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)
A1100 EMERGENCY SERVICES
CFR(s): 482.55

The hospital must meet the emergency needs of patients in accordance with acceptable standards of practice.


This CONDITION is not met as evidenced by:
Based on record review and interview the facility failed to: A. ensure emergency medical supplies and equipment was immediately available to staff to treat a patient that was experiencing an emergency medical condition. REFER to 144 B. provide emergency medical treatment to patients experiencing a medical emergency in 10 (patients #10, 11, 12, 14, 15, 18, 21 (x2), 22, 23, and 24) of 13 patient records reviewed. A review of the incident reports dated January 2023-March 2023 was completed on 5/09/2023. The review revealed 11 (Patients # 11, 12, 14, 15, 17, 18, 20, 21 (x2), 22, 23, and 24) of 11 patients experienced an emergency medical condition while admitted to the behavioral health unit. Two (Patient #10 and #13) of 2 patients receiving outpatient services experienced an emergency medical condition. Hospital staff called 911 and transferred 10 (patients #10, 11, 12, 14, 15, 18, 21 (x2), 22, 23, and 24) of the 13 patients reviewed to other hospitals for a higher level of care. Findings: On 05/09/23, observations made of the hospital's exterior noted signage above an entrance for "Ambulance", there was no signage reflecting "Emergency". During a tour of the hospital the morning of 05/09/23 with Staff #4, an emergency suite was observed as well as two emergency treatment rooms. The emergency suite and treatment rooms appeared to be set up and ready for patients with patient beds made up, crash carts and other supplies however there was no staff noted in the department. In an interview conducted while touring the hospital with Staff #4 on the morning of 05/09/23, Staff #4 noted the emergency department was not open. Staff #4 stated there was no staffing for this department, and patients were not received or accepted through the emergency department, nor were current in-patients provided treatment through the emergency suite or emergency treatment rooms. Staff #4 affirmed that the hospital did not staff the emergency department with nurses, or physicians or have a designated emergency department medical director. Staff #4 stated that the emergency department had not been open since sometime before COVID. During a tour of the hospital 05/08-05/09/23, the only unit observed to be utilized and staffed by the hospital was the locked, behavioral unit. The hospital was not utilizing the licensed medical/surgical beds and was only providing behavioral/psychiatric care. Staff # 1 confirmed in an interview on 05/09/23 that the hospital did not utilize the emergency room or the emergency treatment rooms. When Staff #1 was asked what they would do if a patient on the locked, inpatient behavioral unit had an emergent condition, responded an incident report would be completed and the patient would be assessed by the floor nurse and if necessary, they would call 911 and the patient would be transferred to another hospital for further assessment, stabilization, or treatment. In interviews on 05/08 and 05/09/23, Staff #1 confirmed the emergency department was closed and had been since before 2022. A review of incident reports from January 2023-March 2023 found that 11 patients complaining of medical conditions while admitted to the behavioral unit (Patients # 11, 12, 14, 15, 17, 18, 20, 21 (x2), 22, 23, and 24) were assessed on the behavioral unit and not provided emergency services by the hospital, and two patients receiving outpatient services (Patients #10 and 13) with complaints of medical conditions were not provided emergency services by the hospital. Hospital staff called 911 and transferred 10 (patients #10, 11, 12, 14, 15, 18, 21 (x2), 22, 23, and 24) of the 13 patients to other hospitals for additional assessment, observation, and care. 01/30/23 Patient #24, under the section titled "Summary of incident" the patient complained of "sickle cell crisis Pt asked to call her MD for instruction. Dr called back & she recommended to send to ER", under the section titled "Interventions/Resolutions made during and after the incident" documented " VS 184/102 HR 153, R22, T 97.9" Under the section "Summary of license healthcare professional's findings" documented "EMS picked up patient at 1930 & report given to (Facility 3) and (Facility 4)..." 01/30/23 Patient #23, under the section titled "Summary of incident" documented "Pt had an abnormal EKG... ". Under the section titled Interventions/Resolutions made during and after the incident, "NP (Staff #34) notified and ordered to have pt sent to ER". Under section titled "Summary of license healthcare professional's findings" documented, "Pt was sent to ER" 01/28/23 Patient #22, under the section titled Summary of incident documented, "Patient presents with AMS and unstable blood sugar levels. Patient new admit, referral from Facility #1 (community behavioral center). Came in without medical clearance from ED." Under the section titled Interventions/Resolutions made during and after the incident "Patient sent out to (Facility #2) ED @ 13:45 via city ambulance. Patient sent out for medical clearance." Under the section titled" Summary of treatment given bv the licensed healthcare professional" documented, "Patient sent out to (Facility #2) ED for medical clearance @1345" 01/23/23 Patient #21, under the section titled "Summary of incident" documented "Dr. (Physician #33) ordered to send pt due to change in mental status. Pt left through EMS @2055 with all pertinent paperwork and requested all his belongings." 01/10/23 Patient #18, under the section titled "Summary of incident" documented, "No witnesses of any incident, or injury to this Pt. 1900 PT c/o pain to day shift nurses, at which time LLE foot was said to be swollen and bruised. When asked by (Staff #21) RN Pt stated he fell before coming here but pain started today." Under the section titled "Interventions/Resolutions made during and after the incident" documented, "Provider notified @ 1900, Elevated LLE and Tylenol was given. Pt remained non-wt bearing c LLE elevated until 2100 when EMS took him Provider (Staff #34) NP gave order to send to (Facility #2) to rule out FX and DVT". Under the section titled "Summary of treatment given by the licensed healthcare provider" documented "Monitored pt to stay off feet and resting. Called EMS and (Facility #2) ED." 02/17/23 Patient #15, under the section titled "Summary of incident" documented, "Pt as seen by doctor c/o wrist pain, x-ray ordered and found to be broken (small Fx)." Under the section titled "Interventions/Resolution made during and after incident" documented "Sent to hospital". Under the section titled "Summary of treatment given by the licensed healthcare professional" documented "notified MD, Assess situation/ROM, Sendf to E.R". 02/20/23 Patient #14, under the section titled "Summary of incident" documented, "Pt has been refusing to eat or drink since before admission", under the section titled "Interventions/Resolution made during and after the incident" documented "Dr (Staff #33) ordered to send pt to ER", under the section titled "Summary of treatment given by the licensed healthcare professional" documented "Pt transferred to ER" 03/03/23 Patient #13, who was receiving outpatient services and exhibited stroke-like symptoms including signs of tunnel vision, dizziness, headache, dysphasia, and right-sided facial droop, was assessed by a PTA (physical therapist assistant) and an employee of the outpatient imaging department who was also a paramedic. EMS was called, and the patient was transported to another hospital. Aspire Hospital did not provide emergency services and there was no documentation that the patient was stabilized prior to transfer to another hospital. Patient #13 under the section titled "Summary of incident" documented "Approximately 9:10am- Patient completed physical therapy session and cleaned up and changed clothes in preparation to leave the facility. Patient requested water to drink and then began reporting dizziness and headache, PTA assessment BP 168/98. Patient reported he didn't feel he would be around for his next birthday in June then informed he was having tunnel vision and began showing signs of dysphasia with difficulty word-finding. PTA requested Paramedic assistance and obtained the the patient wallet for ID. Patient reported he wanted paramedic to be aware of religious beliefs. Paramedic from Aspire Hospital Imaging Center entered and began assessment of Mr. (Patient #34). PT was contacted. After ~3-minute assessment 911 was called and emergency services were dispatched. Paramedic and PTA continued assessment and patient care until emergency services arrived. Information provided to EMTs including vitals, assessment details, and face sheet for patient information. PTA informed EMT of patient's recent mental health statements; he reported he is self-medicating with alcohol daily dealing with spouse and adult children, and stated this date that he may be better if he were no longer here". Under the section titled "Interventions/Resolution made during and after the incident" documented "Vitals 160/98 (manual), HR 67, RR16, SPO2 97% RA, No Glucose (no glucometer) Cincinnati stroke scale score @ 5 min (2)m 10m min (4), 20 min (2) Pt never had LOC but did display right sided facial droop & complained of headache on left side posterior of head. PTA assessed BP and contacted Paramedic. Paramedic performed assessments while awaiting EMS.". Under the section titled "The treating licensed health care professional(s) name(s) documented the Paramedic (Staff #35) and PTA (Staff #36). Under the section titled "The treating licensed health care professional(s) name(s)" documented "Staff #35 Paramedic on staff & (Facility #5) County EMS" Under section titled "Summary of treatment given by the licensed healthcare professional" documented "See vitals & Assessment for stroke scales, 911 was called & pt was transported". The incident report documents the "patient was transported by EMS to hospital". There was no documentation the patient was assessed by a physician or stabilized prior to transport by EMS. 03/12/23 Patient #21, "Summary of incident" documented "Patient #21 transferred to Facility #2 ED due to symptoms of Delirium. Patient left facility @1020 via city Ambulance" Under the section titled "Interventions/Resolution made during and after incident" documented "Patient transferred to ED for a level of care the facility cannot provide." Under the section titled "Summary of licensed healthcare professional's findings" documented "Patient is increasingly confused and hallucinating even after antipsychotics prescribed." Under the section titled "Summary of treatment given by the licensed healthcare professional" documented " Dr (Staff #27) gave phone orders to transfer patient to ED" In incident dated 03/29/23, Patient #12, who was complaining of chest pain on scale of 10/10 and with a history of CAD (coronary artery disease) , HTN (hypertension), and recent heart attacks was transferred to Facility #2 via ambulance. There was no indication the patient had been assessed by a physician before transfer. Aspire Hospital did not provide emergency services and there was no documentation the patient was stabilized prior to transfer to another hospital. 03/29/23 Patient #12, under the section titled "Summary of incident" documented, "Patient c/o pain 10/10. Patient has history of CAD, HTN, Recent heart attacks per patient." The section titled "Summary of license healthcare professional's findings" documented, "Patient complaining of chest pain 10/10. Patient vitals taken BP 141/94 P-65 02-99% R-16". Under the section titled "Summary of treatment given by the licensed healthcare professional" documented "MD notified. Patient transferred to Facility #2 via ambulance." Under the section titled "Summary of treatment given by the licensed healthcare professional" documented "Patient sent via ambulance to Facility #2". In the section titled "Follow-Up Notes" documented "1400 As per RN Staff #37 still running tests" "1630 No Answer" "1746 Pt admitted to room 237". Under the section titled "The treating licensed health care professional(s) name(s)" documented RN Staff #38 and Nurse Practitioner Staff #28, there was no documentation the patient was assessed by a physician or stabilized prior to transfer by EMS to Facility #2. 03/29/23 Patient #11, under the section titled "Summary of incident" documented "Patient complained of chest pain to medical doctor. Patient C/o neck & head pain unresolved." The section titled "Interventions/Resolution made during and after incident" documented "Received order from MD to transfer via ambulance to ER." Under the section titled "The treating licensed health care professional(s) name(s) documented NP Staff #28. Under the section titled "Follow-Up Notes" documented "1720 Pt's CT scan & labs WNL (within normal limits). Pt will be sent back via ambulance" 03/30/23 Patient #10, "Summary of incident" documented "Patient was sitting in the IV room while the (SIC) attempted to start an IV on him. Patient's speech started slurring and he became unresponsive. His eyes rolled back and CT tech attempted to arouse him CT Tech shouted for staff to call 911. When 911 staff arrived on (?) patient was already awake. Blood pressure was taken before the arrival of the 911 personnel and reading was low (87/59) When 911 personnel repeated BP, it was within normal limits. Patient refused to go with EMT personnel. CT scan was complete" Under the section titled "The treating licensed health care professional(s) name(s)" documented "None- no treatment given." In interview held in the conference room, the afternoon of 05/10/23, Staff #16 confirmed the emergency department was closed and no emergency services were being provided.