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 May 27, 2015
VIOLATION: PATIENT RIGHTS Tag No: A0115
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observations, interviews and records review, the hospital failed to ensure a safe environment for 2 of 4 units (Psychiatric Intensive Care Unit and Male Adolescent Unit).


A) 28 of 28 beds on the PICU Unit (Psychiatric Intensive Care Unit) had side rails which were ligature risk for mentally unstable patients. A telephone cord greater than two feet in length and a pencil sharpener with an attached cord was available and within easy reach to current inpatients. 1 of 1 medication cart was open and left unsecured on the PICU Unit. A chisel and box cutter were left unattended by workers and were easily available for self-harm behavior on the PICU Unit. This practice placed patients at risk for self-harm behavior.

(Refer to A144)


B) Observation rounds records for 4 of 4 patients (Patient #8, #9, #10 and Patient #11) were left blank and did not document patient location and/or behavior for 2 of 4 units (PICU Unit and the Adolescent Boys Unit).

(Refer to A144)


C) 1 of 1 patient (Patient #3) was placed on LOS (line of sight) observation on 01/23/15. The patient was found in the bathroom with a plastic bag over her head and tied around her neck. Assigned nursing personnel did not ensure line of sight observation was maintained for Patient #3. Patient #3 had to be resuscitated and was sent to the an acute care hospital on [DATE].

(Refer to A144)


Based on observations, interviews and record reviews, it was determined that the deficient practices found posed an immediate jeopardy to the health and safety of patients, and resulted in actual harm to Patient #3. The hospital failed to ensure patients received care in a safe setting in that patients were not provided appropriate level of observation. There were ligature risks and/or self harm materials easily available for current patients.
VIOLATION: PATIENT RIGHTS: TIMELY REFERRAL OF GRIEVANCES Tag No: A0120
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review, the hospital failed to ensure that patient complaints and/or grievances were investigated and/or resolved for 2 of 2 patient/family complaints (Patient #1 and #5).

Findings included:

1) Patient #1's Behavioral Health Integrative Psychiatric assessment dated 07/26/14 timed at 1310 reflected, "Age 8 anger outbursts, physical aggression, anxiety, and mood swings..."

A Telephone Statement dated 08/12/14, timed at 1617, documented by Personnel #30 reflected, "Discussed concerns with Guardian...08/07/14 saw marks on patients side of neck, nail marks and bruising shaped like fingers and that patient had told her he was acting up and trying to hit staff and that the MHT (mental health technician) grabbed him by the neck and held him down on the bed...assured Guardian her concerns were valid and the information will be investigated, apologized for the lack of follow through and that it is not acceptable for patient to have marks on their neck..."

On 05/27/15, at 1220, Personnel #7 was interviewed. Personnel #7 was asked if an event report was completed for Patient #1 regarding marks, scratches, bruises and/or discoloration to Patient #1's neck. Personnel #7 stated "no."

On 05/27/15, at 1245, Personnel #30 interviewed. Personnel #30 provided some notes that she wrote up regarding Patient #1's Guardian's concerns. Personnel #30 stated she saw Patient #1's neck the day he was discharged . Personnel #30 said that Patient #1 had some scratches on the side of his neck it appeared as if there was a bruise. Personnel #30 stated she informed the nurse Personnel #28 and Personnel #28 looked at Patient #1's neck. Personnel #30 stated Patient #1's Guardian reported it happened earlier in the week. Personnel #30 said she reported the Guardian's concerns to Personnel #38. Personnel #30 provided the surveyor some notes she had taken but said she could find no documentation which indicated Patient #1's guardian was provided a follow-up letter or communication regarding the findings of her complaint/grievance. Personnel #30 stated the only other documentation she found was a response to a secondary agency's inquiry. Personnel #30 stated the event should have been investigated.

On 05/27/15, at 1536, Personnel 28 was interviewed. Personnel #28 was asked to review Patient #1's medical record. Personnel #28 stated when Patient #1 was discharged he remembered a small bruise, scratch, marks or discoloration on his neck. Personnel #28 stated his memory was not the best. Personnel #28 was asked if he documented/assessed the bruise, scratch or discoloration. Personnel #28 stated he did not.


2) Patient #5's Face Sheet reflected the patient's hospital admission on 03/26/15 and discharge on 03/30/15. The patient was 9 years old. Final diagnoses included Episodic Mood Disorder and Encopresis.

Nursing Shift assessment dated [DATE], at 1400, by Personnel #7 reflected Patient #5's family stated the patient was "bullied and threatened by peers..." and demanded immediate patient discharge. The notes timed at 18:45 reflected Personnel #7 received a phone call from Patient #5's family member who stated the patient "...was being slapped by other patient...assured them...[Patient #5] had not been abused, beaten, or bullied and was under the direct care of this nurse."

Physician Daily Progress Notes dated 03/29/15, at 1130, noted Patient #5 reported that "one male peer [was] pushing him onto the couch."

On 05/22/15, at 12:30, Personnel #7 was interviewed and stated Patient #5 did not get slapped. When asked how she can be sure the event did not happen, Personnel #7 stated she was the house supervisor and assigned RN to Patient #5's unit "that day" and her name "should have been on the staffing sheet."

Personnel #2 denied during a telephone interview on 06/04/15, at 1615, that there was an investigation or an incident report about the alleged physical altercation involving Patient #5.

The policy and procedure entitled "Grievance Process" with an issue date of 11/15/2010, reflected, "A patient grievance is a written or verbal complaint by a patient, or the patient's representative, regarding the patient's care, abuse, or neglect, issues...hospital shall take action to resolve all grievances promptly and fairly...document all grievances, including final disposition...designated unit/department representative should attempt to contact the complainant within two (2) business days but not more than seven (7) days to acknowledge the concern and verify the problem...efforts should be made to resolve the problem within seven days...the department manager or director or representative should review the concern, take action to address the concern and follow-up with the person reporting the concern...hospital shall review, investigate and resolve each patient's grievance within a reasonable time frame."
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observations, interviews and records review, the hospital failed to ensure 3 of 4 units (Psychiatric Intensive Care Unit, Male Adolescent Unit, and Female Pediatric Unit) provided a safe environment.


1) 28 of 28 beds on the PICU Unit (Psychiatric Intensive Care Unit) had side rails which were ligature risk for mentally unstable patients. A telephone cord greater than two feet in length and a pencil sharpener with an attached cord were easily available and within easy reach to current inpatients. 1 of 1 medication cart was open and left unsecured on the PICU Unit, any patients could have easily accessed the medications stored in the cart. A chisel and box cutter were left unattended by workers, and were available to patients for self-harm behavior on the PICU Unit. A converter cable was observed in easy reach of patients on the female pediatric unit. These condition presented a likelihood of harm to patients.


2) Observation rounds records for 4 of 4 patients (Patient #8, #9, #10 and Patient #11) were left blank and did not document patient location and/or behavior for 2 of 4 units (PICU Unit and the Adolescent Boys Unit).


3) 1 of 1 patient (Patient #3) was placed on LOS (line of sight) observation on 01/23/15. The patient was found in the bathroom with a plastic bag over her head and tied around her neck. Assigned nursing personnel failed to maintain the line of sight observation for Patient #3. Patient #3 had to be resuscitated and was sent to an acute care hospital on [DATE].


Findings included:


1) On 05/22/15, from 1515 to 1550, observation rounds were conducted on the PICU Unit (psychiatric intensive care unit) with Personnel #14. A telephone was observed sitting on the desk counter with greater than two feet of telephone cord attached. A pencil sharpener with an attached cord was sitting on the desk easily available to current inpatients standing at the desk. A medication cart was observed sitting in the middle of the nursing station. The cart was unlocked. The surveyor opened the drawers and medications were stored inside the cart. Medications could be easily accessed by anyone passing by. The key to the cart was sitting on the top drawer. The above observation was verified by Personnel #14. At 1525, a portable air-conditioning unit with an exposed electrical cord of approximately two-and-one-half feet in length was observed next to Patient Room 109. At 1550, the surveyor observed patient beds with side rails. Personnel #16 was asked to count the number of beds on the unit with side rails. Personnel #16 stated all 28 beds had side rails. Personnel #16 verified the side rails posed a ligature risk.

On 05/22/15, at 1609, Personnel #2 was interviewed. Personnel #2 was asked about the bed rails on the PICU Unit. Personnel #2 stated patients could hang themselves on the bed rails.

On 05/26/15, at approximately 1500, Personnel #19 was asked about the portable air-conditioning (AC) unit on PICU Unit observed on 05/22/15. Personnel #19 stated the portable AC unit ("swamp cooler") was used when patient rooms were converted to individual AC units and "should have been removed." Personnel #19 acknowledged the portable AC Unit had a long cord.

On 05/26/15, at 1314, observation rounds were conducted on the PICU Unit. Personnel #11 was standing behind the nursing station. Repairs and/or construction was observed on the unit. Personnel #11 was asked "why the patients have access to the construction area while the construction workers were working." Personnel #11 did not offer an explanation. The construction worker had use of a sheet rock chisel and a box cutter. The worker turned his back and left the items on top of a toolbox. The items were left out of the worker's line of sight as he turned his back and faced the wall. Rounds records were reviewed for Patient #8 and revealed no rounds were completed for 30 minutes and Patient #9's rounds record revealed 45 minutes with no rounds documented.

On 05/26/15, at 1540, a converter cable was observed stuck half-way underneath a TV (television) in the female pediatric unit's common room. Five female patients were observed close by. Personnel #2 removed the cable at that time.


2) Patient #8's Behavioral Health Integrative Psychiatric assessment dated [DATE], timed at 1845, reflected, "22 year old...from hospital...bizarre, paranoid and erratic behavior...has paranoia, grandiose..."

The physician's orders and preliminary plan of care dated 05/25/15, timed at 2150, reflected, "Precautions...assaultive, detox, suicide...level of observation Q (every) 15 minutes..."

The 05/26/15, Patient Rounding: Hourly, 15 Minute and 1:1 Precaution Checklist reflected, "1300 and 1315" rounds were left blank with no patient location and/or behavior documented.

On 05/26/15, at 1317 Personnel #31 verified the above findings.


Patient #9's Behavioral Health Integrative Psychiatric assessment dated [DATE], timed at 1545, reflected, "[AGE] year old presented on an OPC (order of protective custody) for threatening to burn down his families house..."

The physician's orders and preliminary plan of care dated 05/22/15, timed at 1700, reflected, "Precautions suicide...level of observation...Q (every) 15 minutes..."

The 05/26/15, Patient Rounding: Hourly, 15 Minute and 1:1 Precaution Checklist reflected, "1245, 1300, 1315" rounds were left blank with no patient location and/or behavior documented.

On 05/26/15, at 1317 Personnel #31 verified the above findings.

On 05/26/15, at 1330, observation rounds were conducted on the Adolescent Boys Unit with Personnel #25. The observation rounds record for Patient #10 and Patient #11 revealed patient rounds were not completed for 30 minutes.


Patient #10's Behavioral Health Integrative Psychiatric assessment dated [DATE], timed at 0100, reflected, "[AGE] year old male...put a knife to his chest and told officers he was going to kill himself...reports being depressed..."

The physician's order dated 05/26/15, timed at 0100 reflected, "Suicide precautions..."

The 05/26/15, Patient Rounding Hourly, 15 Minute and 1:1 Precaution Checklist reflected, "1315 and 1330...watch this patient." The rounds record was left blank with no patient location and/or behavior documented.

On 05/26/15, at 1331 Personnel #32 verified the above findings


Patient #11's Behavioral Health Integrative Psychiatric assessment dated [DATE], timed at 2034 reflected, "[AGE] year old male...visual and auditory hallucinations...laughs as a response to internal stimuli..."

The physician's orders dated 05/26/15, timed at 0100 reflected, "Suicide precautions..."

The 05/26/15, Patient Rounding: Hourly, 15 Minute and 1:1 Precaution Checklist reflected, "1315, 1330." The rounds record was left blank with no patient location and/or behavior documented.

On 05/26/15, at 1332 Personnel #32 verified the above findings.


3) Patient #3's medical hospital History and Physical dated 01/22/15, timed at 1120, reflected, "33 year old...suicidal behavior, exhibits a depressed mood and suspected overdose...helpless, hopeless...condition...serious requires further inpatient care...transfer to...psychiatric hospital."

The Physician's MOT (Memorandum of Transfer) Orders and Preliminary Plan of Care dated 01/22/15, timed at 1354 reflected, "Precautions suicide...major depressive disorder, recurrent episode."

The Behavioral Health Integrative Psychiatric assessment dated [DATE], timed at 1850, reflected, "Reports attempting to OD (overdose) on multiple pills "yesterday" and rushed to (acute care hospital)...depressed feeling suicidal with plan to overdose...loss of employment, separation with her husband...reports having constant thoughts of wanting to die during her depressed mood..."

The physician's orders dated 01/23/15, reflected, "LOS (line of sight) times 48 hours...noted by RN (registered nurse) on 01/23/15, timed at 1206."

The 01/23/15, nursing shift assessment and progress note timed at 0900, reflected, "Denies homicidal ideations, but states she has suicidal ideation does not have a plan at this time asked patient to sit in dayroom until psychiatrist comes to evaluate her..."

The 01/23/15, nursing shift assessment and progress note timed at 1206, reflected, "Patient put on line of sight for the next 48 hours...charge nurse notified...technician...patient sitting in day area awaiting lunch...1300...patient refused to go to lunch patient in dayroom laying on couch...1416...patient taking prescribed medication...states she will not do it here..."

The patient rounding...hourly, 15 minute and 1:1 precaution checklist dated 01/23/15, reflected, " Line of sight...1500, 1515 (shower room) walking...1530 (unknown behavior/location, could not read)..."

The nursing shift assessment and progress note dated 01/25/15, 1930 late entry for 01/23/15, reflected, "Housekeeping came running from women's side saying come quick...immediately went to follow housekeeper to room...walked into room patient sitting on the floor of shower fully clothed unresponsive...MHT (mental health technician) and myself moved her onto the floor...called code blue...transport to...(medical hospital)..."

The 01/23/15, physician's orders timed at 1535, reflected, "Transfer to...Hospital for evaluation following suicide attempt..."

On 05/26/15, at 0934, Personnel #2 was interviewed. Personnel #2 stated the line of sight was not done. Personnel #2 was asked how the line of sight could be done and every 15 minutes rounds completed on 13 other patients. Personnel #2 did not offer a response.

On 05/26/15, at 1044, Personnel #24 was interviewed. Personnel #24 stated she was on the adult unit on 01/23/15, cleaning patient rooms. Personnel #24 stated she decided to go to room 206 because one of the patients had been discharged . Personnel #24 stated she went to the room and entered the bathroom. Personnel #24 stated she entered the bathroom and sprayed the sink and then proceeded to walk to the shower. Personnel #24 stated she ran into some feet with socks on. Personnel #24 stated the shower stall curtain was closed and when she looked down she saw a pair of feet. Personnel #24 stated she opened the curtain and Patient #3 was slumped in the shower with a plastic bag over her head and tied around her neck. Personnel #24 said, the patient's mouth was open and the plastic bag had been sucked inward. Personnel #24 stated she ran out and hollered for the nurse. Personnel #24 was asked if any staff were watching the patient when she entered the room. Personnel #24 stated she did not see anyone.

On 06/01/15, at 2000, Personnel #18 was interviewed. Personnel #18 stated the unit was full and he was responsible for half of the observation rounds and the female technician was responsible for the other half of the rounds which included Patient #3 who was on line of sight. Personnel #18 stated it was not safe on the unit as the hospital expected the same amount of staff to monitor patients who are on line of sight plus complete Q 15 minute rounds on the rest of the patients.

On 06/01/15, at 2020, Personnel #17 was interviewed. Personnel #17 stated she had worked on the day shift 01/23/15. Personnel #17 stated clothes had been brought in for the patient during her shift. Personnel #17 stated she did rounds with the oncoming technician and made sure she was aware the patient was on line of sight precautions. Personnel #17 stated the technician was the only one she saw for the evening shift before she left. Personnel #17 stated on 01/23/15, the unit was full and they only had two technicians. Personnel #17 stated when a patient is placed on line of sight the patients are told to stay in the day area and are placed in the dayroom to sleep if there is not enough staff.


The Policy and Procedure entitled, "Patient Rights and Responsibilities" with an issue date of 11/15/10, reflected, "The patient has the right to expect reasonable safety in so far as the hospital practices and environment are concerned..."


The Policy and Procedure entitled, "Precaution/Patient Monitoring" with an issue date of 11/15/2010, reflected, "It is the policy of...hospital to provide a safe and secure environment...monitors and modifies the patient care environment so as to protect inpatients by providing furnishings that do not present safety hazards...objects that are identified as hazardous to the patient shall be secured or removed from the environment...purpose of precaution monitoring is to provide protection to the patient and to maintain a safe and therapeutic patient care environment...staff making rounds shall observe patients activity, whereabouts and document observations...patient's on line of sight (LOS) monitoring, shall stay in the visual view, or in the line of sight, of staff at all times."


The Policy and Procedure entitled, "Environmental Rounds and Unit Safety" with an issue date of 11/15/2010, reflected, "Safety is a primary concern of hospital staff...plastic bags are not allowed on the unit...all items brought for patients by visitors are searched at the nurse's station...nurses station is not left unattended...medications are secured in a locked medication room..."
VIOLATION: QAPI Tag No: A0263
Based on interview, and record review, the facility's quality improvement program failed to analyze and track/document adverse patient events for 3 of 3 pediatric and adolescent patients (Patient #1, #5 and #20) in that it failed to investigate when

1) Reported staff inflicted marks, bruising by Patient #1's Guardian which was reported to hospital personnel was not addressed and/or reported to the quality improvement program.

(refer to A 0286


2) Patient #20 who was noted without any bruising or pain upon admission was attacked by a fell ow patient and unexplained facial bruise was found during his hospital stay.

(refer to A 0286


3) Patient #5's family reported the patient had been shoved.

(refer to A 0286)
VIOLATION: PATIENT SAFETY Tag No: A0286
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview, and record review, the facility's quality improvement program failed to analyze and track/document adverse patient events for 3 of 3 pediatric and adolescent patients (Patient #1, #5 and #20) in that it failed to investigate when

1) Patient #1's Guardian reported to hospital personnel that Patient #1 sustained bruising, scratches, discoloration to the neck inflicted by hospital personnel.


2) Patient #20 who was noted without any bruising or pain upon admission, hurt his back and knee, was struck in his testicles by another patient, and acquired an unexplained facial bruise during his hospital stay.


3) Patient #5's family reported the patient had been shoved.


Findings included:


1) Patient #1's Behavioral Health Integrative Psychiatric assessment dated 07/26/14, timed at 1310, reflected, "Age 8 anger outbursts, physical aggression, anxiety, and mood swings..."

The 07/26/14, in-patient Child/Adolescent Nursing Admission Assessment timed at 1450, reflected, "Skin and body assessment...scar...mosquito bites to right lower leg."

The 08/07/14, nursing shift assessment and progress note reflected, "Patient got upset with staff because he wanted to sit in a certain chair, where another patient was already sitting...patient told to go to his room to calm down, patient began to hit and kick staff while screaming (cussing)...began to deescalate while laying down in his room...suddenly patient ran out of his room and charged another patient by trying to push him down...patient still kicking and screaming...tried to calm patient down in the quiet room, attempt was unsuccessful called physician for an order for medication...Thorazine 50 mg, Benadryl 25 mg (milligrams), got consent from grandmother...shot administered." No documentation was found which indicated any bruises, marks and/or discoloration was observed on Patient #1's neck.

The 08/08/14, nursing shift assessment and progress note timed at 1045, reflected, "Patient got upset with staff because he wanted to do whatever he wanted to do...not following directions, became angry with staff and began to hit and scream...(cussing)...patient began to calm down..." No documentation was found which indicated any bruises, marks and/or discoloration was observed on Patient #1's neck.

The 08/12/14, nursing shift assessment and progress note timed at 1748, reflected, "discharged at 1700...denied depression, suicidal ideation, homicidal ideations...discharge aftercare instructions." No documentation was found which indicated marks/bruises and/or discoloration to Patient #1's neck.

A Telephone Statement dated 08/12/14, timed at 1617, documented by Personnel #30 reflected, "Discussed concerns with Guardian...08/07/14 saw marks on patient's side of neck, nail marks and bruising shaped like fingers and that the patient had told her he was acting up and trying to hit staff and that the MHT (mental health technician) grabbed him by the neck and held him down on the bed...assured Guardian her concerns were valid and the information will be investigated, apologized for the lack of follow through and that it is not acceptable for patient to have marks on their neck..."

On 05/27/15, at 1220, Personnel #7 was interviewed. Personnel #7 was asked if an event report was completed for Patient #1 regarding marks, scratches, bruises and/or discoloration to Patient #1's neck. Personnel #7 stated "no."

On 05/27/15, at 1245, Personnel #30 was interviewed. Personnel #30 provided some notes that she wrote up regarding Patient #1's Guardian's concerns. Personnel #30 stated she saw Patient #1's neck the day he was discharged . Personnel #30 said Patient #1 had some scratches on the side of his neck it appeared as if there was a bruise. Personnel #30 stated she informed the nurse Personnel #28 and Personnel #28 looked at Patient #1's neck. Personnel #30 stated Patient #1's Guardian reported it happened earlier in the week. Personnel #30 said she reported the Guardian's concerns to Personnel #38. Personnel #30 provided the surveyor some notes she had taken but said she could find no documentation which indicated Patient #1's guardian was provided a follow-up letter or communication regarding the findings of her complaint/grievance. Personnel #30 stated the only other documentation she found was a response to a secondary agency's inquiry. Personnel #30 stated the event should have been investigated.


2) Patient #20 was hospital admitted on [DATE], at 20:00 and discharged on [DATE], according to the patient face sheet.

The Physician Preadmission Examination Orders dated 05/05/15, at 2012, reflected admission orders included Schizoaffective Disorder, Bipolar type. The patient was 13 years of age.

Inpatient Child/Adolescent Nursing Admission assessment dated [DATE], at 2140, skin and body assessment was left blank. The patient denied pain.

Nursing Shift Assessment and Progress Notes dated 05/07/15, at 0800, reflected Patient #20 complained of back pain after another patient pulled back Patient #20's chair. Patient #20 "missed the chair and hit his back."

Nursing shift Assessment and Progress Note dated 05/12/15, at 0811, noted the patient complained of right knee pain and Ibuprofen was administered.

Nursing Shift Assessment and Progress Note dated 05/12/15, at 18:40, noted Patient #20 was "struck in testicles by another patient."

Physician Orders dated 05/12/15, at 2000, noted an order to x-ray Patient #20's facial bones "stat" and "check for fracture."

Diagnostic Services Report dated 05/12/15, at 0032, reflected an examination of facial bones with a history of pain.

Nursing Shift Assessment and Progress Note dated 05/13/15, at 0100, noted x-ray to Patient #20 was completed...bruises noted to the left side of face. The notes timed at 0805 reflected Patient #20 complained of nose and left jaw pain and Ibuprofen was administered. The patient was discharged on [DATE] without additional nursing documentation.

Personnel #7 was interviewed on 05/27/15, at 1235, and stated she did not have an incident report and did not know where Patient #20's bruise came from.

On 05/27/15, at approximately 1240, Personnel #7 was asked about priorities in the hospital's quality program and stated it was focused on HIPAA, correct documentation, labs, and customer service. Personnel #7 denied being able to provide quality meeting minutes.

Record Review of the hospital Performance Improvement Meeting minutes dated 05/14/15 noted nursing addressed patient falls, nursing education, and hand hygiene.

On 05/27/15, at 1415, Personnel #4 acknowledged the above findings.


3) Patient #5's Face Sheet reflected the patient's hospital admission on 03/26/15, and discharge on 03/30/15. The patient was 9 years old. Final diagnoses included Episodic Mood Disorder and Encopresis.

Nursing Shift assessment dated [DATE], at 1400, by Personnel #7 reflected Patient #5's family stated the patient was "bullied and threatened by peers..." and demanded immediate patient discharge. The notes timed at 1845, reflected Personnel #7 received a phone call from Patient #5's family member who stated the patient "...was being slapped by other patient...assured them...[Patient #5] had not been abused, beaten, or bullied and was under the direct care of this nurse."

Physician Daily Progress Notes dated 03/29/15, at 1130, noted Patient #5 reported that "one male peer [was] pushing him onto the couch."

On 05/22/15, at 1230 ,Personnel #7 was interviewed and stated Patient #5 did not get slapped. When asked how she can be sure the event did not happen, Personnel #7 stated she was the house supervisor and assigned RN to Patient #5's unit "that day" and her name "should have been on the staffing sheet."

Personnel #2 denied during a telephone interview on 06/04/15 at 1615 that there was an investigation or an incident report about the alleged physical altercation involving Patient #5.
VIOLATION: NURSING SERVICES Tag No: A0385
Based on interview and record review, the hospital failed to

1) ensure the RN (registered nurse) supervised and/or evaluated the care provided by 1 of 1 LVN (licensed vocational nurse) Personnel #8 for 1 of 1 patient (Patient #2) who reported withdrawal from medication changes made by the physician.

2) ensure that a registered nurse was available to evaluate and supervise the provision of nursing care for 2 of 4 patient care units (Psychiatric Intensive Care Unit and Adult Unit).

3) ensure that the registered nurse evaluated 4 of 4 adolescent patients for injuries (Patient #13, #14, #15, and #20) who reported they had been in a physical altercation.


See Tag A-395.
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

1) ensure the RN (registered nurse) supervised and/or evaluated the care provided by 1 of 1 LVN (licensed vocational nurse) Personnel #8 for 1 of 1 patient (Patient #2) who reported withdrawal from medication changes made by the physician.

2) ensure that a registered nurse was available to evaluate and supervise the provision of nursing care for 2 of 4 patient care units (Psychiatric Intensive Care Unit and Adult Unit).

3) ensure that the registered nurse evaluated 4 of 4 adolescent patients for injuries (Patient #13, #14, #15, and #20) who reported they had been in a physical altercation.


Findings included:

1) Patient #2's Behavioral Health Integrative Psychiatric assessment dated [DATE], timed at 1822, reflected, "[AGE] year old has mild PTSD (post-traumatic stress disorder)...boss who hated her and harassed her...anxiety, fear related to work...mother committed suicide on her birthday two years ago..."

The 12/09/14, admission physician order timed at 1100, reflected, "Discontinue Cymbalta ...Pristiq 50 mg (milligrams) po (by mouth) everyday..."

The 12/09/14, Adult Program Daily Nursing Assessment reflected, "Patient reports some anxiety over not having seen a doctor yet...patient will see Dr. today..."

The 12/11/14, Physician Orders timed at 1000, reflected, "Discontinue Seroquel XR (extended release) 150 mg every HS (hour of sleep)..."

The 12/10/14, Therapy Note reflected, "Patient reports spacy...reports new medications are causing concentration lapses..."

The 12/10/14, Adult Program Daily Nursing Assessment reflected, "Patient expresses concern over new medications...encouraged to speak to the doctor..." No documentation was found by the nurse which indicated the patient was assessed and/or vital signs taken.

The 12/11/14, Therapy Note reflected, "Reports irritable...nausea from new medications..." No documentation was found by the nurse which indicated the patient was assessed and/or vital signs taken.

The 12/12/14, Therapy Note reflected, "Could not sleep, took four showers...cold sweats, dizzy, crying, could not sleep...believes we are trying to put her inpatient...therapist called Dr ..advised to give patient option of ER (emergency room )... " The above documentation indicated the therapist contacted the physician not the nurse.

The Adult Program Daily Nursing assessment dated [DATE], reflected, "Getting rather "(upset)...having major withdrawal from medication " will leave program if this continues ...reports having withdrawals..." No documentation was found by the nurse which indicated the patient was assessed and/or vital signs taken.

On 05/22/15, at 1304, Personnel #8 was interviewed. Personnel #8 was asked to review (Patient #2's) medical record. Personnel #8 stated she could not remember if the therapists said anything about the patient complaining of withdrawal symptoms to her. Personnel #8 stated that she did document the patient complained about having a reaction to the medication changes the physician made. Personnel #8 was asked if she took the patient's vital signs and assessed the patient when she complained. Personnel #8 stated she did not. Personnel #8 was asked if she was supervised by Personnel #2. Personnel #8 said Personnel #2 had not been over to the PHP (Partial Hospital Program) as far as she knew.


2) On 05/22/15, at 1510, observation rounds were conducted on the PICU (Psychiatric Intensive Care Unit). Personnel #14 and #15 reported they were the assigned nurses. Personnel #14 and #15 were asked who the RN was. Personnel #14 and #15 stated there was no RN assigned to the unit for the 7-3 shift.

The 01/22/15, 7-3 shift staffing sheet reflected, "Personnel #14 and #15 worked on the PICU Unit with no RN."

The 01/22/15, 11-7 shift staffing sheet reflected, "Personnel #31 and #33 worked on the PICU Unit with no RN."

The 01/22/15, 11-7 shift staffing sheet reflected, "Personnel #34 and Personnel #35 worked on the Adult Unit with no RN."

The 01/23/15, 11-7 shift staffing sheet reflected, "Personnel #31 and Personnel #36 worked on the PICU Unit with no RN."

The 05/22/15, 7-3 staffing sheet reflected, "Personnel #14 and Personnel #15 worked on the PICU Unit with no RN."

On 05/22/15, at 1609 Personnel #2 was interviewed. Personnel #2 was asked why the PICU Unit did not have an RN. Personnel #2 stated, "We do the best we can."


3) Patient #13's Discharge Summary noted an admission date of [DATE], and a discharge date of [DATE]. Final diagnoses included Major Depressive Disorder, Severe, Without Psychosis.

The Nursing Shift assessment dated [DATE] did not reflect a physical altercation with another peer.


Patient #14's Discharge Summary reflected an admission date of [DATE]. Patient #14 was discharged on [DATE]. Final diagnoses included Major Depressive Disorder, severe, with Psychosis and Post-Traumatic Stress Disorder.

Therapy Notes dated 03/02/15, at 10:30, reflected the therapist met with Patient #14 "to address the patient complaint about peers threatening her and physical aggression by peers towards pt [Patient #14] over [the] week-end...the pt [Patient #14] discussed not feeling safe..."

The Nursing Shift assessment dated [DATE], did not reflect a physical altercation with another peer.

The Nursing Shift Assessment dated 03/01/15, at 21:08, noted Patient #14 "had an incident 'with another patient who "hit her in the nose and...[Patient #14] had a nose bleed." There was no RN assessment for Patient #14 after the incident.


Patient #15's Face Sheet noted a patient hospital admission date of [DATE], and a discharge date of [DATE]. Admitting diagnoses included severe Depression and Cannabis Abuse.

The Nursing Shift Assessment and Progress Note dated 02/28/15, at 1945, reflected Patient #15 "hit another female in [the] face...escorted to room...was encouraged to express feeling with staff." The shift assessment for medical issues was left blank.

During an interview on 05/22/15, at 1225, Personnel #7 stated that on 02/28/15, at 1830, there was an incident on the female adolescent unit. Patient #13, [AGE], and Patient #14, [AGE], claimed that Patient #15, [AGE], "attacked" them. No injuries were reported or observed.


Patient #20 was hospital admitted on [DATE], at 2000, and discharged on [DATE], according to the patient's face sheet.

Patient #20's Physician Preadmission Examination Orders dated 05/05/15, at 2012, reflected admission orders included Schizoaffective Disorder, Bipolar type. The patient was 13 years of age.

Nursing Shift Assessment and Progress Note dated 05/12/15, at 18:40, noted Patient #20 was "struck in testicles by another patient." There was no evidence of a nursing assessment.

Physician Orders dated 05/12/15, at 2000, noted an order to x-ray Patient #20's facial bones "stat" and "check for fracture."

Nursing Shift Assessment and Progress Note dated 05/13/15, at 0100, noted x-ray to Patient #20 was completed...bruises noted to the left side of face. The notes timed at 0805 reflected Patient #20 complained of nose and left jaw pain and Ibuprofen was administered. The patient was discharged on [DATE] without additional nursing documentation.

Personnel #7 was interviewed on 05/27/15, at 1235, and stated she did not have an incident report and did not know the origin of Patient #20's bruises.