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)
A0178 PATIENT RIGHTS: RESTRAINT OR SECLUSION
CFR(s): 482.13(e)(12)

When restraint or seclusion is used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others, the patient must be seen face-to-face within 1-hour after the initiation of the intervention -- o By a-- - Physician or other licensed independent practitioner; or - Registered nurse or physician assistant who has been trained in accordance with the requirements specified in paragraph (f) of this section.


This STANDARD is not met as evidenced by:
Based on record review and interview: A. The facility failed to ensure that staff had received required education, training, and demonstrated knowledge for the monitoring of any special requirements associated with the one-hour face-to-face evaluation. Failure to provide this training resulted in 6 of 6 RNs (Staff C, Staff E, Staff G, Staff K, Staff L, and Staff M) conducting the one-hour face-to-face evaluation without the required training. B. The facility failed to ensure that a face-to-face evaluation was conducted within one hour after the initiation of the restraint/seclusion intervention on 5 of 5 patients (patient #1, #2, #15, #16, and patient #17). Findings included: A. Required education. Record review of facility policy titled "Provision of Care, Restraint and Seclusion" dated 12/31/18, section 4.1.4 stated that a face to face assessment of the patient was to occur within one hour of initiation of restraint or seclusion by an "authorized RN." Record review of the personnel files for 6 of 6 RNs (Staff C, Staff E, Staff G, Staff K, Staff L, and Staff M) showed that there had been no documented education, training, or demonstrated knowledge to conduct the one-hour face-to-face evaluation. In an interview with Staff O, Human Services Director, on 04/16/2019 at 12:05 PM, she stated that Staff C, Staff E, Staff G, Staff K, Staff L, and Staff M had not received any competency training to be qualified to conduct the one-hour face-to-face evaluation. She went on to say that none of the RNs working at the hospital had received this training. In an interview with Staff C, Interim DON, on 04/16/2019 at 2:00 PM, she stated that none of the RNs working at the hospital had received any competency training to be qualified to conduct the one-hour face-to-face evaluation. B. Face-to-face evaluation within one hour of initiation of restraint/seclusion intervention. Record review of the "Part III - RN or MD Face-to-Face Evaluation" for patient #1, #2, #15, #16, and patient #17 showed no documentation of a signature, date, or time by an RN or an MD for completion of this Face-to-Face Evaluation. In an interview with Staff C, Interim DON, on 04/16/2019 at 2:00 PM, she stated that the "Part III - RN or MD Face-to-Face Evaluation" should document the signature of the individual that completed the evaluation, along with the date and time.