HospitalInspections.org

Based on interview and record review the facility failed to ensure the Chief Nursing Officer was administratively responsible for the entire Nursing Service including making determinations of the types and number of nursing personnel necessary to provide nursing care in the inpatient Behavioral Health Unit (BHU). This deficient practice had the potential to permit unsafe or inappropriate types and numbers of nursing staff in the BHU. The total facility census was 42. The BHU census was six.

Findings included:

1. Record review of the facility's document titled, "Organizational Chart," dated 04/23/15 showed Staff B, Chief Nursing Officer (CNO), was not organizationally responsible for (supervised) the nursing staff in the BHU.

2. During an interview on 06/10/15 at 9:10 AM, Staff I, Register Nurse, Program Director of the BHU, stated the following:
- She was not organizationally responsible to the facility CNO.
- She and the CNO informally discussed nursing policies and procedures used on the BHU for patient care.
- She (Staff I) determined staffing for the BHU without input from Staff B.

During an interview on 06/11/15 at 8:45 AM, Staff B, confirmed she was not the organizational supervisor for the nursing staff in the BHU.