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 04/16/2019
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)
A0115 PATIENT RIGHTS
CFR(s): 482.13

A hospital must protect and promote each patient's rights.


This CONDITION is not met as evidenced by:
Based on observation, review of medical records, and staff interviews, the facility failed to safeguard and uphold the rights of each patient in the facility. A. In 10 of 10 patients (patient #2, 14, 18, 19, 20, 21, 22, 23, 24, and #25) on suicide precautions, patients were being placed in bedrooms and on a psychiatric unit that had multiple observable ligature risks. B. In 10 of 10 patients (patient #2, 14, 18, 19, 20, 21, 22, 23, 24, and#25), patients were being assessed for suicide risk with two different suicide risk assessment tools during the admission process in the Intake Department. This resulted in contradictory suicide risk assessment findings. C. In 1 (patient #24) of 10 patients being assessed as a "high" risk for suicide on the SADPERSONS assessment tool, patient #24 was not placed on a 1:1 as is delineated in the facility's policies. D. In 1 (patient #26) of 20 patients, patient was in bed with the bedroom door closed during a scheduled group time contrary to the hospital policy on observation. E. In 20 of 20 patients (patients #2, 14, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, and #35), patients were placed in bedrooms and on a psychiatric unit with numerous screws that were not tamper resistant. Ten of these patients (patient #2, 14, 18, 19, 20, 21, 22, 23, 24, and #25) were on suicide precautions. Cross reference: A0144