Department of Health & Human Services

Centers for Medicare & Medicaid Services
Form Approved

OMB No. 0938-0391
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)
A0395 RN SUPERVISION OF NURSING CARE
CFR(s): 482.23(b)(3)

A registered nurse must supervise and evaluate the nursing care for each patient.


This STANDARD is not met as evidenced by:
Based on record review and interview, the facility failed to ensure that nursing services provided supervision and evaluation of 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. 1 of 1 patients (Patient #2) had ligature contraband. 2. 1 of 1 patients (Patient #2) did not have suicide risk assessments as outlined in the policy. 3. 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. 4. 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). 5. No check list for staff to identify environmental hazards. Findings included: 1. 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 ... " 2. 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 ... " 3. 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 ... " 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 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 ... " 5. 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 ... "