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)
A0178 PATIENT RIGHTS: RESTRAINT OR SECLUSION
CFR(s): 482.13(e)(12)

When restraint or seclusion is used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others, the patient must be seen face-to-face within 1-hour after the initiation of the intervention -- o By a-- - Physician or other licensed practitioner; or - Registered nurse who has been trained in accordance with the requirements specified in paragraph (f) of this section.


This STANDARD is not met as evidenced by:
Based on record review and interview the facility failed to: 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. Findings: A. Patient #4 Patient #4 was a 21-year-old male admitted to the facility voluntary 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 by Physician #9 revealed he 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. A review of the document titled, "Restraint/Seclusion/Emergency Medication" packet dated 2/15/2023 at 8:30 AM by Staff #30 revealed Patient #4 was agitated, irritable, and yelling uncontrollably. A telephone order was received from Physician #9 at 8:30 AM for Ativan (sedative) 4mg IM, Haldol (antipsychotic) 10mg IM, and Benadryl (antihistamine) 100mg IM and administered to the patient by Staff #30 at 8:50 AM. Review of the 1-hour face to face was as follows: " ...Patient agitated, aggressive, and yelling uncontrollably and refused to be verbally redirected. Patient voluntarily took emergency medication, and he tolerated them well. Patient eventually calmed down and sleep (sic). No vital signs taken due to patient being sedated. The review of systems revealed all systems (skin assessment, circulatory status, genitourinary, reproductive, respiratory status, neurological, and musculoskeletal) were documented as within normal limits. Pain assessment was documented as Yes, but no description as to where or how severe the pain was. The Mental Status exam was only documented as unable to assess due to sedation ..." Staff #1 confirmed the 1-hour face to face was documented and signed by Staff #29 on 2/15/2023 at 8:00 AM. Staff #29 signed the 1-hour face-to-face evaluation 50 minutes prior to the chemical restraint being administered. Patient #26 Patient #26 was a 25-year-old male admitted to the hospital voluntary on 4/26/2023 with a diagnosis of Major Depressive Disorder with suicidal ideation. A review of the medical record revealed Patient #26 was administered a chemical restraint/EBM on 4/30/2023, 5/2/2023 and 5/03/2023. Physician #9 gave a telephone order dated 4/30/2023 at 2:53 PM for Geodon (antipsychotic) 20mg IM NOW x1 and Ativan 2mg IM NOW x1. There was no rationale or specific behaviors justifying the restraint on the physician order. The nurse administered the medication at 2:54 PM. A review of nursing documentation on 4/30/2023 by Staff #19 was as follows: " ...3:00 PM - patient went after another patient to attack and hits his head at the right side. MD notified, Geodon 20 mg Ativan 2mg IM given and tolerated well. Patient sleeping at this time..." Physician #9 gave a telephone order dated 5/02/2023 at 2:27 PM for Ativan 2mg IM NOW x1 and Haldol 10mg IM NOW x1. There was no rationale or specific behaviors justifying the restraint on the physician order. The nurse administered the medication at 2:27 PM. There was no documentation regarding a behavioral emergency at the time the medication was administered. Physician #9 gave a telephone order dated 5/03/2023 at 11:09 AM for Ativan 2mg IM NOW x1 and Haldol 10mg IM NOW x1. There was no rationale or specific behaviors justifying the restraint on the physician order. The nurse administered the medication at 11:19 AM. There was no documentation regarding a behavioral emergency that would require a chemical restraint/EBM at the time the medication was administered. RN Staff #19 documented at 11:00 AM, "Patient received Ativan 2mg and Haldol 10mg IM at right and left deltoid, per patient request, patient tolerated well, noted patient breathing pattern is normal, and sleeping after 30 minutes. Will continue to monitor." Staff #1 confirmed the medications administered IM to Patient #26 on 4/30/2023, 5/02/2023, and 5/03/2023 were administered as a chemical restraint/EBM and there should have been a restraint packet completed. Staff #1 also confirmed there was no 1-hour face to face evaluation completed. Patient #29 Patient #29 was a 62-year-old female admitted to the facility 4/14/2023 involuntary with a diagnosis of Schizophrenia. A review of the Physician orders dated 5/02/2023 noted Physician #9 gave a verbal order for Ativan 2mg IM NOW and Geodon 20mg IM NOW at 4:50 PM. The medication was administered by the nurse at 5:04 PM. A review of the nurse's notes dated 5/02/2023 at 10:44 PM was as follows; "Patient #29 was observed asleep in bed, due to pt received emergency medication of Ativan 2mg and Geodon 20mg IM for agitation, pt is hard to awaken, will continue to monitor pt." Staff #1 confirmed there was no restraint packet or 1 hour face to face completed for the chemical restraint/EBM. Patient #30 A review of the document titled, "Restraint/Seclusion/Emergency Medication" dated 4/02/2023 at 3:30 was as follows: A verbal order was given for Ativan 2mg IM, Haldol 5mg IM, and Benadryl 50mg IM by Physician #9. Patient #30 received an IM injection at 3:30 PM because she was exhibiting "combative behavior". A review of the 1-hour face to face was incomplete. There were no vital signs or refusal by patient. No release criteria was documented as met or not met. No date or time was documented of when the physician was notified. The 1-hour face to face was signed by LVN Staff #32 at 3:30 PM. This was the same time as the medication was administered. During an interview on 5/09/2023 after 1:00 PM, Staff #1 confirmed the 1 hour face to face evaluation was not complete and was signed at the same time the medication was administered. Staff #1 also confirmed LVN's (Licensed Vocational Nurses) were not allowed to complete a 1-hour face to face evaluation. Patient #32 Patient #32 was a 44-year-old male admitted to the hospital on 3/05/2023. A review of the incident report dated 3/5/2023 at 4:00 PM by Staff #19 was as follows: " ...The patient was agitated, irritable, taking clothes off aggressive and yell uncontrollably, and threatening staff.MD notified. Geodon 20mg, Ativan 2mg, Benadryl 50mg ..." There was no time documented on the incident report when the medication was administered. Staff #1 confirmed there was no restraint packet or 1 hour face to face evaluation completed by the Physician or a trained RN. A review of the facility policy titled, "PC.027 Behavioral Health Restraint and Seclusion" with a revision date of 12/12/2022 was as follows: " ...4.0 Restraint and Seclusion for Violent or Self-Destructive Behavior The following standards apply to patients who are demonstrating violent or self-destructive behavior, regardless of their hospital setting. These behaviors jeopardize the immediate physical safety of the patient, staff or others. 4.1 Physician Orders and Physician Assessment 4.1.1 Use of restraint or seclusion is based upon the time limited order with rationale of a physician, clinical psychologist or other authorized licensed independent practitioner in accordance with hospital policy and state law. In addition, the physician order will include: Date, time and signature Rationale and specific behaviors justifying use of restraint or seclusion Type of restraint or seclusion 4.1.2 In the absence of a physician, an authorized RN who has successfully completed restraint and seclusion competency may initiate restraint or seclusion. 4.1.3 When an RN initiates restraint or seclusion, an order will be obtained from a physician as soon as possible after the restraint is initiated. 4.1.4 The original order is based on a face-to-face assessment of the patient by a physician or authorized RN. The face-to-face assessment which is mandatory within 1 hour of the initiation of the restraint or seclusion must be done by a physician or RN other than the RN whenever possible. The results of the assessment will be documented in patient's medical record and will include following: Patient's immediate situation Patient's reaction to the intervention Patient's medical and behavioral condition Need to continue or discontinue restraint or seclusion 4.1.5 The face to face assessment is completed for all episodes of restraint or seclusion regardless of patient being released within the first hour. 4.1.6 If the order or face to face assessment is not completed by the patient's attending physician, the attending physician will be consulted as soon as possible ..." An interview was conducted on 5/09/2023 at 9:00 AM with Staff #20 and #21. Staff #20 was asked when a chemical restraint/EBM was administered, who completes the 1-hour face to face evaluation and how is it documented. Staff #20 stated, "I know a different nurse has to do the face to face. It's not supposed to be the same nurse that gives the medicine. We try and go back and get that done." Staff #20 was then asked if vital signs (blood pressure, temperature, heart rate, respiratory rate, and oxygen level) are taken and documented on the face-to-face form. Staff #20 stated, "Not all the time because the patient will refuse, or they may be sleeping." Staff #20 was asked if he documented a respiratory rate if the patient was sleeping or refused the vital sign assessment. Staff #20 stated, "If I tell you the patient refused, then that should be good enough. If the patient is talking and refuses, then you know the patient is alive. There is no reason for me to document a respiratory rate." Staff #21 was asked if a 1-hour face to face evaluation was always completed when a patient received an IM injection of an EBM. Staff #21 replied, "No, not all the time, but I do most of the time. If a patient takes the medications willingly, sometimes we don't do a restraint packet. Like Patient #26 would come and ask for a shot of Haldol and Ativan because he was very anxious and agitated. We would call the doctor and get an order. Then most of the time he would just go and sleep. Since he asked for the shot, we didn't do a restraint packet on him and that's where the 1-hour face to face is documented." B. A review of the personnel files for 3 (Staff #11, #18, and #19) of 3 RN's was conducted on 5/09/2023 with Staff #1 and #2. Employee files did not reveal training and staff competency to complete a 1-hour face to face evaluation after a chemical restraint/EBM was administered IM to a patient. Employee #11 A review of Employee #11's file revealed acknowledgement documents was signed on 11/14/2022 for the education of: 1. Restraint and Seclusion Process 2. Restraint/Seclusion/Emergency Medication Packet Staff #2 confirmed there was no documentation of the 1-hour face to face training. Employee #18 A review of Employee #18's file revealed acknowledgement documents were signed on 4/26/2022 for the education of: 1. Restraint and Seclusion Process 2. Restraint/Seclusion/Emergency Medication Packet 3. Provision of care-Restraints and Seclusion Further review revealed a Post Test titled, "Conducting the One Hour Face to Face Evaluation for Restraint/Seclusion" was signed by Employee #18 but there was no date when the post test was taken. The post test consisted of 7 questions and there was no pass or fail documented on the test. Employee #19 A review of Employee #19's file revealed an acknowledgement document was signed on 6/1/2022 for the education of Restraint/Seclusion/Emergency Medication Packet and on 10/20/2022 for Restraint and Seclusion Packet. A post test for Restraint and Seclusion was taken with a grade of 80. There was no date on the test. No further education was found in the file. Further review revealed a Post Test titled, "Conducting the One Hour Face to Face Evaluation for Restraint/Seclusion" was signed by Employee #19 but there was no date when the post test was taken. The employee scored a 58 out of a possible 100. An additional test was taken for the one-hour face to face but there was no grade, no signature, or date by the employee. This surveyor was unable to determine when the test was taken. The posttest consisted of 6 questions and there was no pass or fail documented on the test. An interview was conducted on 5/09/2023 at 9:00 AM with Staff #20. Staff #20 was asked if the 1-hour face to face was an annual training. Staff #20 replied, "We do it at orientation. They give us the policy and we sign the paper saying that we got it." Staff #20 was asked to explain the process for the 1-hour face to face. Staff #20 replied, "We try and keep the patients in their rooms for the first 30 minutes after they had a shot just so they don't fall. Then we will go back and see them in an hour or so. The techs can monitor the patients and come and tell us if there is a problem." An interview was conducted with Staff #4 on 5/09/2023 after 1:00 PM. Staff #4 was asked if the RN's had specific training for the 1-hour face to face evaluations. Staff #4 stated they are given the policy on restraints to go over and the training comes from the policy. Staff #4 was asked if there was a policy on the 1-hour face to face evaluation. He replied, "No, all the information was in the restraint policy." During an interview on 5/09/2023 after 1:00 PM, Staff #1 stated, "I know we did a power point on that training." After multiple requests for the 1-hour face to face training, none was received or provided for review. Staff #1 confirmed there was no competencies for the 1-hour face to face evaluation training in 3 (Staff #11, #18, and #19) of 3 personnel files reviewed.