HospitalInspections.org

Based on interview, personnel file review, and facility document review, the facility failed to ensure the Chief Nursing Officer (CNO) met the education and qualification requirement of having a master's degree in psychiatric or 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.

This failure resulted in a lack of staff and facility oversight to direct, monitor, and evaluate the nursing care furnished to the psychiatric patients in the facility.

Findings:

During a concurrent interview and record review on 10/04/23 at 2:35 p.m. with the Human Resources Director (HRD), the CNO's personnel file was reviewed. The CNO's personnel file failed to show the CNO had obtained a master's degree in Psychiatric Nursing or was qualified by education and experience in the care of the mentally ill. The HRD confirmed that the CNO was hired on 3/06/23 and was given six months to produce documentation that she had completed a master's program.

During the same interview on 10/04/23, the HRD stated the CNO was currently on a leave of absence and had not provided documentation to indicate participation in a master's program. The HRD stated the CNO had a master's degree in business administration and a bachelor's degree in nursing. The HRD stated the CNO was unavailable for interview due to being on a leave of absence.

During a review of the CNO's personnel file on 10/05/23 at 10:52 a.m., the CNO's resume indicated work experience in skilled nursing facilities, medical surgical (med-surg) units, emergency department, and intensive care units. The resume indicated skills, which included, "rehab, home health, nursing home, med-surg, emergency, intensive care unit, pharmacy technician experience, medication administration, infection control training, hospice care ...". The CNO's personnel file further indicated that the CNO received Crisis Prevention Intervention (CPI; a training program designed to de-escalate crisis events and teach best practices for managing difficult situation) training in March of 2023 during new hire orientation, which was an annual mandatory training for all staff at the facility.

During an interview on 10/06/23 at 1:22 PM, the Chief Executive Officer (CEO) confirmed she had participated in the CNO's hiring process and stated the CNO's masteral program related to psychiatric nursing was not verified. The CEO stated the CNO did have experience working on a unit with patients who had traumatic brain injury, but the CNO's resume did not indicate documented evidence of ongoing experience in psychiatric nursing.

During the same interview on 10/06/23, the CEO stated the plan was for the CNO to be supervised and have consultations with a designated corporate staff member who had a master's degree in psychiatric nursing, until the CNO could provide proof of completion of a master's program.

During a review of an email sent by the Director of Performance Improvement and Risk Management (DPIRM), dated 10/09/23, at 9:42 a.m., the email included the CNO's resume, with her psychiatric experience highlighted. The highlighted section indicated, "Charge Float Registered Nurse [Facility Name] February 2012 to January 2015. Duties Include: Providing care for patients on Medical/surgical Unit, Emergency Room, Orthopedic Unit, Cardiac Unit...Psychiatric Unit, and Maternity Unit." The resume further indicated the CNO was a travel Registered Nurse at a cancer center from March of 2014 to September of 2014. The resume contained no other documented evidence of experience or training related to psychiatric nursing.

During a review of an undated Job Description for Chief Nursing Officer, the job description listed for the required knowledge and experience "graduate of an accredited school of nursing; master's degree in health care management or nursing, or related field, minimum of five (5) years prior experience in patient care services ..." The Job Description for the Chief Nursing Officer did not indicate documented evidence of the need for the CNO to possess knowledge and experience in psychiatric nursing.

Continued review of the Job Description for Chief Nursing Officer indicated key responsibilities of the CNO, which included, "Organizes programs, policies and procedures that are developed to assess, evaluate and meet the needs of patients of inpatient psychiatric services, psychiatric outpatient clinics and transitional psychiatric programs; Plans, supervises and coordinates care given by RN [Registered Nurse], LVN [Licensed Vocational Nurse], LPT [Licensed Psychiatric Technician], and other mental health workers; Initiates and participates in problem-solving, policy-forming conferences for psychiatric patient care services."

During a review of facility provided documents titled, "CNO Supervision," dated 3/20/23, 4/10/23, 5/9/23, 6/19/23 and 7/14/23, the documents indicated the CNO received consultation with a Regional Director of Risk and Accreditation with a master's degree in psychiatric nursing. The documents indicated discussions of facility issues related to management of the facility and did not include ongoing training and education related to psychiatric nursing.