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)

A0438

FORM AND RETENTION OF RECORDS
CFR(s): 482.24(b)

The hospital must maintain a medical record for each inpatient and outpatient. Medical records must be accurately written, promptly completed, properly filed and retained, and accessible. The hospital must use a system of author identification and record maintenance that ensures the integrity of the authentication and protects the security of all record entries.

This STANDARD is not met as evidenced by:
Based on record review and interview, the facility failed to ensure that the medical records of 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) were accurate and complete as evidenced by: 1. In 21 of 21 medical records (Patient #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, and Patient #23) there were no Patient Observation Rounds. 2. In 1 of 1 medical records the documentation of the death of Patient #2 was incomplete. 3. In 1 of 1 medical records the documentation of Patient #2 ' s request for discharge was incomplete. Findings included: TX00226597 1. Patient Observation Rounds. 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 ... " 2. 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 ... " 3. 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. "