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 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)
A0131 PATIENT RIGHTS: INFORMED CONSENT
CFR(s): 482.13(b)(2)

The patient or his or her representative (as allowed under State law) has the right to make informed decisions regarding his or her care. The patient's rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment. This right must not be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate.


This STANDARD is not met as evidenced by:
Based on record review and interview the hospital failed to ensure, A. the 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. A. A review of patient #1's chart revealed he was admitted on 4/8/23 as an involuntary patient. The facility had applied for an Order of Protective Custody (OPC) on 4/10/23. An OPC is an order issued by a Texas county judge that allows the psychiatric facility to hold the patient and provide treatment and that the judge has determined that the proposed patient presents a substantial risk of serious harm may be demonstrated by the proposed patient's behavior or by evidence that the proposed patient cannot remain at liberty. A review of the patient rights information given to the patients at admission revealed the following, "Order of Protective Custody (OPC) -- Special Rights 1. You have the right to call a lawyer or to have a lawyer appointed to represent you in a hearing to determine whether you must remain in custody until a hearing on court-ordered mental health services is held. 2. Before a probable cause hearing is held, you have the right to be told in writing: a. that you have been placed under an order of protective custody; b. why the order was issued; and c. The time and place of a hearing to determine whether you must remain in custody until a hearing on court-ordered mental health services can be held. This notice must also be given to your attorney. 3. You have the right to a hearing within 72 hours of your detention, except that on weekends or legal holidays, the hearing may be delayed until 4:00 in the afternoon on the first regular workday. The hearing may also be delayed in the event of an extreme weather emergency or disaster. 4. You have the right to be released from custody if a. 72 hours have passed and a hearing has not taken place (excepting weather emergencies and extensions for weekends and legal holidays); b. an order for court-ordered mental health services has not been issued within 14 days of the filing of an application (30 days if a delay was granted); or c. Your doctor finds that you no longer need court-ordered mental health services. Involuntary Patients - Special Rights Under most circumstances, you or a person who has your permission may, at any time during your commitment, ask the court to ask a physician to re-examine you to determine whether you still meet the criteria for commitment. If the physician determines you no longer meet the criteria for commitment, you must be discharged. If the physician determines you continue to meet the criteria for commitment, the physician must file a Certificate of Medical Examination with the court within 10 days of the filing of your request. If a certificate is filed, or if a certificate has not been filed within 10 days and you have not been discharged, the judge may set a time and place for a hearing on your request." A review of patient #1's chart revealed he had a probable cause hearing on 4/14/23 at 1:30 PM. The judge signed the warrant to hold the patient for his hearing on 4/26/23. There was no judgment or written information if the patient had a hearing, an order of commitment, or any time frame that the patient was committed for. There was no documentation that the patient was made aware of the judge's decision or was aware of his rights. A review of patient #3 was admitted to the facility as involuntary on 2/15/23. Patient #3 had a date set for the probable cause hearing on 2/23/23 and the hearing on 3/6/23. There was no evidence in the patient's chart that she was ever made aware of her rights. The patient did not sign any consent on admission. There was no evidence that the patient was told at any other later time of her rights. There was no order found from the judge of commitment for any time frame. An interview with Staff #2 was conducted on 5/9/23. Staff #2 stated that the court liaison was on vacation, and he handled all the court proceedings. Staff #2 stated that the court liaison kept a log of warrants and would share the information. The log revealed patient #1 was not on it. There were only 4 patients on the log. Patient #29 was on the log, but her court date had been extended to 5/8/23. Staff #2 was unable to tell me if the patient was involved in the court process on 5/8/23, if the patient had been committed, and for how long. Staff #2 stated when the court liaison is out the therapist that is responsible for the patients are supposed to turn the paperwork in to the courts however, there was no log and no process to show the surveyor what patients had current warrants and when they were due to go to court. 40989 B. Findings Patient #29 was a 62-year-old female admitted involuntary to the facility 4/14/2023 with a diagnosis of Schizophrenia. As of survey exit date on 5/10/2023 Patient #29 was still an inpatient at the facility. Review of the Psychiatric Evaluation by Physician #9 revealed the patient was delusional, had visual and auditory hallucinations, oriented to person only, and had impaired insight and judgement. There was no documentation by Physician #9 that the patient had the capacity to consent. There was no evidence found that the patient was able to understand where she was, her patient rights, or was mentally competent to understand she was in the facility to receive treatment for mental health care or receive psychotropic medications. Further review revealed the Order of Protective Custody (OPC) did not have a court order for forced medications. A review of the nurses note dated 4/14/2023 was as follows: "...Patient came from Facility #6 unvoluntary (sic). Patient was screaming, yelling, and stating that she belong (sic) to her commanders. Patient has internal stimuli. Physician #9 ordered Geodon 20mg IM (intramuscular) and Ativan 2mg IM. Given as ordered. Patient is in bed sleeping now..." A review of the medical record revealed informed consents for treatment with psychoactive medications were as follows: " ...Trazadone-signed by patient on 4/14/2023 and witnessed by the nurse. Patient #29 did not receive this medication. Patient #29 did not receive this medication prior to the survey exit date of 5/10/2023. Geodon (antipsychotic)-no patient signature. The patient signature line read, took medication-verbal consent on 4/14/2023 and witnessed by two nurses. This medication was administered as an EBM (Emergency Behavioral Medication. Patient #29 received 2 doses of Geodon 20mg IM (intamuscular) between 4/14/2023 and survey exit date of 5/10/2023. Haldol (antipsychotic)-signed by Patient #29 on 4/15/2023 and witnessed by two nurses. Patient #29 received 6 doses of Haldol 1mg by mouth between 4/14/2023 and survey exit date of 5/10/2023. Zyprexa (antipsychotic)-initialed by Patient #29 on 4/16/2023 and witnessed by one nurse. Patient #29 received 30 doses of Zyprexa 10mg by mouth between 4/14/2023 and survey exit date of 5/10/2023. Geodon-no patient signature. The patient signature line read Psychosis, Emergency Meds, patient willingly took meds on 4/28/2023. Witnessed by two nurses. This medication was administered as an EBM. Thorazine (antipsychotic)-signature on patient line states psychotic, yelling, growling dated 4/17/2023 and witnessed by two nurses. This medication was administered as an EBM. Patient #29 received 2 doses of Thorazine 50mg IM between 4/14/2023 and survey exit date of 5/10/2023. Thioridazine (Thorazine-antipsychotic)-signed by the patient on 5/02/2023 and witnessed by two nurses . Patient #29 received approximately 9 doses of Thorazine 50mg by mouth and approximately 29 doses of Thorazine 100mg by mouth between 4/14/2023 and survey exit date of 5/10/2023. .." A review of Physician #9's progress note dated 5/04/2023 was as follows: " ...Patient does not have moments of clarity while here, no waxing and waning of symptoms making delirium unlikely ..." During an interview on 5/10/2023 after 9:00 AM Staff #22 confirmed Patient #29 received multiple doses of Zyprexa, Geodon, Haldol, and Thorazine prior to the survey exit date of 5/10/2023. An interview was conducted with Staff #1 on 5/10/2023 after 9:00 AM. Staff #1 confirmed there was no route of administration or medication dose listed on any of the informed consents for psychotropic medications. Staff #1 was asked if the staff got informed consent from the patient for EBM's. Staff #1 stated, "If the patient takes the medications willingly, the staff will get the patient to sign the informed consent or take a verbal consent". Staff #1 was asked if the medications were administered as a behavioral emergency how was there time to get informed consent. Staff #1 replied, "She most likely agreed to take the shot." An interview was conducted with Staff #22 on 5/10/2023 after 9:00 AM. Staff #22 was asked if Patient #29 had the capacity to understand the risks and benefits of the psychoactive medications that she was taking. Staff #22 stated, "Well when I am with her, I can talk to her and I think she understands them." Staff #22 was asked when the physician increases the dose of the antipsychotic medication did the nursing staff and physician sign a new consent and explain the possible risks and benefits to the patient. Staff #22 stated, "No, I was told we did not have to do that if it was the same medication. When we do the first consent, we write the name of the medication on the consent and go over the medication with the patient." A review of the facility policy titled, "Informed Consent for Psychoactive Medications RI.014", with a review date of 12/08/2020 was as follows: "...POLICY It is the policy of Aspire Hospital to obtain consent for treatment with psychoactive medication. An exception would be a emergency situation. Each patient has a right to clear information about his/her behavioral healthcare and possible treatment options. An interpreter will be provided whenever necessary. The physician is to inform the patient's to their right to the extent permitted by law to refuse treatment interventions, including medications. The physician will discuss benefits, risks, side effects of medications and alternative treatments. The discussion will be documented in the medical record. Informed consent shall be obtained by the physician or treatment provider. DEFINITIONS Capacity-A persons ability to: Understand the nature and consequences of a proposed treatment, including benefits, risks and alternatives to the proposed treatment and Make an informed decision whether to undergo the proposed treatment..." Staff #23 was asked if Patient #29 had the capacity to understand the risks and benefits of the medications. Staff #23 confirmed Patient #29 did not have the capacity to understand anything since her admission on 4/14/2023.