Statement of Deficiencies

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)

A0118

PATIENT RIGHTS: GRIEVANCES
CFR(s): 482.13(a)(2)

The hospital must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance.

This STANDARD is not met as evidenced by:
Based on interview, record review, and observation, the facility failed to establish a process for prompt resolution of 10 of 10 randomly selected patient grievances. These ten grievances were made by seven patients (Patient #21, 23, 24, 25, 26, 27, and #28). Specifically, the facility failed to inform each patient of the name of the individual to contact to file a grievance. Finally, there was no documentation that the facility applied what it learned from the grievances as part of its continuous quality improvement activities. This was evidenced by five complaints against one nurse made by five different patients with no documentation that there had been an investigation into the allegations. Findings included: Record review of Policy RI.005, "Patient and Family Grievance Guidelines," revised 12/8/2020, showed the facility "will provide an effective mechanism for handling patient/family grievances as an important part of providing quality care and service to our patients ... All patients and families will be informed of the grievance process upon admission ... [The facility] requires all personnel to promptly alert the program leadership and the ... Patient Advocate concerning any patient grievance ... The hospital has an established grievance resolution process ... Data collected regarding patient grievances, as well as other complaints that are not defined as grievances, will be included in the hospital's Performance Improvement Plan ... PROCEDURE 1.0 Patients and their family members are informed of the patient's rights and responsibilities upon admission, and the process by which they can voice any concerns related to their rights and/or treatment ... 9.0 Leaders and medical staff follow a process for collecting, investigating, and addressing clinical practice concerns." Staff J (Intake Coordinator) provided a copy of the "Patient & Family Resource Guide." Record review of the "Patient & Family Resource Guide' stated: "COMPLAINT PROCESS ... If you or your family feels that your concerns are not being resolved ... you can inform any staff member that you wish to speak to ... the patient advocate." In an interview with Staff J (Intake Coordinator) on 6/21/2021 at 11:45 am, she stated that she did not know who had been appointed as the patient advocate. She stated, the name of the patient advocate, along with a phone number, was not being provided to new admissions in the Intake Department. In an interview with Staff P (Unit RN) on 6/22/2021 at 11:00 am, he stated that he did not know who had been appointed as the patient advocate. He also stated that name and phone number of the patient advocate was not displayed on the unit. At that time, observation of the inpatient unit revealed that the name of the patient advocate and information on how to contact the patient advocate was not displayed on the unit for the patients to see. In an interview with Staff A (CNO) and Staff B (Director of Quality) on 6/17/2021 at 11:00 am, Staff A stated that there was no patient advocate to address patient complaints and grievances. He then appointed Staff B as the "Patient Advocate" to oversee the grievance process. Staff A stated that he could not produce a complaint or grievance log for 2021. In an interview with Staff B (Director of Quality) on 6/22/2021 at 1:3, she stated that she had reviewed the QAPI minutes for 2021, adding that complaints and grievances had not been reviewed and analyzed through the hospital's QAPI process. Record review of the QAPI binder for 2021 showed no reports to QAPI from the Patient Advocate on complaints and grievances, thus no review or analysis of the data found in the complaint binder for 2021. Record review of the "Complaint" binder showed numerous complaints on a form titled, "Quality Improvement Complaint Form." A sampling of ten random complaints/grievances was taken from the binder. These ten complaints/grievances were made by seven patients (Patient #21, 23, 24, 25, 26, 27, and #28). A review of each complaint/grievance is outline below. Record review of the "Separation Record" for Staff Q (RN) dated 5/10/2021 showed that Staff Q voluntarily resigned for another job. Would you rehire this employee? "Yes." The form was signed by Staff A (CNO) and witnessed by Staff U (HR). Patient #21. Review of Quality Improvement Complaint Form dated 3/16/2021 at 8:34 am for Patient #21 showed the complaint was received on 3/16/2021. There is no documentation as to who received the complaint form. Patient #21 stated, she felt "unsafe with Patient #22, adding that Patient #22 made "uncalled for remarks," stared at her, and "came far too close to touching my breast." There was no documented follow-up by any staff at the facility. Patient #23. Review of Quality Improvement Complaint Form for Patient #23 showed the complaint was dated 2/16/2021 (not timed) but signed by the patient on 2/18/2021 (not timed). Patient #21 made a complaint against Staff Q (RN), stating that Staff Q did not respond appropriately to her elevated blood pressure of 176/100 and pulse of 140. Staff Q offered the patient Atarax. At the request of the patient, vital signs were taken a second time. BP was 160/100 and pulse 148. Patient #23 stated Staff Q asked the medication nurse what to do. They contacted Staff R (RN). Staff R called the physician. He ordered clonidine. Patient #23 also stated, she could hear Staff Q discussing "personal business" of other patients. There was no documented follow-up by any staff at the facility. Patient #24 - three complaints. Review of Quality Improvement Complaint Form for Patient #24 showed the complaint was dated 2/16/2021 at 8:00 (unsure if AM or PM) but signed by the patient on 2/19/2021 (not timed). Patient #24 complained that Staff Q spoke to his mother about his treatment, adding he had not given consent for staff to speak with his mother. He also complained about the wound care he received from Staff Q. There was no documented follow-up by any staff at the facility. Review of Quality Improvement Complaint Form for Patient #24 showed the complaint was dated 2/18/2021 at 3:1. Patient #24 filed a complaint against Staff T (Recreation Therapist). The complaint was illegible. There was no documented follow-up by any staff at the facility. Review of Quality Improvement Complaint Form for Patient #24 showed the complaint was dated 3/8/2021 (not timed). Patient #24 complaint that Staff S (Unit RN) threatened to send him to a psychiatric intensive care unit if he did not stop self-harming, "meanwhile another patient was throwing things, ... yelling, masturbating in front of the of other patients, showing his penis to the other patients, and threatening everyone around him." There was no documented follow-up by any staff at the facility. Patient #25. Review of Quality Improvement Complaint Form for Patient #25 showed the complaint was dated 3/9/2021 at 10:15 am. The complaint was filed against Staff Q. The patient stated, she woke up around 4:30 am and told Staff Q that she "was not feeling good." Patient #25 alleged that Staff Q told her that she was "fine" and to "go lay down." There was no documented follow-up by any staff at the facility. Patient #26. Review of Quality Improvement Complaint Form for Patient #26 showed the complaint was dated 2/4/2021 (not timed). The complaint was filed against Staff Q. The content of the complaint is illegible. There was no documented follow-up by any staff at the facility. Patient #27. Review of Quality Improvement Complaint Form for Patient #27 showed the complaint was dated 2/5/2021 at 12:fpm. The complaint was filed against Staff Q for being "rude" and "gossiping." Much of the content of the complaint is illegible. There was no documented follow-up by any staff at the facility. Patient #28 - two complaints. Review of Quality Improvement Complaint Form for Patient #28 showed the complaint was dated 4/7/2021 at 12:2. Patient #28 requested "access to board games, puzzles, coloring books, and other things of therapeutic means." There was no documented follow-up by any staff at the facility. Review of Quality Improvement Complaint Form for Patient #28 showed the complaint was dated 4/8/2021 at 12:5. Patient #28 stated the TV in the front dayroom was not working and "having only one TV in the back is starting to become an issue with people wanting to see different television programs." There was no documented follow-up by any staff at the facility.