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)

A0169

PATIENT RIGHTS: RESTRAINT OR SECLUSION
CFR(s): 482.13(e)(6)

Orders for the use of restraint or seclusion must never be written as a standing order or on an as needed basis (PRN).

This STANDARD is not met as evidenced by:
Based on interview and record review, the facility failed to ensure that restraints were never ordered as a standing order or as needed basis (PRN). This was evidenced by 6 of 6 randomly selected patients (Patient #32, 33, 34, 35, 36, and #37) with medications ordered as a "one unscheduled dose." Findings included: Record review of Policy PC.025, "Restraint and Seclusion," revised 12/9/2020 showed: "3.1 Physician Orders ... 3.1.5 Restraints and/or seclusion may NOT be ordered PRN or by standing orders." In an interview with Staff X (Pharmacist) on 6/18/2021 at 9:00 am, she stated that the combination of Haldol, Ativan, and Benadryl is often ordered as "one unscheduled dose" for treatment of behavioral problems and is to be given if the patient needs it. She went on to say, "Technically, that's a PRN." In an interview with Staff D (Medical Director) on 6/22/2021 at 10:18 am, he stated that an "unscheduled" dose of IM Haldol, Ativan, and Benadryl was a "PRN" medication, adding that these medications cannot be written as PRN medications. In an interview with Staff W (RN) on 6/18/2021 at 10:00 am, she stated that calling a physician for an emergency medication can "sometimes be long." She also stated that an "unscheduled dose" is to be given "if you need it. It would be a PRN, but not like a normal PRN." In an interview with Staff Y (LVN) on 6/18/2021 at 12:5, she stated: 1) A now dose for a combination of IM Haldol, Ativan, and Benadryl is good for up to four hours; 2) A one unscheduled dose of IM Haldol or Benadryl is good for up to 30 days; and 3) A one unscheduled dose of IM Ativan is good for up to 5 days. She concluded, "In other words, an unscheduled dose of IM Haldol or Benadryl stays on the MAR (Medication Administration Record) for 30 days whereas IM Ativan would stay on the MAR for 5 days." This information was then shared with Staff X (Pharmacist). She stated that Staff Y's explanation was accurate, adding that some patients were discharged with these medications still active on their MAR, as was the case with Patient #37. Staff X (Pharmacist) provided a list of 22 instances in which Haldol, Ativan, and Benadryl were ordered and administered in combination as an unscheduled dose. There were 6 of 22 random instances (Patient #32, 33, 34, 35, 36, and #37) reviewed. The results of that review were. Patient #32. Record review of the Physician Orders for Patient #32 showed: 1) Orders 0177204, 0177205, and 0177206 (each medication had an order number): Haldol 5 mg, Ativan 2 mg, and Benadryl 50 mg IM ordered on 5/1/2021 at 10:06 am as one unscheduled dose for aggression and agitated [sic]. The stop date was 5/31/2021 for the Haldol and Benadryl; 5/6/2021 for the Ativan. 2) Order 0177207: Haldol 5 mg, Ativan 2 mg, and Benadryl 50 mg IM was again ordered on 5/1/2021 at 10:36 am as one unscheduled dose for aggression and agitation. The stop date was 5/31/2021 for all three medications. Record review of the Medication Administration Record for Patient #32 showed that Haldol 5 mg, Ativan 2 mg, and Benadryl 50 mg (order 0177207) were administered IM on 5/1/2021 at 10:28 am. The patient was aggressive and had attacked staff. Orders 0177204, 0177205, and 0177206 were not documented on the MAR as having been administered. Patient #33. Record review of the Physician Orders for Patient #33 showed: Orders 0178011, 0178012, and 0178013: Haldol 10 mg, Ativan 4 mg, and Benadryl 100 mg IM ordered on 5/19/2021 at 1:2 - 1:2 as one unscheduled dose. An indication for these medications was not documented. The stop date for these medications was 6/18/2021 for the Haldol and Benadryl; 5/24/2021 for the Ativan. Record review of the Medication Administration Record for Patient #33 showed that Haldol 10 mg, Ativan 4 mg, and Benadryl 100 mg (orders 0178011, 0178012, and 0178013) were administered IM on 5/19/2021 at 1:3. Patient #34. Record review of the Physician Orders for Patient #34 showed: Orders 0176871, 0176872, and 0176873: Haldol 10 mg, Ativan 4 mg, and Benadryl 100 mg IM ordered on 4/23/2021 at 4:1 - 4:14 pm as one unscheduled dose for agitation. The stop date for these medications was 5/23/2021 for the Haldol and Benadryl; 4/28//2021 for the Ativan. Record review of the Medication Administration Record for Patient #34 showed that Haldol 10 mg, Ativan 4 mg, and Benadryl 100 mg (orders 0176871, 0176872, and 0176873) were administered IM on 4/24/2021 at 1:56 am - 1:58 am for extreme agitation and aggression without incident. NOTE: The Haldol, Ativan, and Benadryl, ordered as one unscheduled dose, was given 9 ½ hours after it was ordered. Patient #35. Record review of the Physician Orders for Patient #35 showed: Orders 0177466, 0177467, and 0177468: Haldol 10 mg, Ativan 4 mg, and Benadryl 100 mg IM ordered on 5/6/2021 at 5:57 pm - 5:59 pm as one unscheduled dose for aggression. The stop date for these medications was 6/5/2021 for the Haldol and Benadryl; 5/11/2021 for the Ativan. Record review of the Medication Administration Record for Patient #35 showed that Haldol 10 mg, Ativan 4 mg, and Benadryl 100 mg (orders 0177466, 0177467, and 0177468) were administered IM on 5/6/2021 at 6:00 pm - 6:09 pm after Patient #35 attacked another patient. Patient #36. Record review of the Physician Orders for Patient #36 showed: Order 0176555: Haldol 5 mg, Ativan 2 mg, and Benadryl 50 mg IM ordered on 4/17/2021 at 6:02 pm as one unscheduled dose for mania, psychosis, and agitation. The stop date for these medications was 4/22/2021. Record review of the Medication Administration Record for Patient #36 showed that Haldol 5 mg, Ativan 2 mg, and Benadryl 50 mg (order 0176555) were administered IM on 4/17/2021 at 6:37 pm. Patient #37. Record review of the Medication Order Inquiry for Patient #37 showed: IM Haldol 5 mg, Ativan 2 mg, and Benadryl 50 mg ordered 1/17/2021 at 8:00 pm by Staff D (Medical Director) as one unscheduled dose. The end date for the Haldol and Benadryl was 2/16/2021; for the Ativan, 1/22/2021. The discontinue date for all three medications was documented as 2/1/2021. Record review of Medication Administration Record for Patient #37 showed that Haldol 5 mg, Ativan 2 mg, and Benadryl 50 mg were administered IM on 1/17/2021 at 7:37 pm - 8:00 pm. Record review of the Discharge Order by Staff D (Medical Director) for Patient #37 showed: Discharge home 1/25/2021. As was indicated by Staff X (Pharmacist), the one unscheduled order for IM Haldol 5 mg, Ativan 2 mg, and Benadryl 50 mg ordered 1/17/2021 at 8:00 pm by Staff D (Medical Director) was still an active order at the time of discharge.