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)
A0397 PATIENT CARE ASSIGNMENTS
CFR(s): 482.23(b)(5)

A registered nurse must assign the nursing care of each patient to other nursing personnel in accordance with the patient's needs and the specialized qualifications and competence of the nursing staff available.


This STANDARD is not met as evidenced by:
Based on record review and interview, the facility failed to ensure that the registered nurse assigned the nursing care of 19 of 19 patients (patients 1-19) to other nursing personnel in 1 of 1 instance. Findings included: Record review of Policy PC.016, "Patient Care Assignments," revised 12/9/2020, showed, "It is the policy ... to assign patient care on inpatient each shift to the nursing staff based on staff specialized qualification, competence, level of training, preparation, and assessed patient needs. Nursing care capabilities shall be considered in assignment of patients. The Charge Nurse will assign the nursing care of patients each shift." Record review of the "Hospital Unit Patient Care and Supervisory Report Sheet" for 6/17/2021, Staff K (Charge Nurse) did not assign the nursing care of 19 patients (patients 1-19) to any staff members, including Staff L (RN), Staff M (CNA/Tech), Staff N (CNA/Tech), and Staff O (CNA/Tech). Record review of the "Final Census Report," dated 6/17/2021, showed a census of 19 patients (patients 1-19). In an interview with Staff A (CNO) on 6/17/2021 at 2:00 pm, he stated that the nursing care of patients is not assigned to staff members by the charge nurse, adding that the report sheet would be revised to come into compliance with the regulation.