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)

A0397

PATIENT CARE ASSIGNMENTS
CFR(s): 482.23(b)(5)

A registered nurse must assign the nursing care of each patient to other nursing personnel in accordance with the patient's needs and the specialized qualifications and competence of the nursing staff available.

This STANDARD is not met as evidenced by:
Based on record review and interview, the facility failed to ensure staff had been properly trained provided annual training and competencies for 6 of 6 nursing staff members 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. 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. Findings included: 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. 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. In an interview with RN #86 on 12/03/2015, at 1115, she stated she was on day two of on the job training. The process of rounding every 15 minutes had not been explained to her. She did not know the patients on suicide precautions. 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."