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)

A0178

PATIENT RIGHTS: RESTRAINT OR SECLUSION
CFR(s): 482.13(e)(12)

When restraint or seclusion is used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others, the patient must be seen face-to-face within 1-hour after the initiation of the intervention -- o By a-- - Physician or other licensed practitioner; or - Registered nurse who has been trained in accordance with the requirements specified in paragraph (f) of this section.

This STANDARD is not met as evidenced by:
Based on interview and record review, the facility failed to ensure that 6 of 6 patients (Patient #29, 30, 32, 33, 34 and #36) 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 6 of 6 registered nurses (Staff K, Staff L, Staff P, Staff R, Staff S, and Staff W) on the rules and regulations governing restraint, seclusion, and use of medications for emergency situations, as well as competency-based training for conducting the one-hour face-to-face assessment for patient in restraints or seclusion. Findings included: Record review of Policy PC.025, "Restraint and Seclusion," revised 12/9/2020, showed, "The face-to-face assessment which is mandatory within one hour of the initiation of the restraint or seclusion must be done by a physician or RN other than the RN who initiated the action." In an interview on 6/17/2021 with Staff L (RN) at 12:00 pm, she stated that the one-hour face-to-face by a qualified RN is to be done within an hour of release from restraint or seclusion. In an interview with Staff K (RN) on 6/17/2021 at 12:25 pm, she stated that IM Haldol, Ativan, and Benadryl given in combination would not be considered an emergency-use medication if the patient took it "willingly." In an interview with Staff L (RN) on 6/17/2021 at 12:00 pm, she stated that IM Haldol, Ativan, and Benadryl given in combination would not require a one-hour face-to-face if the patient was "willing" to take the medication. She also stated, "I do not know if we do things right or wrong," adding she had been an ICU nurse prior to coming to work in a psychiatric hospital "at the end of July 2020 - almost a year ago." Record review of Human Resource personnel files for the following staff members were reviewed: Staff K (RN), Staff L (RN), Staff P (RN), Staff R (RN), Staff S (RN), and Staff W (RN). There was no evidence of current competency-based training for conducting the one-hour face-to-face assessment for patient in restraints or seclusion. In an interview with Staff U (HR Director) on 6/22/2021 at 2:00 pm, she stated that none of the RNs were current with the required competency-based training for conducting the one-hour face-to-face assessment for patient in restraints or seclusion. Six patients with no face-to-face completed within one hour after the initiation of restraint or seclusion. Patient #29. Record review of Physician Order and Progress Note for Seclusion/Restraint dated 5/7/2021 showed that Staff P (RN) obtained an order for Restraint (9:28 am - 9:30 am), Seclusion (9:30 am - 12:30 pm), and Haldol 10 mg, Ativan 4 mg, and Benadryl 100 mg IM one time for aggression from Staff G (MD) for Patient #29. Staff W (RN) provided a one-hour face-to-face on 5/7/2021 at 12:30 pm, three hours after the initiation of restraint. Patient #30. Record review of Physician Order and Progress Note for Seclusion/Restraint dated 5/12/2021 showed that Staff W (RN) obtained an order for Restraint (3:27 pm - 3:30 pm), Seclusion (3:30 pm - 3:35 pm), and Thorazine 50 mg, Ativan 2 mg, and Benadryl 50 mg IM one time for aggression from Staff G (MD) for Patient #30. A Progress Note, dated 5/12/2021 (not timed), was written by Staff L (RN). Staff L (RN) provided a one-hour face-to-face on 5/12/2021 at 6:00 pm, two and one-half hours after the initiation of restraint. Patient #32. Record review of Physician Order and Progress Note for Seclusion/Restraint dated 5/1/2021 showed that Staff K (RN) obtained an order for Restraint (9:47 am - 9:47 am) from Staff D (MD) for Patient #32. A one-hour face-to-face evaluation was not documented in the medical record. In an interview with Staff B (Director of Quality) on 6/25/2021 at 2:00 pm, she stated the one-hour face-to-face evaluation was not completed for Patient #32 following restraint on 5/1/2021 at 9:47 am. Patient #33. Record review of Physician Order dated 5/19/2021, 1:24 pm - 1:25 pm, showed Haldol 5 mg, Ativan 2 mg, and Benadryl 50 mg IM ordered for Patient #33. Record review of the Medication Administration Record for Patient #33 showed that Haldol 5 mg, Ativan 2 mg, and Benadryl 50 mg IM were given on 5/19/2021 at 1:35 pm. A one-hour face-to-face evaluation was not documented in the medical record. In an interview with Staff B (Director of Quality) on 6/25/2021 at 2:00 pm, she stated that the one-hour face-to-face evaluation was not completed for Patient #33 after the administration of Haldol 5 mg, Ativan 2 mg, and Benadryl 50 mg on 5/19/2021, 1:24 pm - 1:25 pm. Patient #34. Record review of Physician Order dated 4/23/2021, 4:10 pm - 4:14 pm, showed Haldol 10 mg, Ativan 4 mg, and Benadryl 100 mg IM ordered for Patient #34. Record review of the Medication Administration Record for Patient #34 showed that Haldol 10 mg, Ativan 4 mg, and Benadryl 100 mg IM were given on 4/24/2021, 1:56 am - 1:59 am. Further review showed that a one-hour face-to-face evaluation was not documented in the medical record. In an interview with Staff B (Director of Quality) on 4/23/2021, 4:10 pm - 4:14 pm, she stated that the one-hour face-to-face evaluation was not completed for Patient #34 after the administration of Haldol 10 mg, Ativan 4 mg, and Benadryl 100 mg IM. 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. Administration Comment by Staff Y (LVN): Patient manic, psychotic. Took willingly. In an interview with Staff B (Director of Quality) on 6/25/2021 at 2:00 pm, she stated the one-hour face-to-face evaluation was not completed for Patient #36 following restraint on 4/17/2021 at 6:37 pm.