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SUNDANCE HOSPITAL 7000 US HIGHWAY 287 ARLINGTON, TX 76001 Oct. 29, 2014
VIOLATION: MAINTENANCE OF PHYSICAL PLANT Tag No: A0701
Based on observation and interview the hospital failed to ensure the physical plant and/or hospital environment was maintained in an effective and safe manner for 2 of 4 patient care units (PICU (Psychiatric Intensive Care Unit) and the Adult General Psychiatric Unit). This practice placed patients and staff at risk for injury.

Findings Included:

On 10/29/14 at 1630 observation rounds were conducted on the PICU (Psychiatric Intensive Care Unit) with Staff #3 and Staff #4. The following observations were made:

The TV (television) room on the PICU Unit had a flat screen TV attached to the wall. The cable box with a long attached cord was observed hanging from the TV. The box was left dangling from the TV and was resting on top of the table.

The floor of the TV room was soiled with debris and dirt. The floor had a brown sticky substance and stains on the floor of the room.

The storage closet located in the TV room was inspected. The floor of the room had greater than 10 large plastic bags stored on the floor of the room. Personal items which included clothes were scattered on the floor of the room. Staff #3 stated the room was supposed to be kept clean and all the items kept off the floor. Staff #3 verified the room needed cleaning.

The clean linen room was inspected. The room had a soiled geri-chair and a soiled wheelchair stored with the clean linen. Staff #3 verified the above findings.

On 10/29/14 at 1705 the Adult General Psychiatric Unit was observed with Staff #4. The following observations were made:

A metal shelf unit was observed against the wall in the day area. The interior shelves were stained/dirty and needed cleaning.

Two large sectional couches and two smaller couches were observed in the day area. The vinyl cushions on the furniture was torn and split.

The nursing station entrance from the day area was observed. The formica which covered the counter ledge which separated the day area from the nursing station was cracked and broken. A large piece of formica was missing leaving sharp edges and exposed wall board underneath.

On 10/29/14 at 1730 Staff #4 acknowledged and verified the above observations.
VIOLATION: PATIENT RIGHTS: PRIVACY AND SAFETY Tag No: A0142
Based on observation, interviews and record review the hospital failed to provide a safe environment and ensure privacy was provided for patients admitted to 2 of 4 patient care units. The PICU (Psychiatric Intensive Care Unit) and the Adult General Psychiatric Unit in that,

1) admitted patients to the PICU Unit and the Adult General Psychiatric Unit from 10/19/14 through 10/23/14 exceeded the allowed bed capacity of 28 beds for each unit. Patient privacy was not provided for five consecutive days. Patients slept on the couches and in the seclusion rooms. This practice placed patients and/or staff at risk for injury due to overcrowding.

2) Current Safety concerns were observed on the PICU Unit and the Adult General Psychiatric Unit during the survey on 10/29/14.

Findings Included:

1) The Census Reports for the Adult General Psychiatric Unit dated 10/19/14 through 10/23/14 reflected the following:

The 10/19/14 census report reflected, "30" inpatients (2) over the 28 bed capacity.

The 10/20/14 census report reflected, "31" inpatients (3) over the 28 bed capacity.

The 10/21/14 census report reflected, "32" inpatients (4) over the 28 bed capacity.

The 10/22/14 census report reflected, "34" inpatients (6) over the 28 bed capacity.

The 10/23/14 census report reflected, "33" inpatients (5) over the 28 bed capacity.

The Census Reports for the PICU Unit dated 10/19/14 through 10/23/14 reflected the following:

The 10/19/14 census report reflected, "30" inpatients (2) over the 28 bed capacity.

The 10/20/14 census report reflected, "31" inpatients (3) over the 28 bed capacity.

The 10/21/14 census report reflected, "31" inpatients (3) over the 28 bed capacity.

The 10/22/14 census report reflected, "31" inpatients (3) over the 28 bed capacity.

The 10/23/14 census report reflected, "29" inpatients (1) over the 28 bed capacity.

On 10/28/14 at 1600 Staff #3 was interviewed. Staff #3 stated the hospital received some admissions from another hospital during the above dates. Staff #3 stated patients had to sleep on couches and some in the seclusion rooms on a mattress. Staff #3 stated the patients had to sleep like this until discharges occurred the next day. Staff #3 stated this practice was a patient right issue and any patient admitted to the unit was supposed to have a bed. Staff #3 stated the 28 bed capacity should not have been exceeded.

On 10/29/14 at 1030 Staff #1 was interviewed. Staff #1 stated the hospital should not have exceeded the bed capacity on the units and not admitted those patients. Staff #1 stated he accepts full responsibility.

2) On 10/29/14 at 1630 observation rounds were conducted on the PICU Unit with Staff #3 and Staff #4. The following observations were made:

The TV (television) room on the PICU Unit was observed. The built in cabinets had metal handles on the upper and lower cabinets. There were greater than 15 handles in total. The PICU patients were at risk for self harm behaviors. Staff #3 stated she was aware of the self harm risk.

Room 106 Bed B had (7) plastic spoons and (1) fork in the top drawer of a nightstand on wheels. The night stand had removable drawers and the exterior surface of the drawer had large metal handles. Staff #4 verified the findings.

Room 102 was observed with (2) beds with metal side rails which when in the upright position had to be manually lowered. The side rails placed PICU patients at risk for self-harm behavior. Staff #4 verified the observation.

The nursing station was open to the PICU patients observed lined up at the desk. A black phone was sitting on top of the desk and had approximately 3-4 feet of cord attached. The cord was available and within the reach of patients standing at the desk. Staff #3 verified the observation.

The nursing station had an open entrance area. The entrance was accessible to patients. A small 3 drawer plastic unit was observed. The first drawer of the unit had greater than 10 long shoe strings inside the drawer. Staff #5 stated the shoe strings should not be in the drawer and that they were accessible to the patients.

The Adult General Psychiatric Unit was observed at 1705 with Staff #4. The following was observed:

Room 212 was observed. Two plastic handles were sitting on the shelf of the wardrobe. Staff #4 stated the handles were from a plastic valuables bag and stated she wondered where the plastic bag was. The bathroom had a thick large rubber band sitting on the bathroom sink. The surveyor removed the items and handed them to Staff #5. Staff #5 verified the items were not allowed. The surveyor asked where the safety check sheet was for the day. Staff #5 stated a safety check record had not been completed.

On 10/29/14 at 1730 Staff #3 and Staff #4 verified the above observations found on the PICU Unit and the Adult General Psychiatric Unit.

The policy and procedure entitled, "Patient Rights and Responsibilities" with an issue date of 11/15/10 reflected, "The patient and/or family has the right, within the law, to personal....privacy, personal safety...and the patient has the right to expect reasonable safety in so far as the hospital practices and environment are concerned..."
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
Based on interview and record review the hospital failed to ensure 1 of 11 patients (Patient #5) was evaluated and/or assessed by an RN (registered nurse) for two consecutive days 10/22/14 and 10/23/14 while receiving inpatient psychiatric services for depression and suicidal ideations.

Findings Included:

(Patient #5's) Client Face Sheet reflected, "Patient #5 was admitted to the hospital 10/21/14 at 0927..."

(Patient #5's) Psychiatric Evaluation dated 10/23/14 reflected, "Presents secondary to worsening depression and suicidal ideation ...has had suicidal ideation with thoughts of cutting himself with a razor...patient is paranoid and feels that people are after him..."

(Patient #5's) Nursing Shift Assessment and Progress Notes were reviewed and revealed no nursing assessment for 10/22/14 and 10/23/14.

On 10/29/14 at approximately 1715 Personnel #3 was interviewed. Personnel #3 stated no nursing assessment was found for 10/22/14 and 10/23/14.

The policy and procedure entitled, "Assessment and Reassessment of Patients" with an issue date of 11/15/10: reflected, "An accurate record of the patient's condition, care, and treatment is provided throughout the hospital visit ....an RN (registered nurse) will reassess the patient based on the patient needs, but at least 12 hours after the initial comprehensive nursing assessment has been completed..."