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)
A0168 PATIENT RIGHTS: RESTRAINT OR SECLUSION
CFR(s): 482.13(e)(5)

ยงยง482.13(e)(5) - The use of restraint or seclusion must be in accordance with the order of a physician or other licensed practitioner who is responsible for the care of the patient and authorized to order restraint or seclusion by hospital policy in accordance with State law.


This STANDARD is not met as evidenced by:
Based on record review and interview, the facility failed to ensure that an order was obtained from a physician to restrain 1 of 1 patient (Patient #31). Findings included: Record review of policy PC.025, "Restraint or Seclusion," revised 12/9/2020, showed: "[The facility] strives to ... uphold the dignity of each individual by protecting the patients' rights and well-being ... 3.0 ... Orders for restraint or seclusion are given by a physician or other authorized licensed independent practitioner primarily responsible for the patient's ongoing care ... 3.1.1 Use of restraint is based upon the order ... 3.1.3 When an RN initiates restraint, an order will be obtained from a physician as soon as possible after the restraint is initiated." Patient #31. Record review of Physician Order and Progress Note for Seclusion/Restraint dated 5/1/2021 showed that Staff K (RN) restrained Patient #31 10:27 am - 10:28 am and never obtained an order from the physician. In an interview with Staff A (CNO) on 6/22/2021 at 2:fpm, he stated that a physician must provide an order for seclusion or restraint. Record review of the Human Resources (HR) personnel file for Staff K (RN) showed that she started to work at the facility June 2017. The RN job description was signed 6/5/2017. The job description stated that the RN "Complies with physician orders." There was no evidence in the HR personnel file that Staff K had training on policy PC.025, "Restraint or Seclusion."