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)
A0468 CONTENT OF RECORD: DISCHARGE SUMMARY
CFR(s): 482.24(c)(4)(vii)

[All records must document the following, as appropriate:] Discharge summary with outcome of hospitalization, disposition of care and provisions for follow-up care.


This STANDARD is not met as evidenced by:
Based on interview and record review, the facility failed to ensure that 2 of 2 Discharge Summaries dictated by MD #56 accurately and completely documented the outcome of Patient #1 ' s hospitalization. Findings included: TX00226597 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.