| Statement of Deficiencies | (X1) Provider/Supplier/CLIA Identification Number 670093 | (X3) Date Survey Completed 12/10/2015 |
| 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) |
| A0043 | GOVERNING BODY CFR(s): 482.12 There must be an effective governing body that is legally responsible for the conduct of the hospital. If a hospital does not have an organized governing body, the persons legally responsible for the conduct of the hospital must carry out the functions specified in this part that pertain to the governing body ... This CONDITION is not met as evidenced by: The Governing Body of the facility failed to ensure: · The facility's policies and procedures were enforced; · A safe, ligature proof environment was provided; · Medical records were complete; · Environment of Care Safety Rounds were documented; · Discharge Summaries were complete; · Yearly competencies for staff that provide patient care were completed; · Staff had CPI (Crisis Prevention Institute) training prior to working with patients; · An updated copy of the Bill of Rights was given to patients; · Rounds were made on patients every 15 minutes; · RN assigned 15 minute round intervals to staff; · Patient's rooms were free of ligature contraband; · RN provided oversight of the Unit Round Worksheet; · Each patient had a Patient Observation Rounds sheet; · Staff could identify patients on suicide precautions; and · Suicide Risk Assessments were done. The Governing Body failed to ensure that patients received care in a safe environment. The environment was not non-ligature proof resulting in the suicide of a patient. The RN was not providing oversight for the 15 minute rounds nor was there consistency in the RN's responsibility for making rounds. Staff could not identify patients on suicide precautions. There was not a checklist for staff to identify environmental hazards. Cross reference A-0115 Patient Rights. The Governing Body failed to ensure that the medical record department provided executive accountability for the patient's medical records. Medical records were incomplete and inconsistencies were found in the records. Instead of each patient having an individualized Observation Rounds Sheet for 15 minute rounds, all of the rounds were documented on the Unit Round Worksheet. The Unit Round Worksheet was not part of the medical record. The Patient Observation Rounds policy stated that each patient was to have an observation flow sheet. There were inconsistencies in the timeframes for Suicide Risk Assessments by the RN. Patients did not receive a current copy of the Bill of Rights during the admission process; nor was a copy of the signed Bill of Rights kept as part of the permanent chart. Cross reference A-0431 Medical Records. The Governing Body failed to ensure that there was an organized nursing service that provided safe nursing care. A staff member stated she had not made 15 minute rounds but charted she had made the rounds. Another staff member documented assessments on a patient. Video surveillance didn't support the claim. Nursing staff members were unable to identify patients on suicidal precautions. A patient hung himself using what was described as a pajama string or a shoe lace, which were contraband items. RN Suicide Risk Assessments were not documented according to policy guidelines. Techs and RNs were not using Patient Observation Rounds Sheets to document the 15 minute rounds. RNs were not providing oversight of the Unit Round Worksheet. Techs and RNs were not using a checklist to identify environmental hazards. Staff in the admissions department were not providing patients with a current copy of the Bill of Rights and a copy of the signed Bill of Rights was not part of the permanent record. Nursing staff were functioning with an incomplete orientation and no annual competency assessments. Cross reference A-0385 Nursing Services. |