HospitalInspections.org

Based on job description review, personnel file review and staff interviews the hospital failed to ensure psychiatric nursing services were directed by a Registered Nurse (RN) who has a master's degree in psychiatric or mental health nursing and on-going training in psychiatric nursing with documented consultation from a nurse with a Master's in Psychiatric Nursing and current North Carolina licensure as a Registered Nurse.

The findings include:

Review of the job description for the State Director of Nursing presented on 10/21/2014 revealed the description was signed by State Director of Nursing on 06/10/2014. Review of the "Qualifications" section revealed "Current North Carolina Licensure".

Personnel file review of Director of Nursing for the hospital revealed the staff member was a Registered Nurse (RN). File review revealed the RN had an Bachelor's Degree in Nursing. File review revealed documentation of limited (less than 1 year) experience in the care of the mentally ill.

Interview with the DON 10/22/2014 at 1435 revealed previous psychiatric/mental health nursing experience starting as an Emergency Department nurse that had a psychiatric holding area. The holding area was for psychiatric patients seen in the ED and were waiting for an inpatient bed placement. The interview revealed she floated to this holding area to provide nursing coverage. The interview revealed she started as a staff nurse at the hospital January 2014 and floated between Acute and PRTF. The interview revealed she moved into a position of second shift supervisor for the Acute and PRTF prior to accepting position as DON.

Interview with Hospital Chief Executive Officer (CEO) on 10/22/2014 at 1000 revealed a State Director of Nursing (SDON) had been hired that would cover all hospitals in the State. The interview revealed the SDON met the regulatory qualification requirements as Director of Nursing. The interview revealed the SDON was the consultation nurse for the hospital's Director of Nursing (DON) since the DON did not meet the qualification requirements as a DON. The interview revealed the DON had applied in October, 2014 to start continuing education in January, 2015 to also assist in meeting the qualification requirements. The interview revealed the SDON did not have a current North Carolina license.