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)
A0179 PATIENT RIGHTS: RESTRAINT OR SECLUSION
CFR(s): 482.13(e)(12)

[the patient must be seen face-to-face within 1 hour after the initiation of the intervention -- ] ยง482.13(e)(12)(ii)To evaluate - 1. The patient's immediate situation; 2. The patient's reaction to the intervention; 3. The patient's medical and behavioral condition; and 4. The need to continue or terminate the restraint or seclusion.


This STANDARD is not met as evidenced by:
Based on record review and interviews, the facility failed to ensure that a thorough one-hour face-to-face evaluation was conducted on 4 of 5 patients (patient #1, #2, #15, and #17). Findings: Record review of policy, "Restraint and Seclusion" reviewed/revised December 31, 2018, showed: " ... 4.1.4 The original order is based on a face to face assessment of the patient by a physician or authorized RN, to occur within one hour after the initiation of restraint or seclusion. The results of the assessment will be documented in the patient's medical record and will include the following: 4.1.4.1 Patient's immediate situation 4.1.4.2 Patient's reaction to the intervention 4.4.1.3 Patient's medical and behavioral condition 4.1.4.4 Need to continue or discontinue restraint or seclusion ..." Record review of the seclusion/restraint "packet" revealed the following components: 1. Physician Orders for Seclusion/Restraint; 2. Part I - RN Progress Note; 3. Part II - RN Post Special Treatment Procedure Assessment; 4. Part III - RN or MD Face-to-Face Evaluation; 5. Performance Improvement: Special Treatment Procedure; 6. Special Treatment Procedure Flowsheet; and 7. Staff Debriefing: Post Seclusion/Restraint. Record review of the "Part III - RN or MD Face-to-Face Evaluation" showed that the form did not prompt the evaluation of the patient's reaction to the intervention and the patient's medical and behavioral condition. The form did prompt the RN to evaluate the following: 1. Indication for seclusion/restraint, and; 2. Present mental status findings, and physical status. Physical status prompted documentation of vital signs, complaints of discomfort, and physical assessment. Record review of the restraint packet for patient #1 showed that Staff E, an RN, initiated a restraint on Patient #1 on 02/19/19 at 1:56 AM. The mental status, physical status, and need to terminate or continue the restraint/seclusion in "Part III - RN or MD Face-to-Face Evaluation" were marked "N/A." Record review of the restraint packet for patient #2 showed that Staff E, an RN, initiated a restraint on Patient #2 on 03/20/19 at 1:39 AM. The indication for restraint, mental status, physical status, and need to terminate or continue the restraint/seclusion in "Part III - RN or MD Face-to-Face Evaluation" were marked "N/A." Record review of the restraint packet for patient #15 showed that Staff K, an RN, initiated a restraint on Patient #15 on 03/06/19 at 5:17 PM. The indication for restraint, mental status, physical status, and need to terminate or continue the restraint/seclusion in "Part III - RN or MD Face-to-Face Evaluation" were left blank. Record review of the restraint packet for patient #17 showed that Staff L, an RN, initiated a restraint on Patient #17 on 03/23/19 at 10:21 PM, followed by seclusion at 10:25 PM. The vital signs and physical assessment in "Part III - RN or MD Face-to-Face Evaluation" were blank. In an interview on 4/16/19 at 12:10 PM, Staff C, the interim DON, stated that there should be no blanks on the "Part III - RN or MD Face-to-Face Evaluation" and that "N/A" is not an acceptable entry on the form.