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)

A0385

NURSING SERVICES
CFR(s): 482.23

The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse.

This CONDITION is not met as evidenced by:
Based on record review and interview, the facility failed to ensure that nursing services provided and documented safe nursing care and practice for 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) as evidenced by: 1. 2 of 2 staff members (Tech #72 and RN #81) inconsistency in the documentation on Patient #2. 2. 4 of 4 staff members (Tech #83, RN #58, Tech #70, and LVN #84) were unable to identify patients on suicide precautions. 3. 1 of 10 patients (Patient #2) had ligature contraband on 11/26/2015. 4. 1 of 1 patients (Patient #2) did not have suicide risk assessments as outlined in the policy. 5. 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) did not have Patient Observation Rounds Sheets. 6. RN was not providing oversight of the Unit Round Worksheet affecting 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). 7. No check list for staff to identify environmental hazards. 8. 6 of 6 nursing staff (LVN #55, RN #58, RN #81, Tech #70, RN #86 and Tech #72) had incomplete orientation and/or competency assessments for 5 of 5 nursing staff members. 1. Inconsistencies in the Documentation on Patient #2. Record review of Nursing 12 Hour Assessment by RN #81 dated 11/26/2015, at 2100, revealed that Patient #2 was alert and oriented to person, place, time and situation, speech within normal limits, goal directed thought processes, no hallucinations, willing to contract for safety, adequate appetite and sleep and a full physical examination. RN #81 documented pain management of lower back pain with a score of 3 on the pain scale. Record review of surveillance video for 11/26/2015, with Personnel #52 and #53 revealed a non-audio video. The following events were noted: · At 1912, RN #81 arrived to the nurse's station. · At 1930, RN #81 went to a side room to get report. · At 1940, Patient #2 came to the nurse's station to get a cookie. · At 1941, RN #81 returned to the nurse's station. He did not interact with Patient #2. · At 1946, Patient #2 left the nurse's station. · At 1947, Patient #2 went to his room. · At 1948, Patient #2 exited his room and sat on a couch in the hallway across from his room. · At 2004, Patient #2 returned to his room. · At 2011, the door to Patient #2's room opened slightly for about 20 seconds then shut quickly. · At 2027, LVN #55 entered Patient #2's room, immediately exited the room and ran toward the nurse ' s station. In an interview with Personnel #52 and #53 on 12/10/2015, at 1355, they both stated that there was no evidence on the surveillance video that RN #81 verbally interacted with Patient #2. As they viewed the video they stated that RN #81 could not have completed the evaluations on Patient #2 that he documented in the medical record. In an interview with Tech #72 on 12/03/2015, at 1210, she stated that on 11/26/2015, she did not do the 15 minute rounds on 10 of 10 patients (Patient #2, #5, #8, #14, #16, #19, #20, #25, #26, and Patient #27) at 0815 but "falsely documented" on the Unit Round Worksheet she had done them. She also stated she later crossed out the entries on Patient #2 rounds for 2015 and 2030 after Patient #2 was found dead. Record review of a Disciplinary / Counseling Form for Tech #72 dated 11/30/2015, [not timed] revealed that Tech #72 was suspended for five days because of "falsifying documentation on 15 minute rounds" and "pre-charting of every 15 minute rounds" on 11/26/2015, at 2000. The report further stated that the "sentinel event occurred during time that rounds should have occurred." It was signed by Tech #72, DON #51 and Human Resources Director #88. In an interview with RN #60 on 12/04/2015, at 1000, she stated, . "There's a problem at night with techs not making rounds." She went on to say that she has seen techs at night not do the rounds but document the rounds as having been done 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 or more frequently as ordered by the physician for each 24-hour period ... 1.0 Patient observation rounds are recorded on the observation flow sheet for each patient by the assigned staff member ... 10.0 Documentation of the 15 minute patient observation rounds occurs at the assigned time and not in advance ... " 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 ... 911 was called ... Hospital administration, attending MD and patient relatives was [sic] notified of patient's current status." RN #81 did not document time of death, doctor pronouncing death, disposition of patient's body, clothes, and valuables, and any specific circumstances or instructions as given by the Medical Examiner or next of kin. Record review of Policy & Procedure: Patient Death dated 12/08/2014 revealed: ".....4.0 Nursing staff will document in the progress notes recorded time of death, doctor pronouncing death, disposition of patient ' s body, clothes, and valuables, and any specific circumstances or instructions as given by the Medical Examiner or next of kin ..." 2. 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 ... " 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. Suicide Risk Assessments and Progress Note Documentation. In an interview with DON #51 on 12/03/2015, at 1315, she stated that the RNs document their assessments, including suicide assessment, every 12 hours. Record review of Patient #2's medical record revealed a nursing assessment every 12 hours. Record review of the Policy & Procedure, Progress Record Documentation, dated 12/18/2014, revealed: "3.2 The Registered Nurse reassesses the patient and documents in the progress notes every shift not to exceed 8 hours ... " Record review of the Policy & Procedure, Suicide Risk Assessment and Precautions, dated 12/08/2014 revealed: " 6.0 Patients on suicide precautions will be reassessed [by the] RN every 8 hours ... 8.0 The reassessments will be documented in the progress notes of the medical record... 9.0 All nursing staff are responsible to observe patients on suicide precautions and will be assigned specific intervals on the staff assignment sheet ... " 5. No Patient Observation Rounds Sheets. Record review of the Unit Round Worksheet dated 12/03/2015, revealed a one page document with 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) listed on the form. Documentation of the whereabouts of each patient was documented every 15 minutes. In an interview with RN #58 on 12/03/2015, at 1030, she stated the Unit Round Worksheet is not part of the permanent chart. The worksheets "are kept indefinitely, I think." She also stated there is one Unit Round Worksheet per shift and that the 15 minute checks are documented on this form for all patients. She also stated that each patient does not have an individual observation rounds sheet. Record review of Policy & Procedure: Patient Observation Rounds dated 12/08/2014 revealed: "1.0 Patient observation rounds are recorded on the observation flow sheet for each patient by the assigned staff member ... 11.0 All rounds must be maintained as part of the medical record ... " 6. 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 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 ... 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 ... " 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 ... " 8. Incomplete orientation and/or competency assessments. In an interview with Tech #70 on 12/03/2015, at 1040, he stated 15 minute rounds were not covered in orientation. Record review of four personnel files (LVN #55, RN #58, RN #81 and Tech #72) revealed that none of them had received annual and training with competencies in for 2014 and 2015. RN #82 was hired on 11/11/2015. RN #82's personnel file did not contain certification of Crisis Prevention Institute (CPI) training. In an interview with Human Resources Director #88 on 12/10/2015, at 1555, she stated (when asked about annual competencies), "Competencies are done once every three years." She went on to say that yearly competencies stopped in 2013. She stated CPI training was mandatory and that RN #82 was working the unit and had not had CPI training. Record review of the Policy & Procedure, Suicide Risk Assessment and Precautions, dated 12/08/2014 revealed: " 19.0 All new employees responsible for patient care will receive orientation regarding Management of Suicidal Patients. All staff will successfully complete the Suicide Prevention competency annually. "