and therapeutic environment. The total facility census was 10. The BHU census was five.

Findings included:

During an interview on 05/12/15 at 4:30 PM, Staff C, Human Resources (HR) Director, stated that:
- The facility's plan was to use an Advanced Practice Nurse (APN) with psychiatric experience as the Psychiatric Nurse Manager for the BHU.
- The Psychiatric Nurse Manager was not in place and she had no definitive start date for the APN.
-The previous manager of the BHU did not meet the education and experience requirements for the BHU Director/Manager position.
-The previous manager of the BHU was now the Lead Registered Nurse (RN) and continued to provide clinical oversight for the unit.

Record review of the facility's job description titled, "BHU Director/Manager showed the minimum requirements of the job to be a graduate of an accredited school of nursing and master's degree in healthcare management or nursing or be qualified by education and experience.

During an interview on 05/14/15 at 11:00 AM, Staff U, Chief Financial Officer (CFO), stated that the facility plan was to have had an APN with Psychiatric experience take over the responsibilities of oversight of the BHU. Staff U stated that the APN was not available to start her duties as Manager of the BHU and he was not sure when she would be available.

Based on observation, interview and record review the facility failed to ensure the Behavioral Health Unit (BHU) Activities were directed by a staff member qualified by training and/or education to provide therapeutic activities to this unit. The failure to ensure a qualified activities director for the unit had the potential to prohibit those patients from achieving their maximum potential outcomes through appropriate and individualized therapeutic activities. The facility census was 10. The BHU census was five.

Findings included:

1. Record review of the facility's BHU job description titled, "Director of Activities/Assistant to Social Worker", dated 03/2014, showed the minimum qualification for the position was a Bachelor's Degree and/or State activities certificate.

2. During an interview on 05/13/15 at 10:30 AM, Staff D, Registered Nurse (RN), BHU Lead RN, stated that the current activities director for the BHU was Staff H, Licensed Practical Nurse (LPN). She stated that Staff H had not been certified in activities and there had been no plan developed for her to become certified.

During an interview on 05/14/15 at 9:15 AM, Staff H, LPN, stated that she was responsible for maintaining the activities program for the BHU. She stated that:
- She was one of a group that came together to plan a weekly activities calendar.
- The group consisted of a Certified Nursing Assistant (CNA), herself and the intake counselor;
- Her previous experience in activities had been to fill in and help with activities for long term care residents in a nursing home.
- She was not certified in activities and there had been no plan developed for her to become certified.

During an interview and concurrent record review of the personnel file for Staff H on 05/14/15 at 3:00 PM, Staff C, Human Resources (HR) Director, stated that she was aware the Director of Activities for the BHU did not have a Bachelor's degree or State activities certification. She stated that there had been no plan developed for Staff H to become certified.