| 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) |
| A0392 | STAFFING AND DELIVERY OF CARE CFR(s): 482.23(b) The nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for care of any patient. This STANDARD is not met as evidenced by: Based on review and interview the facility failed to ensure adequate staffing levels to ensure patient and staff safety. Findings: During a tour of the facility on 5/8/23 in the afternoon the surveyor observed one large patient care area with a nurse's station in the middle. At the front of the nurse's station were two double doors and also at the back. This allowed one side of the unit to be closed off from the other creating two separate units. The nurses could observe both sides from the nurse's station. There was an ER unit and a medical unit that were not open or functioning. An interview was conducted with Staff #1 on 5/9/23 concerning staffing. Staff #1 stated that she does the nurse and mental health technician staffing. Staff #1 was asked how she determines how to staff the unit. Staff #1 stated that she staffs 3 nurses (2 RN's and 1 LVN) and 3 techs at all times. Staff #1 was asked if she had a grid or matrix that showed her minimum staffing grid. Staff #1 stated, "We did have a matrix, but I don't have one anymore." Staff #1 stated that she just puts people in when she needs extra people, but she sticks with the 3 techs, and 3 nurses for 1-21 patients. Staff #1 was unable to provide an acuity scale to show when she needed to increase staff. There was no information on the staffing sheets for a patient who was being admitted or discharged, patient required a line of sight, the patient was ordered a 1:1, or requiring more staff if the milieu was changing or disruptive. Staff #1 stated that she makes those decisions on what she is being told by the staff. Staff #1 confirmed that if she was not available there was no one else making those determinations and there was no documented process. A review of the policy and procedure " Nursing Staffing and Assignments" stated, " 3. Core staffing requirements have been established for each unit based upon the types of patients admitted to the unit, acuity needs, unit geography, and availability, of support staff and methods of patient care delivery. The hospital will schedule a minimum of two (2) licensed nurses on every shift for the behavioral unit and a minimum of (1) licensed nurse for the medical psych unit. A licensed nurse will be on each unit at all times. A charge nurse on each shift provides relief and backup for the assigned nurses." The policy and procedure were not accurate to the types of units available nor were there "core staffing requirements" available. There were no acuity levels. The surveyor was unable to determine safe staffing levels. |