The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

Based on observation, interview, record review and policy review, the facility failed to ensure staff were qualified by orientation, training, and education to provide care and oversight to patients in the Behavioral Health Unit (BHU) for eight of the nine staff reviewed for unit specific orientation, training and/or experience to meet the needs of patients who were:
- Placed in physical holds by staff for behavioral purposes.
- Known to have risk factors for sexually inappropriate behavior.
- In need of general patient care in a safe environment.
- Involved in Activity Therapy.
The failure to ensure staff are qualified to meet the patients' specific needs had the potential to prohibit those patients from achieving their maximum potential outcomes in a safe environment. The total facility census was eight. The BHU census was five.

Findings included:

1. Record review of the job description in effect when Staff L, BHU Manager, was hired on 07/20/14 titled, "Interim Nurse Supervisor: Psychiatric," dated 03/2014, showed the following minimum qualifications did not require that nursing services be managed by a qualified registered nurse (RN) with a master's degree in psychiatric and mental health nursing, or its equivalent, from a school of nursing accredited by the National league of Nursing, or be qualified by education and experience in the care of the mentally ill.

Record review of the current job description titled, "BHU Nurse Manager," dated 02/2015, showed that the BHU Manager minimum qualifications included, "Two to four years' previous experience in supervision and/or teaching helpful; background in geriatrics, psychiatry, pediatrics, and/or emergency medicine with experience as a charge nurse valuable.

During an interview on 02/25/15 at 9:30 AM, Staff L stated that she was the Director of the BHU. She stated that she had no special certification or qualifications in psychiatric nursing. She stated that her direct supervisor was Staff C, Director of Nursing (DON).

During an interview on 02/25/15 at 10:45 AM, Staff C stated, "I know we have been talking with someone who is qualified [to be a consultant to Staff L in the BHU].

During an interview on 02/25/15 at 10:55 AM, Staff F, Director of Human Resources, stated that the administration was aware that Staff L was not qualified by education or experience to be the Nurse Manager of the BHU.

2. Record review of the resume for Staff L showed that she obtained her RN status with an Associate of Arts Degree in Nursing. Her previous position was in outpatient nursing care at the facility and that going back to 1989 there was no evidence of further education or psychiatric nursing experience.

During an interview on 02/25/15 at 12:58 AM, Staff L stated that she had worked at another facility that had a 10 bed psychiatric unit. When asked if she managed the BHU or worked in the BHU at that facility she stated, "No".

3. Record review of the facility's policy titled, "New Employee Orientation," dated 03/28/14, showed the following direction:
- All employees would be oriented to all facets of their job.
- The Department Manager/Director or Supervisor orientated the employee to the department, unit, work setting and/or the program specific policies and procedures.
- Each employee's personnel file contained the completed orientation documentation.
- Staff and Licensed Independent Practitioners were required to complete a job/program specific orientation checklist before they performed patient care, treatment and services.
- The Human Resources Department was responsible for the facilitation of orientation training that included; Restraints, The Distinction between De-escalation and Clinical Seclusion, and Restraint, Abuse and Neglect.

4. Record review of facility personnel files showed no job specific orientation (education related to actual unit that the staff member will work on; policies, procedures, physical environment, and specific expectations) for eight staff on the BHU of nine files reviewed. Files reviewed included: Staff L, BHU Manager; Staff M, BHU Licensed Practical Nurse (LPN); Staff H, Licensed Psychiatric Counselor (LPC); Staff J, Director of Security, Staff I, AA, BB, Security Officers; and Staff DD, RN.

5. During an interview on 02/24/15 at 10:00 AM, Staff I, stated that he had no BHU orientation.

6. Record review of Staff I's essential job functions and job summary showed Staff I's responsibilities included:
- He would provide all aspects of patient care.
- Provide service that reduced the likelihood of medical and health care errors.
- Assisted with general patient care needs.
There was no required education, experience or training related to the care of behavioral health patients.

7. During an interview on 02/24/15 at 10:15 AM, Staff L, Registered Nurse (RN), stated that:
- Prior to her current position as BHU Manager, she had no nursing experience in a behavioral health facility.
- She had previously worked in a residential care facility that admitted a limited number of elderly persons with behavior problems.
- There was no formal unit orientation or education for the BHU staff.
Staff L did not have previous experience providing nursing care or managing settings where behavioral health care patients were admitted . She had no orientation or training to qualify her to provide nursing services to meet the needs of the behavioral health patients of the unit.

8. During an interview on 02/24/15 at 10:45 AM and on 02/25/15 at 2:20 PM, Staff J, Security Director, stated that:
- Security staffed the BHU at all times.
- He had no training specific for behavioral health patients (how to recognize problems, needs and how to provide a safe environment) and he did not provide such training to his staff.
- There was no BHU specific orientation for security guards.
- Specific training about behavioral health topics would be good.

9. During an interview and observation on 02/24/15 at 10:30 AM, Staff M, prepared materials for an Activity Therapy group and stated that the Activity Therapy Director had been out on leave for "quite a while" and that she (Staff M) was not a trained Activities Therapist, however she (and other staff) "put together their own" therapy activities that were more fun, interactive, and different than the activities available from the "file".
Staff M was not oriented or trained as a Activity Therapist or qualified to develop patient activity therapy.

During an interview on 02/25/15 at 9:20 AM, Staff K, BHU Certified Nurse Assistant (CNA), stated that she had worked in the BHU for approximately one year, she had not received training specific to behavioral health patients before she was assigned to the BHU or during her employment. She stated that training related to behavioral health patients would help her to do her job.

10. During interviews on 02/24/15 at 2:50 PM and on 02/25/15 at 12:57 PM , Staff L stated that when Security Guards were hired to work in the BHU, they did not receive BHU specific orientation because they answered to Staff J, and did not provide patient care.

During a concurrent interview on 02/25/15 at approximately 1:30 PM, Staff F, Human Resources Manager, and Staff C, Director of Nurses, stated that they thought employees received unit specific orientation from the department manager.