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SUNDANCE HOSPITAL 7000 US HIGHWAY 287 ARLINGTON, TX 76001 Oct. 18, 2013
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
Based on interview and record review the hospital failed to ensure 1 of 4 patients (Patient #1) was evaluated/reassessed by the RN (Registered Nurse) and/or ensured vital signs were obtained when a change of condition was identified.

Findings Included:

The Discharge Summary dated 09/14/13 timed at 12:30 PM reflected, "(Patient #1) suffered a consequence of a level drop after eating peers snack...prone to irritability with peers to include aggressive and bullying behaviors...at times still prone to regress episodes...still prone to behaviors that included trying to intimidate, provoke, and bully younger peers, but with decreased intensity and severity..."

The physician's orders dated 08/23/13 timed at 07:00 AM reflected, "Give Phenergan IM (intramuscular) now for nausea/vomiting...Phenergan 25 mg (milligrams) po (by mouth) every 6 hr (hours) prn (as needed) for nausea and vomiting..."

The physician's orders dated 08/23/13 timed at 10:30 AM reflected, " Imodium two mg po every 4 hours prn for diarrhea..."

The nursing shift assessment and progress note dated 08/23/13 timed at 10:38 AM reflected, "Complains of nausea/vomiting times one and diarrhea times one...at 14:20 PM notified Step-mother of emesis and diarrhea times two...gave consent for imodium 2 mg at 14:09 PM...at 19:40 PM...participates in group..." It was noted no vital signs and/or follow-up assessment documentation was found after the administration of the above medications.

The nursing shift assessment and progress note dated 08/24/13 at 01:00 AM reflected, "Phenergan 25 mg po given for nausea/vomiting..." No vital signs and/or assessment related to the nausea and/or vomiting was documented.

The nursing shift assessment and progress note dated 08/25/13 timed at 04:00 AM reflected, "Up to nursing station complaining of nausea...medicated with phenergan 25 mg po...reported diarrhea times two...had diarrhea times three...given imodium 2 mg po..." No follow-up re-assessment and/or vital signs were obtained.

The MAR (medication administration record) dated 08/25/13 timed at 13:30 PM reflected, "Imodium 2 mg po every four hours as needed...given."

The nursing shift assessment and progress note not timed dated 08/25/13 reflected, "Imodium 2 mg given for diarrhea..." No vital signs and/or re-assessment documentation was found.

The nursing shift assessment and progress note dated 08/26/13 timed at 18:50 PM reflected, "Patient complaining of diarrhea...2 mg imodium given...also complaining of stomach pain and nausea..." No vital signs and/or reassessment documentation was found.

The nursing shift assessment and progress note dated 08/27/13 timed at 05:00 AM reflected, "Vomited times one...07:00 AM...reported his stomach hurt...08:00 AM...stomach still hurts...14:00 PM...complains of nausea provided water..." No vital signs were documented.

On 10/18/13 at 03:10 PM Personnel #6 was interviewed. Personnel #6 was asked to review (Patient #1's) medical record. Personnel #6 verified nursing personnel did not take (Patient #1's) vital signs and/or reassess (Patient #1) after receiving medications for complaints of nausea/vomiting and diarrhea.

The policy and procedure entitled, "Assessment and Reassessment of Patients" with an issue date of 11/15/10 reflected, "Vital signs and the completion of other gathering may be assigned to other nursing staff...reassessment of patients are to be completed when there is a significant change in patient condition..abnormal, or non-standard responses and treatments are documented in detail...assessment/reassessment data and patient response to the intervention may be included..."