HospitalInspections.org

Based on document review and staff interview, the agency failed to accept and update the pharmacy policy and procedures.

Findings include:

In reviewing the policy and procedures for pharmacy there was no evidence of the policy and procedures being accepted by the administration or medical staff.

No further information offered at closing at 3:15 p.m. on 5/08/13.

Based on document review, staff interview, and policy and procedure review the above facility failed to provide adequate staffing in the geriatric-psychiatric unit, the emergency room and acute care unit in 19 of 19 days.

Findings include:

1. In the geri-psych unit of the above facility, it is required to have a qualified director of psychiatric nursing services. The director must be a registered nurse who has a master's degree in psychiatric and mental health nursing, or its equivalent. (this is per psychiatric unit criteria work sheet) In 19 of 19 days reviewed on the schedule, from April 19, 2013 until May 08, 2013, there has been no Psych Nursing Director.

In an interview with the Interim Director of Nursing and the Administrator on 05/08/13 at 1:30 p.m. this was discussed, and even though there has been an RN in the unit at times, none were qualified per regulation cited above.

2. On the following dates, 4/26, 4/27, 4/28, 4/30, 5/01, 0/04, 5/05, 5/06, and 5/07/2013 there was only one (1) RN on the day schedule for the acute med-surgery unit and the emergency room.

In an interview with the Interim Director of Nursing at 1:15 p.m. 5/08/13, she stated she has been working so many nights because they are working so short staffed.

3. The Administrator stated, "I am going to get each area staffed with a director. It's just so much to get fixed." This was stated on 5/08/13 at 2:00-2:30 p.m.

There was no further information provided at the exit conference at 3:15 p.m. on 5/08/13.