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 Jan. 28, 2016
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on observation, record review and interview the facility failed to preserve the rights of one of one patient (Patient #24) to receive care in a safe setting. Patient #24 who had a history of a previous suicide attempt and had been physician assessed to be suicidal approximately three hours prior to surveyor observation, had access to objects that the patient could have used for potential self-harm or in harming others.

Findings included:

Observations on the hospital's adult psychiatric floor on 01/28/16 at 11:55 reflected two metal boxes with recreational blocks in the patient's day room at approximately 11:55. The boxes were bendable and breakable into sharp pieces.

Observations on the adult psychiatric unit in Patient #24's room on 01/28/16 at 12:00 reflected one bottle of body wash and one bottle of hand lotion. Both were marked "for external use only." Hospital Employee #3 stated at that time that she did not know why the items were left in Patient #24's room.

Hospital Employee #28's Physician's Daily Progress Note dated 01/28/16 at 09:00 reflected Patient #24 had suicidal ideation.

Patient #24's Physician's Psychiatric Evaluation dated 01/28/16 by Hospital Employee #28 noted Patient #24, prior to her admission to the hospital, had sought care at an acute care hospital Emergency Department for her suicidal ideation "claiming that if she was able to find a way to kill herself right now she would do it..." The patient told the physician that her suicidal thoughts were "...getting stronger and stronger...had a suicide attempt in the past by overdose...has a history of assault..." Hospital Employee #28 noted the initial step in the patient's care plan was preventing her from injuring herself or others.

Patients' Rights Policy dated 08/11/14 reflected that the patient has the right to a treatment environment that "...ensures protection from harm..."
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview the hospital failed to ensure that a registered nurse evaluated the nursing care for two of nine patients (Patients #25 and #29).
1) Patient # 25 who suffered from [DIAGNOSES REDACTED], fell in the shower on 01/26/16 and was not further assessed for potential injuries according to hospital policy and standard of nursing care.
2) Patient #29 experienced a fall in his room on 10/06/15 without further documented assessment by nursing staff. The patient was sent out to emergency care seven hours later.



Findings included:

1) Patient #25 Preadmission Exam and Certification dated 01/20/16 at 22:38 reflected the patient was admitted for daily suicidal thoughts, mood swings, aggression, suicidal and homicidal ideation, and anger outbursts. The patient suffered from [DIAGNOSES REDACTED]. She was placed on assault and suicide precautions.

Nursing Shift Assessment and Progress Note dated 01/26/16 at 18:00 reflected Patient #25's "....vital signs [were] stable after fall in shower..." There was no evidence of additional nursing assessment data. Nursing notes timed at 19:00 reflected "vital signs stable..."

Hospital Employee #2 acknowledged during an interview on 01/28/16 at 13:15 that there was no evidence of a head to toe assessment of the patient by nursing staff.

2) Patient #29's Pre-Admission Exam and Certification dated 10/05/15 at 10:46 reflected the patient was admitted for Paranoid Schizophrenia.

Nursing Shift assessment dated [DATE] at 03:30 reflected that Patient #29 "...had [a] fall in room." No further patient assessment was noted.

Discharge Orders dated 10/06/15 at 10:30 reflected an order to send the patient to acute emergency care for "...elevated delirium...rule out ...brain injury..."


Hospital Employee #1 acknowledged the above findings during an interview on 01/28/16 at 10:20.


Hospital Fall Prevention Policy dated 08/11/14 noted the procedure that "...if a fall occurs, the nurse will complete a head-to-toe assessment of the patient..."

The Texas Board of Nursing requires all nurses to "...accurately and completely report and document...the client's status including signs and symptoms...[and] nursing care rendered..." (http://www.bon.texas.gov/rr_current/217-11.asp)