Statement of Deficiencies

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)

A0144

PATIENT RIGHTS: CARE IN SAFE SETTING
CFR(s): 482.13(c)(2)

The patient has the right to receive care in a safe setting.

This STANDARD is not met as evidenced by:
Based on document review and interview the facility failed to: 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 emergency medical supplies and equipment was immediately available to staff to treat a patient that was experiencing an emergency medical condition. The facility was unable to provide adequate staff to safely care for a mentally ill patient with aggressive psychosis. Patient #4 was discharged to the police without appropriate community referrals and follow up appointments. This deficient practice had the likelihood to cause harm to all patients admitted and treated for suicidal ideation and psychosis. Findings A. Patient #4 Patient #4 was a 21-year-old male admitted voluntary to the hospital on 2/14/2023 at 6:25 AM with a diagnosis of Psychosis and severe substance abuse-Methamphetamine, Cocaine, Adderall, alcohol, and Benzodiazepines. He had a past medical history of Cerebral Palsy and Seizures. A review of the Psychiatric Evaluation dated 2/14/2023 at 3:29 PM by Physician #9 revealed the patient was only oriented to person and place, not time or situation. He had poor memory and recall, impaired insight, and impaired judgement. The psychiatrist documented the patient was highly anxious, easily agitated, and had a difficult time answering questions. The discharge plan documented by Psychiatrist #9 was to discharge the patient when he was no longer a danger to himself and others, his level of depression was decreased, had reduced anxiety and psychosis, and when he was compliant with treatment and medication management. Staff #1 confirmed he had not met the criteria when he left the facility with the police. A review of the medical record revealed Patient #4 received a chemical restraint/EBM (emergency behavioral medication) on 2/15/2023 at 8:30 AM because he became agitated, aggressive towards staff, irritable, and yelling uncontrollably. A review of the nurse's note dated 2/15/2023 at 3:00 PM was as follows: " ...0900-Patient agitated and aggressive towards staff. Patient was uncontrollably yelling and screaming. Patient stating that he hates everyone because they are looking at him. Patient believes that everyone is a cop. Staff engaged in 1:1 communication and verbal redirection. Patient refused to be redirected. Attending psychiatrist notified of the situation and ordered emergency medication as follows: Ativan 4mg IM, Haldol 10mg IM, and Benadryl 100mg IM The Emergency medication administered on bilateral deltoid. Patient tolerated medication well. Staff will continue to monitor Q15 minutes for safety ..." Review of the nurses notes dated 2/16/2023 was as follows: "Patient started getting agitated and aggressive and went to his room at around 0800. Patient was throwing hygiene products all over his room. Staff started to verbally redirected (sic) and deescalate patient. Patient observed to escalate, angry, aggressive, and agitated. Patient refused to be verbally redirected and started to approach the nurses station and pulled out and broke the glass windows. Patient asking staff to give his freedom. Patient continued to state verbal threats that he will destroy more property if he gets pissed off one more time. Staff called 911 at around 0803. DON and attending psychiatrist notified of the incident. Cops came at around 0810. Cops picked up patient and left facility at 0845." A review of the discharge summary by Physician #9 dated 2/16/2023 at 3:57 PM was as follows: " ...Course of Treatment-Patient admitted in acute psychotic state. He had multiple episodes of anger and mood swings, lashing out at staff and other patients. This morning, he became irate and ripped down the partition on the nurse's station. Cops were called and patient was escorted out. Mom came to pick him up from hospital. Condition at discharge-Not improved (labile, aggressive, cops called and discharged to mom) Discharge to-Home with family ..." An interview was conducted with Staff #22 and #25 on 5/10/2023 after 11:00 AM. Staff #22 was asked if she remembered calling the police on Patient #4. Staff #22 stated, "Yes, he was tearing the place apart. He busted the window at the nurses' station and was trying to bend the metal frame." The nurses were asked if the facility had a process in place to ensure that the patients and staff were safe when an event like this occurred. The nurses confirmed there was no policy on how to handle this type of situation, so they just call the police. Staff #22 stated, "I'm going to call the cops because I am not going to risk my life when a patient strung out on drugs becomes that aggressive. We had to do this before because a patient became aggressive. Patient #4 was mad and aggressive when he got here." Staff #22 was asked if any of the staff tried to de-escalate the patient? Staff #22 replied, "There was no de-escalating him. We had to just shut the door in the hallway after we moved the other patients until the police got here. We do not have very many men that work here and it's mostly just us women and we could not control him." Staff #22 was asked if the police left with the patient or did his family come and pick him up. She confirmed that she did not see anyone come and get him and that the police left the building with the patient. An interview was conducted with Staff #1 on 5/10/2023 after 11:00 AM. Staff #1 was asked if the family picked the patient up after the police left the building with the patient. She stated, "I cannot say for sure." She also confirmed Physician #9 was not there at the time of discharge and there was no documentation by Physician #9 that the family was contacted to pick the patient up at the facility. Physician #9 documented the patient was discharged home with his mom and Staff stated during interviews he left with the police. Staff #1 confirmed there was no discharge order completed by Physician #9 and that Patient #4 was discharged from the facility without a safe discharge in place. Again, Staff #1 stated there was no follow up on the incident and they were unsure of the patients safety and the safety of others at time of discharge. Staff #2 confirmed no follow up documentation was found in the medical record by the nursing team, physicians, or risk management team regarding the incident after the patient left the facility. She also confirmed the physician was not present at the time of discharge and there was no staff debriefing or education following the incident. B. A tour of the locked Psychiatric Unit was conducted on 5/08/2023 at 10:00 AM with Staff #1 and Staff #3. Staff #1 was asked where the emergency treatment room was located on the locked unit. Staff #1 replied, "We do not have a treatment room on the unit. We can take the patient to the Emergency Department for exam if we need to." Staff #1 was asked if the Emergency Room was opened and staffed for emergencies. She replied, "No, the emergency room is closed." Staff #1 was asked if the Unit had an emergency cart with emergency medications, supplies, and equipment. Staff #1 confirmed there was no emergency crash cart located on the locked unit. An interview was conducted on 5/8/2023 at 10:15 AM with Staff #11 and Staff #24. Staff #11 and #24 were asked if a patient had a medical emergency, where was the emergency medical equipment located. Staff #24 stated, "We have oxygen stored in the equipment room, but we would normally call 911 if it was a life-threatening emergency." Staff #11 and Staff #24 were asked if the facility had an automated external defibrillator (AED) and suction equipment available. The staff responded saying there was no AED on the unit but they did have suction equipment in the equipment supply room but they were unsure if the suction equipment was working. Staff #24 was asked if a patient required treatment for a minor incident, where could the patient be examined privately. The nurse confirmed there was no emergency treatment room on the unit where a patient could be examined privately other than in the patients assigned room. An interview was conducted with Staff #20 on 5/9/2023 after 9:00 AM. Staff #20 confirmed the locked unit did have an AED. Staff #20 went into the medical record room within the nurses station and pulled out a dark colored duffle bag stored in a lower cabinet. The duffel bag contained an AED, an ambu bag (bag valve mask that can be connected to oxygen to provide respiratory support to a patient) and oral airways. Staff #20 confirmed the AED was not checked daily for operational use. The equipment and supplies were not checked on a routine basis and he could not confirm when the last time the supplies had been replaced. Staff #7, #21, #22, #23, and #25 confirmed they were not aware that the AED and airway supplies were stored in the medical record room.