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)

A0438

FORM AND RETENTION OF RECORDS
CFR(s): 482.24(b)

The hospital must maintain a medical record for each inpatient and outpatient. Medical records must be accurately written, promptly completed, properly filed and retained, and accessible. The hospital must use a system of author identification and record maintenance that ensures the integrity of the authentication and protects the security of all record entries.

This STANDARD is not met as evidenced by:
Based on record review and interview, the facility failed to ensure that 3 of 3 seclusion and restraint packets (Patient #29, #30, and #31) were accurately written and properly filed as evidenced by three seclusion and restraint packets with no patient identifiers (name). The three packets were found in a folder in an office. Findings included: Record review of Policy IM.002, "Documentation: Medical Record and Non-Medical Record," revised 12/11/2020, showed: "Documentation ... is to be ... accurate ... The medical record is a legal document; thus, it includes facts." In an interview with Staff V (Medical Records Manager) on 6/18/2021 at 1:09 pm, she stated that each page of a patient's medical record is to have the patient's name on it. In an interview with Staff U (HR Director) on 6/25/2021 at 2:00 pm, she stated that each page of a patient's medical record is to have the patient's name on it, adding that this was taught in the orientation of new employees. Staff U provided a portion of orientation entitled, "Documentation." Record review of "Documentation" (not dated or timed) provided by Staff U (HR Director) showed: "When filing papers into the patient's chart, double check that all papers belong to that patient ... Every page of a medical record ... should have a patient label on it. 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). Staff W (RN) provided a one-hour face-to-face on 5/7/2021 at 12:30 pm. Observations were documented every 5 minutes by Staff P (RN). Patient debriefing was documented by Staff L (LVN) on 5/7/2021 at 1:00 pm and Staff debriefing was documented by Staff P on 5/7/2021 at 1:00 pm. There is no documentation of the patient's name anywhere in the Seclusion/Restraint packet. 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). 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. Observations were documented every 5 minutes by various staff members. Patient debriefing was documented by Staff P (RN) on 5/12/2021 (not timed). Staff debriefing was documented by Staff W (RN) on 5/12/2021 (not timed). There is no documentation of the patient's name anywhere in the Seclusion/Restraint packet. Patient #31. 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 (10:27 am - 10:28 am). The one-hour face-to-face is not documented. There is no documentation of the patient's name anywhere in the Seclusion/Restraint packet.