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||Sept. 25, 2015|
|VIOLATION: PATIENT RIGHTS: INFORMED CONSENT||Tag No: A0131|
|**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review the hospital failed to ensure a four hour written request for discharge by the legal guardian for 1 of 3 patients (Patient #1) was provided. The hospital did not have a written physician's order to legally hold the minor patient.
The Behavioral Health Integrative Psychiatric assessment dated [DATE] timed at 1322 reflected, "Patient aggressive towards teacher at school...is not remorseful...mother states ...patient threatened to run away...mood swings...I'm just gonna go away..."
The Discharge Against Medical Advice (AMA) form dated 05/01/15 timed at 1639 reflected, "I understand that I will be released within four (4) hours from the time of my request unless...I withdraw my Demand for Release, or...my doctor feels I am likely to cause serious harm to myself...(signed by legal guardian)...physician notification...1842...physician decision...detain patient/intent to evaluate for court ordered treatment...note...physician must be notified and respond within four hours...a separate order must be written in the patient file to reflect the order and disposition received from the physician..."
The Nursing Shift Assessment and Progress Note dated 05/01/15 timed at 1640 reflected, "Mom here to sign AMA informed Mom of AMA process...1840 Dr...informed of AMA placed on 24 hour hold."
The physician orders dated 05/01/15 through 05/02/15 revealed no physician order which indicated the minor adolescent was being physician ordered held.
The 05/02/15 physician daily progress note dated 05/02/15 timed at 1000 reflected, "Patient is doing ok today and is without complaints...mood is better, no suicidal ideations...patient is stable and appropriate for discharge to home today..." No documentation was found which addressed the legal guardian's written request for discharge signed 05/01/15.
On 09/25/15 at 1250 Personnel #2 was interviewed. Personnel #2 was asked by the surveyor to review Patient #1's medical record. Personnel #2 stated no physician order to hold the minor was written and the physician did not document anything about the legal guardian's four hour request to discharge the patient and the reason for holding the patient.