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 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)
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, interview, and record review, the facility failed to: 1. 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; environment of care risk assessment was conducted; suicidal patient was monitored closely in the Intake Department; wall-mounted TV was free of exposed electrical wiring and tie-off points; seclusion room bathroom was a safe environment; and oxygen cylinders were properly stored and secured. Cross reference Tag A0144 - Patient Rights: Care in Safe Setting - CFR 482.13(c)(2) 2. ensure that restraints were not ordered as a standing order or as needed basis (PRN Cross reference Tag A0169 - Patient Rights: Restraint or Seclusion - CFR 482.13(e)(6) 3. 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) 4. 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 patient in restraints or seclusion. Cross reference Tag A0178 - Patient Rights: Restraint or Seclusion - CFR 482.13(e)(12) 5. promote the personal privacy 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) 6. 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)