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 Feb. 10, 2016
VIOLATION: PROVIDING ADEQUATE RESOURCES Tag No: A0315
Based on review of records and interview the hospital's governing board did not provide adequate resources to follow it's processes to review patient grievances, in that there was no incident or grievance report completed for 1 of 1 patient (Patient #6), after the hospital was informed of this incident through a grievance by Patient #6's mother.

Findings Included:

1.) On 10/22/15 at 2006 the Nursing Shift Assessment Progress Note reflected, Patient
#6's Mother asked to speak to a nursing supervisor. She reported her son was touched inappropriately by his roommate.

2.) The incident log and grievance log for 10/01/15 through 12/30/15 did not include documentation involving this event.

3.) In an interview with Hospital Staff #6, it was reported that she did not complete an incident report after reporting this incident to her supervisor.

Policy

The hospital Patient Rights Policy dated 08/11/2014 reflected, "All patients receiving mental health services at Sundance Hospital will be granted the following rights: The rights, benefits, responsibilities and privileges guaranteed by the constitutions and laws of United States and the State of Texas."

The hospital Abuse, Neglect, and exploitation of patients Policy dated 08/11/2014, reflected, "...all clinical staff will document and immediately report suspected cases..."