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)

A0431

MEDICAL RECORD SERVICES
CFR(s): 482.24

The hospital must have a medical record service that has administrative responsibility for medical records. A medical record must be maintained for every individual evaluated or treated in the hospital.

This CONDITION is not met as evidenced by:
Based on record review and interview, the facility failed to ensure that medical records were complete and/or free of inconsistencies 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) as evidenced by: 1 RN #81's documentation in Patient #2's chart on 11/26/2015, inconsistent with video surveillance. 2 Tech #72's documentation on Unit Round Worksheet of 10 out of 10 patients (Patient #2, #5, #8, #14, #16, #19, #20, #25, #26, and Patient #27) on 11/26/2015, inconsistent with her interview. 3 15 minute rounds not documented on an individual observation rounds sheet 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). 4 Inconsistency in the timeframes in which suicide risk assessments and progress notes are documented. 5 A signed copy of the Bill of Rights was not a part of the medical records of 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). 6 In 1 of 1 medical records the documentation of the death of Patient #2 was incomplete. 7 In 1 of 1 medical records the documentation of Patient #2's request for discharge was incomplete. 8 2 of 2 Discharge Summaries dictated by MD #56 accurately and completely documented the outcome of Patient #1 ' s hospitalization. Findings included: 1. Inconsistency in Patient #2 ' s Chart and Video Surveillance. 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. 2. Inconsistency in Tech #72's Unit Round Worksheet Documentation and Her Interview. 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 ... " 3. No Patient Observation Rounds Sheets. Record review of the Unit Round Worksheet dated 12/03/2015m 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. 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. Bill of Rights. Record review of the medical records 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) revealed that 26 of 26 charts did not have a signed copy of the Bill of Rights as part of the permanent medical record. Record review of Admission Packet revealed Patient's Bill of Rights was missing the last page. It was also an outdated version. In an interview with DON #51 on 12/10/2015, at 1400, she presented another version of the Patient's Bill of Rights. It was also an outdated version. She stated patients received a copy of the admission paperwork found in the Admission Packet. A current version was found on line at the Texas DSHS website. Record review of Policy & Procedure, Admission to Behavioral Health Service, dated 12/08/2014, revealed: " ... Patients will receive appropriate patient rights ... prior to admission ... The facility or the administrator ' s authorized designee may admit a person for whom a proper request for voluntary inpatient services is filed if they determine: ... The person has been informed of the person ' s rights as a voluntary patient. " 6. Incomplete Documentation of Patient #2's Death. 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 ... " 7. Patient #2's Request for Discharge on 11/25/2015. In an interview with RN #58 on 12/10/2015, at 1220, she stated that Patient #2 ' s son requested to be discharged. RN #58 and RN #69 (Charge Nurse) had Patient #2 sign a Request for Release from Voluntary Admission. Record review of Request for Release from Voluntary Admission dated 11/25/2015, at 1520, revealed Patient #2 signed a request to be released from the facility. RN #58 and RN #69 witnessed the request. Record review of Patient #2 ' s Medical Record dated 11/25/2015, did not reveal any documentation by RN #69 of Patient #2's request and reason he requested to be released from the hospital. There was no documentation of an assessment of the patient's legal, physical, and mental health status including the potential for the risk of harm of self or others. In an interview with RN #58 on 12/10/2015, at 1220, she stated she could not find documentation by RN #69 of the Patient #2's legal, physical, and mental health status including the potential for the risk of harm of self or others. She further stated it was her expectation as a nurse supervisor that Nurse #69 document the request for release from voluntary admission in the medical record. "When you're too busy, this can happen. RN #69 was too busy." Record review of Policy & Procedure, AMA [Against Medical Advice] Discharge Prevention Guidelines, dated 12/08/2014, revealed: "4.0 ... The patient must request early or AMA discharge in writing ... Staff receiving the request for discharge should document the request and reason for the request in the medical record ... " Record review of Policy & Procedure, AMA Discharge dated 11/20/2013, revealed: "If a patient requests discharge ... a 4-hour letter will be completed by the patient. A Registered Nurse will assess the patient ' s legal, physical, and mental health status including the potential for the risk of harm to self or others. The RN will notify the patient ' s attending physician." 8. Discharge Summaries: Patient #1 - Two Admissions. Patient #1's admission on 08/22/2015 and discharge on 08/29/2015. Record review of Registration Admission face sheet for Patient #1 revealed the patient was admitted on 08/22/2015, and discharged on 08/29/2015, at 0437. Record review of an Incident Report by RN #60 dated 08/28/2015, at 1136, revealed that Patient #1 was transferred from the facility to a medical surgical hospital for evaluation of chest pain radiating to the left arm. Record review of Discharge Summary for Patient #1 by MD #56 dated 09/25/2015, at 1623 revealed discharge on 08/29/2015. "Condition on discharge: improved (level of depression decreased, reduced anxiety, reduced psychosis, compliant with treatment plan and medication management.) Follow up with medical - routine. Psychiatric follow-up in 2 weeks with psychiatrist." There was no mention of the transfer to a medical surgical hospital for evaluation of chest pain. The reason for admission, a suicide risk assessment, prognosis, dietary and/or activity restrictions, and name of individual providing aftercare were not included. Patient #1's admission on 08/29/2015 and discharge on 09/04/2015. Record review of Registration Admission face sheet for Patient #1 revealed the patient was admitted on 08/29/2015 and discharged on 09/04/2015. Record review of Cardiology Consultation by MD #62 on 08/29/15, at 1310, for Patient #1 revealed chest pain, renal disease, chronic pulmonary embolism and chronic diastolic heart failure. MD #62 stated the patient needed better blood pressure control, follow-up with a cardiologist as an outpatient and " better stabilization on her multiple antipsychotic medications prior to further aggressive workup from cardiac standpoint." Record review of Discharge Summary for Patient #1 by MD #56 dated 09/105/2015, at 1812, revealed discharge on 09/04/2015. "Improved condition. Follow up with medical - routine. Psychiatric follow-up in two weeks with psychiatrist." The reason for admission, suicide risk assessment, prognosis, dietary and/or activity restrictions, special procedures, consultation findings and recommendations, and name of individual providing aftercare were not included. In an interview with Personnel #53 on 12/04/2015, at 1315, he stated there had been some problems with completion of medical records by physicians. Record review of Policy & Procedure: Psychiatric Discharge Summary dated 12/08/2014 revealed that the format should include: reason for admission, suicide risk assessment, prognosis, dietary and/or activity restrictions, special procedures, consultation findings and recommendations, and name of individual providing aftercare.