| Statement of Deficiencies | (X1) Provider/Supplier/CLIA Identification Number 670093 | (X3) Date Survey Completed 06/22/2021 |
| 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) |
| A0043 | GOVERNING BODY CFR(s): 482.12 There must be an effective governing body that is legally responsible for the conduct of the hospital. If a hospital does not have an organized governing body, the persons legally responsible for the conduct of the hospital must carry out the functions specified in this part that pertain to the governing body ... This CONDITION is not met as evidenced by: Based on observation, interview, and record review, the Governing Body failed to effectively discharge its oversight responsibilities in the overall operation of the hospital Findings included: The Governing Body failed to: 1. establish a process for prompt resolution of patient grievances. Specifically, the facility failed to inform each patient of the name of the individual to contact to file a grievance. In addition, there was no documentation that the facility applied what it learned from the grievances as part of its continuous quality improvement activities. Cross reference Tag A0118 - Patient Rights: Grievances - CFR 482.13(a)(2) 2. promote the personal privacy of patients by posting their full names on a window at the nurse's station. Cross reference Tag A0143 - Patient Rights: Personal Privacy - CFR 482.13(c)(1) 3. ensure that bedrooms and bathrooms were free of tie-off points; beds were secured to the floor; electrical outlets were safe; "Environment of Care Safety Rounds" were completed; an environment of care risk assessment was conducted; a suicidal patient was monitored closely in the Intake Department by properly trained staff in the management of suicidal patients; a wall-mounted TV was free of exposed electrical wiring and tie-off points; the seclusion room bathroom was a safe environment; and oxygen cylinders were properly secured. Cross reference Tag A0144 - Patient Rights: Care in Safe Setting - CFR 482.13(c)(2) 4. ensure an order was obtained from a physician to restrain a patient. Cross reference Tag A0168 - Patient Rights: Restraint or Seclusion - CFR 482.13(e)(5) 5. ensure that medications used in emergency situations were not ordered as a standing order or on as needed basis (PRN). Cross reference Tag A0169 - Patient Rights: Restraint or Seclusion - CFR 482.13(e)(6) 6. ensure that patients were seen face-to-face within one hour after the initiation of restraint or seclusion by a physician, or a registered nurse trained to conduct the one-hour face-to-face assessment. In addition, the facility failed to properly train registered nurses on the rules and regulations governing restraint, seclusion, and use of medications in emergency situations, as well as competency-based training for conducting the one-hour face-to-face assessment for a patient in restraints or seclusion. Cross reference Tag A0178 - Patient Rights: Restraint or Seclusion - CFR 482.13(e)(12) 7. ensure that the registered nurse assigned the nursing care of patients to other nursing personnel. Cross reference Tag A0397 - Patient Care Assignments - CFR 482.23(b)(5) 8. ensure that seclusion and restraint packets were accurately written and properly filed as evidenced by patient identifier (name). Cross reference Tag A0438 - Form and Retention of Records - CFR 482.24(b) |