| Statement of Deficiencies | (X1) Provider/Supplier/CLIA Identification Number 670093 | (X3) Date Survey Completed 11/18/2014 |
| Name of Provider or Supplier Aspire Hospital | Street Address, City, State 2006 South Loop 336 West, Suite 500, Conroe, TX | |
| For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency. | ||
| (X4) ID Prefix Tag | Summary Statement of Deficiencies
(Each deficiency should be preceded by full regulatory or LSC identifying information) |
| A0396 | NURSING CARE PLAN CFR(s): 482.23(b)(4) The hospital must ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient. The nursing care plan may be part of an interdisciplinary care plan This STANDARD is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure that nursing staff developed a current care plan for 5 of 10 sampled patients ( Patient ID # 2, #3, # 4, # 6, # 8) based on their assessed needs. These five (5) sampled patients had been assessed as at risk for falling. Fall prevention was not addressed in any of their nursing care plans. Two(2) of the five patients sustained an actual fall ( Patient ID # 6, # 8). Findings include: TX # 00204338 Patient # 6 Review of the facility self-reported intake # TX 00204 revealed Patient # 6 fell on 09-05-14. She had climbed onto an ottoman, then fell. She was sent to the ER with a suspected fractured wrist and a hematoma on the right side of her head. Patient # 6 did not return to the facility following the ER visit. Record review on 11-18-14 of Patient # 6's clinical record revealed she was a 69 year old female admitted to the facility on 09-03-14 with diagnoses of Major Depressive Disorder (MDD) and chronic pain syndrome. Review of Patient # 6's "Fall Risk Assessment," dated 09-03-14, revealed she had a history of 1-2 falls in the past 3 months; took 3 - 4 of the medications listed that are fall risk factors, and had 1-2 of the predisposing disease processes. Patient # 6 had listed : "Fall Score Total: 8.0." Interview on 11-18-14 at 1:45 p.m. with Registered Nurse (RN) #4, she stated that a total fall score of 8.0 was considered high risk. She reported that Low Risk was 1-3 points; Moderate Risk was 4-7 points ; and High Risk was 7-10 points. RN # 4 went on to say that patients who were assessed as moderate or high risk for falls would have this addressed as a problem in their care plan. Record review on 11-18-14 of Patient # 6's Care Plan,( dated 09-03-14) failed to reveal Fall Risk as an identified problem. Quality Manager # 2 was unable to locate fall risk as a problem on Patient # 6's care plan. Patient # 8 Record review on 11-18-14 of Patient # 8's clinical record revealed he was a 60 year old male admitted to the facility on 08-28-14 for opiod detoxification. Review of Patient # 8's "Assessment Report," dated 08-28-14 revealed he was assessed as "Moderate " risk for falls with "fair insight and poor judgement." Record review on 11-18-14 of Patient # 8's Care Plan,( dated 08-28-14) failed to reveal Fall Risk as an identified problem. Quality Manager # 2 was unable to locate fall risk as a problem on Patient # 8's care plan. Review of facility Incident Log for last 3 months, revealed Patient # 8 fell in the shower on 09-01-14. Current Patients : # 2, # 3, # 4: Observation on 11-18-14 at 1:30 p.m. revealed Patients # 2, and # 4 were current in-patients. Both patients were wearing yellow arm bands that signified they were at high risk for falls, according to RN # 4. RN # 4 went on to say that Patient # 3 had been discharged and had just left the facility. Record review on 11-18-14 of the "Nursing Cardex and Treatment Report Sheet," dated 11-18-14. revealed Patients # 2, # 3, and #4 were currently placed on "fall precautions." Record review on 11-18-14 of Patient # 2, # 3, and # 4's Care Plan, failed to reveal Fall Risk as an identified problem. RN # 4 was unable to locate fall risk as a problem on Patients' # 2, # 3, and # 4 care plans. Record review on 11-18-14 of facility policy titled" Nursing Assessment/Re-Assessment," dated 10-08-14, read: Purpose: to collect data about the health status of a patient based on an assessment...to be able to devise a patient plan of care...Procedure: Complete Nursing Diagnosis section by making a check mark in the appropriate box(s) next to the diagnosis. The assessment included information regarding the patient's: ...risk of fall...appropriate nursing diagnoses will be entered and the appropriate level of intervention will be selected...' |