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 Nov. 21, 2014
VIOLATION: PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION Tag No: A0123
Based on interview and record review, it was determined the hospital failed to ensure 1 of 10 patients (Patient #2's) guardian and/or responsible party was provided written notice regarding the results of a grievance filed regarding (Patient #2's) hospital inpatient stay.

Findings Included:

The grievance complaint logs revealed an undated complaint/grievance sent to the hospital from (Patient #2's) Guardian regarding concerns he had during (Patient #2's) inpatient stay in May 2014.

A hospital letter addressed to (Patient #2's) guardian dated 05/28/14 reflected, "I recently received a letter from you regarding your grievance related to your child's stay this letter serves as a follow-up to our initial telephone conversation on 05/28/14...we will be investigating and addressing the items listed in your letter...a follow-up letter will be sent once we conclude the investigation...signed by Personnel #1."

On 11/21/14 at 1125 Personnel #1 was interviewed. Personnel #1 was asked to provide evidence that a follow-up letter was sent to (Patient #2's) Guardian which addressed his written complaint/grievance he sent to the hospital. Personnel #1 stated she could not provide evidence that a follow-up letter was sent to (Patient #2's) Guardian which addressed his concerns.
VIOLATION: PATIENT RIGHTS: EXERCISE OF RIGHTS Tag No: A0129
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview the hospital failed to ensure the rights of minors to receive inpatient services in an area separated from adult patients for 1 of 14 adolescent patients (Patient #26) in that Patient #26 was able to exchange a written note with an adult patient (Patient #3) and experienced a worsening of psychiatric symptoms after staff took the note away.

Findings Included:

Patient #26, [AGE], was admitted on [DATE] and discharged on [DATE]. Patient #26 was admitted for increased mood instability and self-harming behavior. Prior to hospitalization had auditory and visual hallucinations, felt hopeless and helpless. The patient had a history of self-mutilation behavior multiple suicide attempts.

Patient #26's nursing documentation dated 08/26/14 timed at 2106 noted that Patient #26 "...was writing love notes to an adult patient on...unit...staff took notes away... pt [Patient #26] became very agitated...crying...wouldn't leave the...[nursing] station and kept asking for letters back...ripped decor off ceiling and kept trying to scratch arm with nails..." The hospital provided an undated handwritten note which reflected, "...I miss you every time your [you are] on the unit and go to dinner..."

Patient #3's face sheet noted the [AGE] year old patient was admitted on [DATE] and discharged on [DATE]. A document titled "Inpatient Child/Adolescent Nursing Admission Assessment" noted Patient #3 was admitted for Suicidal Ideation with a plan to cut or strangle herself.

On 08/26/14 at 20:00 nursing documentation reflected Patient #3 "...was moved ...because she and an adolescent girl was [were] passing notes."

Personnel #4 stated on 11/21/14 at approximately 10:00 that in August 2014 overflow PICU (Psychiatric Intensive Care Unit) patients (adults) were housed in a unit next to the adolescent girls unit. Personnel #4 stated that adult patients had to go through the adolescent unit in order to go to dinner or attend groups, and stated the only other exit was an emergency escape to the hospital's parking lot.

The Hospital Patient Rights Policy dated 10/15/11 noted "...the special rights of minor receiving inpatient mental health services included the right to receive inpatient services in an area separated from adults receiving services..."