HospitalInspections.org

Based on observation, document reviews and staff interviews, it was determined the facility failed to construct a seclusion room to ensure patients rights to a least restrictive intervention in addressing patient behavior that is violent or destructive to self or others.

Findings include:

The facility stated in its Plan of Correction dated November 22, 2010, that the "space on the unit shall be evaluated and options shall be developed for appropriate seclusion space by the Director of Facilities and Director of Mental Health. A plan will be in place in 45 days. Construction will be completed by February 28, 2011." However, during a tour of the Mental Health Unit on March 7, 2011 at 11:30 AM, it was noted that the facility did not have a dedicated seclusion room.

This finding was verified by Staff #2 at that time.

THIS IS A REPEAT CITATION FROM THE INITIAL SURVEY OF OCTOBER 22, 2010.

Based on a review of personnel records, staff interview and medical records, the hospital did not ensure that personnel are properly credentialed and qualified for their title and position.

Findings include:

Putnam Hospital has a Psychiatric Unit/Mental Health Services, which is required to meet both the general criteria for hospital units and the specific criteria for psychiatric units. The psychiatric unit must furnish, through the use of qualified personnel, psychological, social work, psychiatric nursing, occupational and recreational services.

1. A review of the hospital's job description for the director of psychiatric nursing services revealed that the person must be a registered nurse who has a master's degree in psychiatric and mental health nursing, or its equivalent, from a school of nursing accredited by the National League for Nursing, or be qualified by education and experience in the care of the mentally ill. The director must demonstrate competence to participate in disciplinary formulation of individual treatment plans; to give skilled nursing care and therapy; and to direct, monitor, and evaluate the nursing care furnished.

Review of the personnel record of Staff #14, who was recently promoted to a Director of Nursing in Mental Health Services, on 1/2011, revealed that the graduate degree was a Masters of Science in Nursing Administration, not a Masters in Psychiatric/Mental Health Nursing. According to the resume, Staff #14 had worked as a staff nurse in Psychiatric and Mental Health nursing from 2/1976 to 2/1978 and and as a Clinical Adjunct Professor from 9/1996 to 5/2002, which does not qualify her by education and current experience in the care of the mentally ill.
Therefore, the newly designated Director of Psychiatric Nursing Services is not qualified in accordance with accepted standards of practice and established facility policies and procedures, including the facility's job description for this position.

THIS IS A REPEAT CITATION FROM THE INITIAL FEDERAL ALLEGATION SURVEY OF OCTOBER 22, 2010.