| Statement of Deficiencies | (X1) Provider/Supplier/CLIA Identification Number 670093 | (X3) Date Survey Completed 05/11/2023 |
| 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) |
| A0115 | PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient's rights. This CONDITION is not met as evidenced by: Based on review and interview the facility failed to: 1. review, analyze, and report to the Governing Body (GB) complaints and grievances through the Quality Assessment Performance Improvement (QAPI) process, failed to have a clear understanding of the complaint vs grievance process, failed to ensure the patient's complaint or grievance was effectively handled in a timely manner, and failed to inform the patients of any resolutions to their complaints and grievances. see Tag A0119 2 A. ensure patients were instructed on their involuntary status, and warrants were filed in a timely manner with results available to the patient and surveyor. Failed to have written documentation that the patient was aware of their rights, court hearing dates, and awareness of the judge's decision on their legal status after the court hearings in 3 of 3 (patient #1, #3, and #29) charts reviewed. B. patients had the capacity to understand the risk and benefits of treatment with psychotropic medications before signing an informed consent in 1 (Patient #29) of 1 medical record reviewed. see Tag A0131 3. A. have a safe process in place to provide care and safely discharge an aggressive psychotic/suicidal patient in 1 (Patient #4) of 1 medical record reviewed. B. ensure that emergency medical supplies and equipment were immediately available to staff to treat a patient that was experiencing an emergency medical condition. This deficient practice had the likelihood to cause harm to all patients being admitted and treated for suicidal ideation and psychosis. If the facility is unable to provide care to a mentally ill patient with aggressive psychosis and the patient leaves with the police with no discharge planning is in place, the patient places himself and others at risk of imminent harm or death. see Tag A0144 4. A. ensure that chemical restraints administered were identified as a chemical restraint/ emergency behavioral medication (EBM) B. ensure a process was in place for continuous monitoring after administering a chemical restraint/emergency behavioral medication for side effects, respiratory or cardiac distress, and assessment of medication effectiveness and safety after administration in 3 of 3 (Patients #1,4, and 5) patient charts reviewed. C. follow their own policy and procedures to ensure the restraint packet was filled out appropriately and completely, a face-to-face was conducted by a trained individual, and patient/ staff debriefing was completed and appropriate in 3 of 3 (Patient #1,4, and 5) charts reviewed. D. ensure chemical restraints were added to the restraint log and monitored through Risk and Quality in 3 of 3(Patient #1, 4, and 5) charts reviewed. The deficient practices were identified under the following Condition of Participation, CFR 482.13 Patient Rights, and were determined to pose an Immediate Jeopardy (IJ) to patient health and safety and placed all patients in the facility at risk for the likelihood of harm, serious injury, and possible death. see Tag A0160 5. A. ensure a 1-hour Face to Face was completed by the provider or a trained RN within one hour of the administration of a chemical restraint/EBM (emergency behavioral medication) in 5 (Patient #4, #26, #29, #30, and #32) of 5 medical records reviewed. B. ensure RN's (Registered Nurses) completed training of the 1-hour face to face evaluation before evaluating a patient after a chemical restraint. see Tag A0178 |