The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

SUNDANCE HOSPITAL 7000 US HIGHWAY 287 ARLINGTON, TX 76001 July 10, 2012
VIOLATION: MEDICAL STAFF - ACCOUNTABILITY Tag No: A0049
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review the Governing Body failed to ensure medical staff provided quality of care for 1 of 7 patients (Patient #1). (Patient #1) was admitted to the Psychiatric Hospital 06/22/12. (Patient #1's) medical medications administered at home were not continued, although the physician documented to continue home medications, the physician failed to write orders for home medications to be continued during (Patient #1's) inpatient stay. (Patient #1) became ill 06/24/12 and was sent to the medical hospital ED (Emergency Department) where he was administered his home medications.

Findings included:

The pre-admission exam and certification dated 06/22/12 timed at 19:28 PM reflected, "Yesterday pt (patient) grabbed his brother at the back of the neck and pushed his face down into his food ...also shoved brother into wall and charged at his step-father last night ...pt increasingly aggressive over the last two days at home...medications Advair 250/50 BID (twice a day), Singulair 10 mg (milligrams) po (by mouth) daily...Nasonex 25 mg...sprays every day...Zyrtec 10 mg po hs (hour of sleep), Intuniv 4 mg (milligrams) po (by mouth) daily, Levemir 13 units subcutaneous bid, Prevacid 30 mg po bid, Lithium 300 mg po bid, Seroquel XR 300 mg po bid, Celexa 20 mg po hs, Humalog 1 to 10 carb ratio and inhaler 15 minutes before physical activity or going outside ...Axis III ... Asthma, Type I Diabetes and GERD (Gastrointestinal Esophageal Reflux Disease)..."

The Universal Medication List dated 06/22/12 signed by the nurse and the patient's legal guardian reflected, "Advair 250/50 mg bid...Singulair 10 mg, Nasonex 25 mg inhalation spray, Intuniv 4 mg daily, Prevacid 30 mg po bid... Seroquel XR 300 mg bid were last taken 06/22/12 ..."

The physician admitting orders dated 06/22/12 timed at 19:28 PM reflected, "Patient may have incomplete medication information requiring further verification...once information is obtained, please reconcile medication orders with attending or medical consult M.D....finger stick blood glucose before meals and hour of sleep...insulin sliding scale regular insulin subcutaneously BG (blood glucose) 0-40: No insulin, give 4 ounces of orange juice, or 8 ounces of 2% milk, or 4 ounces of regular soft drink and notify the doctor...BG 41-60 ...no insulin, give 4 ounces of orange juice or 8 ounces of 2% milk, or 4 ounces of regular soft drink...BG 61-200 no insulin, if blood sugar greater than 70 and patient is symptomatic, treat with [DIAGNOSES REDACTED] protocol as defined above, BG 201-250 2 units, BG 251-300 4 units, BG 301-350 6 units, BG 351-400 8 units, BG 401-450 10 units, BG greater than 451: 12 units, and notify doctor...if patient maintains a blood glucose greater than 180 on 3 separate occasions in a 24 hour period, then notify the doctor, if the patient has a single blood glucose less than 40, or greater than 400 then notify the doctor ...repeat accu-check 15-30 minutes after treating [DIAGNOSES REDACTED] as defined as above, until blood glucose greater than 60..."

The 06/22/12 physician orders timed at 22:10 PM reflected, "Medical consult for DM (Diabetes Mellitus) and medical clearance...Levemir 13 units SC (subcutaneous) twice daily... telephone orders from Staff #7..."

The undated History and Physical completed by Staff #6 reflected, "Past medical history...has a complicated diabetic program, on Levemir twice a day and a very regimented sliding scale and diet issues...has Asthma, Gastrointestinal Reflux Disease, Allergic Rhinitis, Depression ...plan...psychiatric evaluation and stabilization...we will continue home medications, sliding scales, and proper diet....I talked to him aggressively about following his home regimen..." No physician's orders were found which indicated the patient was ordered home medications which included Advair and Prevacid.

The physician orders dated 06/23/12 timed at 18:45 PM reflected, "Transfer to Medical Hospital)....or emergency room of parents choice to evaluate pulmonary condition..." (Patient #1) was sent to the ED on 06/24/12 not 06/23/12.

The MAR (Medication Administration Record) dated 06/24/12 reflected, "Imodium 4 mg (milligrams) at onset of diarrhea then 2 mg po (by mouth) q4 hr (every four hours) prn (as needed) for diarrhea...medication given at 15:50 PM..."

The Interdisciplinary progress note dated 06/24/12 timed at 15:50 PM reflected, "Pt complaining of upset stomach and diarrhea. Pt given Imodium 4 mg ...will continue to monitor for safety...at 18:20 PM...mother called regarding patient meds (medications) explained to mother patient had not been given some of his medications for asthma..."

The Interdisciplinary progress note dated 06/24/12 timed at 18:45 PM reflected, "Pt in lobby with staff and family...pt c/o (complaining of) being light headed...asked patient if he thought his blood sugar was low and replied yes...blood sugar done by patient and father in lobby with staff and fire department present...blood sugar was 255...patient started breathing hard and fell into father's arms...father placed patient on floor and talked to him while fire the department took vitals and oral history...pt continued to breathe hard ...patient was loaded onto a gurney and taken away via ambulance..."

The ED (Emergency Department) medical record reflected the following;

The American Medical Response Pre-Hospital Care Report dated 06/24/12 timed at 18:59 PM reflected, "Pt states abdominal pain times 2 days...abdominal pain/discomfort 10 on scale of 10 ...medication list given to (medical hospital ED)..."

The Medical Hospital's ED (Emergency Department) medical record dated 06/24/12 timed at 19:40 PM reflected, "Abdominal pain x (times) 2 (two) d (days)...positive for n/v (nausea/vomiting)...(psychiatric hospital)...did not give meds...Zofran 4 mg IV (Intravenous) ...blood sugar 248...medical history...Diabetes Mellitus, Asthma and GERD...[AGE] year old presents with history of DM (Diabetes Mellitus)...with abdominal pain times two days ...positive for pallor...positive for vomiting, shaking...patient also had asthma attack given two puffs of inhaler with improvement...(psychiatric hospital) lost list of medications so patient was not receiving meds (medications) since admission to (psychiatric hospital)...medications administered Levemir 13 units SQ (subcutaneous) at 23:47 PM, Zyrtec 5 mg po, Prevacid 30 mg po, Celexa 20 mg po, Lithium 300 mg po and Seroquel 600 mg po given at 23:39 PM...parents signed AMA..."

On 07/03/12 at 12:00 Noon Staff #3 was interviewed. Staff #3 stated (Patient #1) was sent out to the hospital on [DATE]. At 12:15 PM Staff #3 said the nursing staff and the physicians did not follow through on ordering (Patient #1's) home medications which included Prevacid and Advair. Staff #3 stated everyone was focused on (Patient #1's) diabetes not the other medications he had been taking at home.

On 07/05/12 at 09:45 AM Staff #7 was interviewed. Staff #7 stated over the weekend he was contacted about (Patient #1's) respiratory system. Staff #7 said he was informed (Patient #1) was about to have a breathing attack. Staff #7 stated the nurse told him the parents felt like their son was about to have a breathing attack and wanted him sent to the medical hospital. Staff #7 stated the physicians and nursing personnel missed the patient's medical medications. Staff #7 stated the focus was on the patient's diabetes.

On 07/10/12 at 12:40 PM Staff #6 was interviewed by telephone. Staff #6 stated he remembered (Patient #1) had multiple medical problems. Staff #6 stated the focus after talking to the nursing staff was (Patient #1's) diabetes, carbohydrate counts and blood sugar checks. Staff #6 stated he typically orders home medications but could not remember if he did in this case. The surveyor informed Staff #6 he documented home medications would be continued. Staff #6 stated he must have been focused on the patient's diabetes.

The Medical Staff Bylaws dated 12/03/12 reflected, "The purpose of the Medical Staff are to ensure that all patients receiving treatment from the Facility receive uniform quality patient care...to provide oversight of care, treatment, and services provided by practitioners with privileges, provide a uniform quality of patient care, treatment and services, and report to and be accountable to the Governing Board..."
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review the hospital failed to ensure 1 of 1 RN (Registered Nurse) Staff #5 supervised LVN (Licensed Vocational Nurse) Staff #8 and/or evaluated (Patient #1's) condition. Staff #5 was unaware (Patient #1) complained of a stomach ache and had diarrhea on 06/24/12 at 15:50 PM.

Findings included:

The pre-admission exam and certification dated 06/22/12 timed at 19:28 PM reflected, "Yesterday pt (patient) grabbed his brother at the back of the neck and pushed his face down into his food ...also shoved brother into wall and charged at his step-father last night ...pt increasingly aggressive over the last two days at home...medications Advair 250/50 BID (twice a day), Singulair 10 mg (milligrams) po (by mouth) daily...Nasonex 25 mg...sprays every day...Zyrtec 10 mg po hs (hour of sleep), Intuniv 4 mg (milligrams) po (by mouth) daily, Levemir 13 units subcutaneous bid, Prevacid 30 mg po bid, Lithium 300 mg po bid, Seroquel XR 300 mg po bid, Celexa 20 mg po hs, Humalog 1 to 10 carb ratio and inhaler 15 minutes before physical activity or going outside ...Axis III ... Asthma, Type I Diabetes, GERD (Gastrointestinal Esophageal Reflux Disease)..."

The undated History and Physical completed by Staff #6 reflected, "Past medical history...has a complicated diabetic program, on Levemir twice a day and a very regimented sliding scale and diet issues...has Asthma, Gastrointestinal Reflux Disease, Allergic Rhinitis, Depression ...plan...psychiatric evaluation and stabilization...we will continue home medications, sliding scales, and proper diet....I talked to him aggressively about following his home regimen..."

The MAR (Medication Administration Record) dated 06/24/12 reflected, "Imodium 4 mg (milligrams) at onset of diarrhea then 2 mg po (by mouth) q 4 hr (every four hours) prn (as needed) for diarrhea...medication given at 15:50 PM..."

The physician orders dated 06/23/12 timed at 18:45 PM reflected, "Transfer to (Medical Hospital)... or emergency room of parents choice to evaluate pulmonary condition..." (Patient #1) was sent to the ED on 06/24/12 not 06/23/12.

The Interdisciplinary progress note dated 06/24/12 timed at 15:50 PM By Staff #8 reflected, "Pt complaining of upset stomach and diarrhea. Pt given Imodium 4 mg ...will continue to monitor for safety...at 18:20 PM...mother called regarding patient meds (medications) explained to mother patient had not been given some of his medications for asthma..."

The Interdisciplinary progress note dated 06/24/12 timed at 18:45 PM documented by Staff #5 reflected, "Pt in lobby with staff and family...pt c/o (complaining of) being light headed...asked patient if he thought his blood sugar was low and replied yes...blood sugar done by patient and father in lobby with staff and fire department present...blood sugar was 255...patient started breathing hard and fell into father's arms...father placed patient on floor and talked to him while fire department took vitals and oral history...pt continued to breathe hard ...patient was loaded onto a gurney and taken away via ambulance..."

The ED (Emergency Department) medical record reflected the following;

The American Medical Response Pre-Hospital Care Report dated 06/24/12 timed at 18:59 PM reflected, "Pt states abdominal pain times 2 days...abdominal pain/discomfort 10 on scale of 10 ...medication list given to (medical hospital ED)..."

The Medical Hospital's ED (Emergency Department) medical record dated 06/24/12 timed at 19:40 PM reflected, "Abdominal pain x (times) 2 (two) d (days)...positive for n/v (nausea/vomiting)...(psychiatric hospital)...did not give meds...Zofran 4 mg IV (Intravenous) ...blood sugar 248...medical history...Diabetes Mellitus, Asthma and GERD...[AGE] year old presents with history of DM (Diabetes Mellitus)...with abdominal pain times two days ...positive for pallor...positive for vomiting, shaking...patient also had asthma attack given two puffs of inhaler with improvement...(psychiatric hospital) lost list of medications so patient was not receiving meds (medications) since admission to (psychiatric hospital)...medications administered Levemir 13 units SQ (subcutaneous) at 23:47 PM, Zyrtec 5 mg po, Prevacid 30 mg po, Celexa 20 mg po, Lithium 300 mg po and Seroquel 600 mg po given at 23:39 PM...parents signed AMA..."

On 06/29/12 at approximately 03:00 PM Staff #8 was interviewed. Staff #8 was asked to review (Patient #1's) medical record. Staff #8 stated she gave (Patient #1) Imodium for complaints of an upset stomach and diarrhea.

On 07/10/12 at 04:00 PM Staff #5 was interviewed. Staff #5 was asked whether (Patient #1) became ill prior to (Patient #1's) transfer to the emergency room on 06/24/12. Staff #5 stated not that he was aware of. Staff #5 was asked whether the LVN he worked with reported to him (Patient #1) was complaining of a stomach ache, diarrhea and was administered Imodium. Staff #5 stated, "No I did not." Staff #5 said (Patient #1) returned from the GYM and then was taken to visitation. Staff #5 stated he was called out to the lobby during visitation as the patient had vomited with his step-father present. Staff #5 said the patient's step-father was upset. Staff #5 stated the patient was sent to the medical hospital.

The policy entitled, "Services Nursing" with the issue date of 11/15/10 reflected, "The RN will supervise and evaluate nursing care for each patient and assign the nursing care to other nursing personnel in accordance with patient needs and staff qualifications and competency..."

The policy entitled, "Documentation Requirements with an effective date of 11/01/10 reflected, "Documentation in the medical record must be sufficient to...justify the treatment, document the course and results and promote continuity of care among providers..."

The Standards of Nursing Practice Title 22, Part II, Chapter 217, Rule 217.11 reflected, "Standards Specific to Vocational Nurses. The licensed vocational nurse practice is a directed scope of nursing practice under the supervision of a registered nurse...Standards Specific to Registered Nurses. The registered nurse shall assist in the determination of healthcare needs of clients and shall...evaluating the client's responses to nursing interventions...implementing nursing care..."