Statement of Deficiencies

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)

A0115

PATIENT RIGHTS
CFR(s): 482.13

A hospital must protect and promote each patient's rights.

This CONDITION is not met as evidenced by:
Based on observation, record review, and interview, the hospital failed to ensure that services were provided in compliance with all applicable rules and standards as evidenced by: 1. Failure to provide a safe non-ligature proof environment In 16 of 16 patient rooms (rooms 100, 101, 102, 103, 105, 106, 107, 108, 202, 203, 204, 205, 206, 207, 208 and 209) creating suicide risk and widespread endangerment to 21 of 21 patients (Patient #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, and Patient #23). 2. Suicide of Patient #2 due to unsafe non-ligature proof environment and failure of staff to perform 15 minute rounds per policy. 3. Environment of care safety rounds were not documented. 4. Medical records were incomplete and/or inconsistent on 26 of 26 patients (Patient #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #25, #26 and Patient #27). 5. Incomplete orientation and/or competency assessments for 6 of 6 Nursing Services personnel (LVN #55, RN #58, RN #81, Tech #70, RN #86 and Tech #72) providing patient care. 6. 26 of 26 patients (Patient #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #25, #26 and Patient #27) did not have a signed copy of the Bill of Rights in their charts. Findings included: 1. Non-ligature Proof Environment. Observation of the adult psychiatric unit on 12/03/2015, at 1000, revealed 16 of 16 patient rooms (rooms 100, 101, 102, 103, 105, 106, 107, 108, 202, 203, 204, 205, 206, 207, 208 and 209) had hinges on the bathroom and bedroom doors that were not ligature proof. Record review of Unit Round Worksheet dated 12/03/2015, revealed 21 of 21 patients in 15 of the 16 patient rooms (rooms 100, 101, 102, 103, 105, 106, 107, 108, 202, 203, 204, 205, 206, 208 and 209) that had hinges on the bathroom and bedroom doors that were not ligature proof. In an interview with Personnel #53 on 12/03/2015, at 1000, he stated that the hinges on the doors had been identified as a suicide risk. 2. Suicide of Patient #2. Record review of Nursing 12 Hour Assessment by RN #81 dated 11/26/2015 at 2020 revealed that Patient #2 was "observed hanging on the door hinges with a string around his neck..... " In a phone interview with RN #81 on 12/07/2015, at 0800, he stated he was the charge nurse on the night of 11/26/2015. He got out of report at 1935 and began checking physician's orders. He stated rounds were made on time by the techs. LVN #55 discovered that Patient #2 had hung himself. He went to the room and untied a "black string" from the door hinge that was around Patient #2's neck. It looked like a "shoe lace." He also stated, "The RN makes rounds from time to time if not busy with admissions ... sometimes I have to make rounds ... If we have four admissions, I make rounds when I get caught up ... Sometimes there's 3 to 4 admissions waiting for us ... There's lots of calls on the phone." In an interview with Tech #72 on 12/03/2015, at 1210, she stated that on 11/26/2015, she was busy helping Tech #76 with a total care patient until 2035 but was supposed to be making rounds. She stated she did not do the 15 minute rounds at 0815 but documented she had done them and later crossed out the 2015 and 2030 entries she had made on the Unit Round Worksheet for Patient #2. She stated she did not know if Patient #2 was on suicide precautions the night he hung himself. She stated that suicidal patients are to have "no strings ... every now and then we will find contraband in the patient rooms." She stated she has found draw strings in pajamas in the patient rooms in the past. Record review of Psychiatric Evaluation by MD #67 dated 11/23/2015, at 1935, revealed Patient #2 was an 88-year old male, admitted status post two failed suicide attempts, carbon monoxide poisoning and a gun, just prior to admission. Record review of [Physician's] Orders by MD #67 dated 11/23/2015, at 0937, revealed Patient #2 was on Suicide Precautions. Further review of all physician's orders revealed the Suicide Precautions were not discontinued during his hospital stay. Record review of Social Worker Note by Licensed Professional Counselor (LPC) #68 dated 11/24/2015, at 1045, revealed: Patient #2 stated he was upset due to health problems and did not want to be a burden his family. Record review of the Psych Safety Rounds Assessment for Patient #2 by LVN #75 dated 11/26/2015, at 0952, revealed Patient #2 was monitored every 15 minutes by staff with "visual inspection of the patient and environment, and a completed search ...No items removed." Record review of Group Progress Note by Therapist #65 dated 11/23/2015, at 1230, revealed: Patient #2 stated he met his second wife on Thanksgiving. He became tearful "as he still misses his second wife." 3. Patient #2 had Ligature Contraband. In an interview with LVN # 55 on 12/03/2015, at 1420, stated that on 11/26/2015, (Thanksgiving Day) she found Patient #2 dead in his room. She also stated that Patient #2 died when he hung himself with a "navy blue, maybe black string." He used the middle hinge of the door leading into his room from the hallway. She stated, "Usually techs inventory and remove contraband material ... Strings are cut from clothing if the patient opts to keep it." Patients are not allowed "shoe strings or belts." Patient #2 was on "suicide precautions." In an interview with RN #60 on 12/04/2015, at 1000, she stated that an investigating officer told her the string around Patient #2's neck looked like a string from pajama pants. Record review of Policy & Procedure: Contraband Search Guidelines dated 12/08/2014 revealed: "1.0 Belongings Search. All Patients' belongings will be searched for potentially hazardous items by behavioral health staff on admission ... 1.4 ... look for belts or drawstrings and remove from clothing ... 1.6.13 Belts, cords, straps, ties, and shoelaces....... " 4. RN Responsibility in Providing Oversight of the Unit Round Worksheet. In an interview with RN #58 on 12/03/2015, at 1030, she stated she makes rounds every 4 hours and documents this on the Unit Round Worksheet. She stated this is the policy. In an interview with DON #51 on 12/10/2015, at 1600, she stated that the Charge RN is supposed to review the Unit Rounds Worksheet and make rounds on the patients every four hours. She stated this is the policy. In an interview with Tech #70 on 12/03/2015, at 1040, he stated he takes the board to the RN for the RN to make rounds every four hours. In an interview with Tech #85 on 12/03/2015, at 1100, she stated the RN does not always check patients when they do the four hour documentation on the rounds sheet. In an interview with RN #60 on 12/04/2015, at 1000, she stated, "Every few hours" the RN makes sure the rounds are being done. "We make sure the board is complete every four hours. The RN initials it ... and returns the board to the tech after signing it." She makes rounds on patient "when I have time ... there is no specific time to make rounds, usually at group and meal times." Record review of Policy & Procedure: Patient Observation Rounds dated 12/08/2014, revealed: "11.0 ... The Charge RN will review the patient observation rounds flow sheet at the end of each shift to ensure completion of rounds as assigned and sign....... " Record review of Policy & Procedure: Clinical Hand-Off Communication dated 12/08/2014, revealed: " A 5. After listening to shift report the outgoing RN will round with the incoming RN ... " 5. No Staff Assignments for 15 Minute Round Intervals. Record review of 7P-7A Patient Care and Supervisory Report Sheet [assignment sheet] dated 11/26/2015, revealed four staff members: RN #81, RN #82, Tech #72 and Tech #76. Techs #72 and #76 were assigned to do "rounds." Designated round intervals had not been assigned to the techs. Staff had not been assigned to monitor hallways. Record review of 7A-7P Patient Care and Supervisory Report Sheet [assignment sheet] dated 12/03/2015, revealed six staff members: RN #58, RN #87, LVN #84, Tech #70, Tech #83 and Tech #85. Techs #70, #83 and #85 were assigned to do "rounds." Designated round intervals had not been assigned to the techs. Staff had not been assigned to monitor hallways. In an interview with Tech #72 on 12/03/2015, at 1210, she stated, "Rounds are not assigned by the RN. Usually who gets the rounds board first does the first two hours of rounds." Record review of Policy & Procedure: Patient Observation Rounds dated 12/08/2014, revealed: "Patient observation rounds are to be performed on all patients by the assigned nursing staff at a frequency of every 15 minutes ... 1.0 ... The Charge Nurse will assign staff responsibility for round intervals on patients each shift and document on the shift assignment sheet ... 3.0 ... Staff are to be assigned to monitor hallways at all times......" 6. Identification of Patients on Suicide Precautions. In an interview with Tech #83 on 12/03/2015, at 1010, she stated she was not able to name the patients on suicide precautions. In an interview with RN #58 on 12/03/2015, at 1030, she stated, "There were too many patients on suicide precautions to name...... I need to look at the report sheet." In an interview with Tech #70 on 12/03/2015, at 1040, he stated he was unable to name the patients on suicide precautions. In an interview with LVN #84 on 12/03/2015, at 1120, she stated she didn't look to see what patients were on suicidal precautions. "I know we have some." She stated she was unable to name the patients on suicide precautions. Record review of Policy & Procedure: Patient Observation Rounds dated 12/08/2014, revealed: "1.0 Patient observation rounds...... All staff assigned will update the flow sheets during their shift to reflect any changes in precaution level......." Record review of the Policy & Procedure: Suicide Risk Assessment and Precautions dated 12/08/2014 revealed: " ... 10.0 The observation flow sheet will clearly indicate patients on suicide precautions ... " 7. Environment of Care Safety Rounds. Record review of the Unit Round Worksheet dated 11/26/2015, revealed that there was not a checklist for staff to identify environmental hazards on the form. In an interview with DON #51 on 12/03/2015, at 1315, she stated there was not a check list for staff to use to identify environmental hazards. Record review of Policy & Procedure, Environment of Care Safety Rounds dated 12/08/2014, revealed: "..... A systematic approach will be operational to proactively identify environment risks and minimize the harm risk to patients or others. Staff will actively participate in this approach by identifying and reducing environmental risks ... 1.0 Once a day, Environment of Care Safety rounds will be conducted by assigned staff and documented on checklist ... "