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)
A0454 CONTENT OF RECORD: ORDERS DATED & SIGNED
CFR(s): 482.24(c)(2)

All orders, including verbal orders, must be dated, timed, and authenticated promptly by the ordering practitioner or by another practitioner who is responsible for the care of the patient only if such a practitioner is acting in accordance with State law, including scope-of-practice laws, hospital policies, and medical staff bylaws, rules, and regulations.


This STANDARD is not met as evidenced by:
Based on document review and interview the hospital failed to ensure that telephone/verbal orders were authenticated promptly by 3 (Physician #9, Physician #27, and Provider #28) of 3 providers in 2 (Patient #26 and Patient #29) of 2 medical records reviewed. Also, the hospital failed to follow their own policy and ensure that only a Registered Nurse was accepting verbal and/or telephone orders from the Medical Staff Providers. A review of medical records was conducted on 5/10/2023 after 10:00 AM with Staff #23. Findings: Patient #26 Patient #26 was a 25-year-old male admitted voluntary to the facility on 4/26/2023 with a diagnosis of Major Depressive Disorder and Psychosis with Suicidal Ideation. All telephone orders dated 4/26/2023 at 4:12 AM were accepted by LVN (Licensed Vocational Nurse) Staff #31. A review of the orders revealed Physician #9 gave telephone orders for admission, medications, ancillary (lab and x ray), and nursing on 4/26/2023. Physician #9 failed to authenticate the telephone orders until 5/08/2023 at 1:10 PM. This was 12 days after the telephone orders were accepted by the hospital staff. Further review of the physician orders revealed Physician #9 gave telephone orders for the following medications: " ...4/26/2023 at 8:38 AM Zyprexa (antipsychotic) 10 mg tab by mouth. Now order for a new patient 4/29/2023 2:41 PM Valium (sedative) 5 mg tab by mouth NOW 4/28/2023 10:18 AM Ativan (sedative) 2mg IM NOW 4/30/2023 2:54 PM Ativan 2mg IM NOW 4/30/2023 2:53 PM Geodon (antipsychotic) 20mg IM NOW 5/03/2023 11:10 PM Haldol (antipsychotic) 10mg IM NOW 5/03/2023 11:09 PM Ativan 2mg IM NOW 5/02/2023 2:27 PM Ativan 2mg IM NOW 5/02/2023 2:27 PM Haldol 10mg IM NOW ..." Physician #9 failed to authenticate the telephone orders until 5/08/2023 at 1:10 PM. A review of the telephone orders dated 4/30/2023 by Physician #27 was as follows: " ...9:49 AM Valium 10mg tablet by mouth twice a day 12:57 PM Zyprexa 15mg tablet by mouth NOW 12:58 PM Valium 10mg tablet by mouth NOW ..." As of survey exit date on 5/10/2023, the telephone orders given by Physician #27 had not been authenticated. This was 10 days after the telephone orders were accepted by the hospital staff. Patient #29 Patient #29 was a 62-year-old female admitted to the facility Involuntary on 4/13/2023 with a diagnosis of schizoaffective disorder and Psychosis. The Psychiatric Evaluation revealed the patient was delusional, had visual and auditory hallucinations, oriented to person only, had impaired insight, and impaired judgement. A review of the medical record for Patient #29 revealed Physician #9 gave telephone orders on 4/14/2023 at 10:07 AM for admission, medications, ancillary (lab and x ray), and nursing orders. Physician #9 failed to authenticate the telephone orders until 5/08/2023 at 1:10 PM. This was 24 days after the telephone orders were accepted by the hospital staff. A review of the physician orders dated 4/14/2023 at 2:46 PM revealed Provider #28 gave telephone orders for medications. The orders were as follows: " ...Synthroid (hormone) 88mcg daily by mouth and Lipitor (medication used to lower your cholesterol) 40 mg at bedtime ..." As of survey exit date 5/10/2023, Provider #28 failed to authenticate the telephone orders. Further review revealed telephone orders were accepted by LVN Staff #22. The orders were as follows: " ...4/23/2023 10:18 AM Ativan 2mg by mouth. Telephone order given by Physician #27 ... 4/27/2023 at 2:06 PM Dulcolax 10 mg by mouth now. Telephone Order given by Provider #28 ..." As of survey exit date 5/10/2023, Physician #27 and Provider #28 failed to authenticate the telephone orders. A review of the facility policy titled, "Verbal/Telephone Orders, Policy #IM.003" with a review date of 12/11/2020 was as follows: " ...POLICY It is the policy of Aspire Hospital that only a licensed registered nurse may accept telephone or verbal orders from the physicians. Verbal orders will be accepted in emergency situations only when immediate written or electronic communication is not feasible and will be documented with the date and time that the verbal order is received. The physician or covering physician will be responsible for authenticating the order with his/her signature, as soon as possible, but within 48 hours of the verbal/telephone order unless state law is more restrictive ..." During an interview with Staff #22 on 5/10/2023 after 11:00 AM she confirmed she was not aware that the facility policy did not allow LVN's to take verbal orders. An interview was conducted with Staff #23 on 5/10/2023 after 11:00 AM. Staff #23 was asked if the facility uses telephone orders on a regular basis. Staff #23 replied, "Sometimes we have no other option. We do not have doctors in the hospital all the time. If one of us nurses do the intake, we call the doctor for orders and some of the orders are just routine that we use for every patient but if the patient needs specific orders, then we get them from the physician as well. We put the orders in the system and then the doctor signs them. Sometimes the doctor is not here until the next day, so we have to make sure that we have orders to care for the patient." Staff #1 confirmed that verbal and telephone orders were not routinely signed within 48 hours. She also confirmed LVN's were taking telephone/verbal orders.