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 March 11, 2016
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
Based on interview and record review the RN (Registered Nurse) failed to evaluate and reassess 1 of 10 patients (Patient #11) after (Patient #11) verbalized she was sexually assaulted by a hospital employee.

Findings included:

The psychiatric evaluation dated 01/30/16 reflected, "Transferred from...after drinking alcohol and overdosing on Restoril...two year anniversary of her daughters homicide...still having difficulty with her passing and grieving her death..."

The nursing shift assessment and progress note dated 02/01/16 revealed no nursing assessment and/or documentation regarding Patient #11's allegation that hospital staff sexually assaulted her.

The nursing shift assessment and progress note dated 02/02/16 timed at 0900 reflected, "States she does not feel safe here..."

The Behavioral Healthcare Therapy Note dated 02/04/16 timed 0930 to 1030 reflected, "Patient reports being sexually assaulted and concerned for other patient safety..."

On 03/10/16 from 1250 to 1310 Personnel #1 was interviewed by telephone. Personnel #1 reviewed Patient #11's medical record. The surveyor asked if Patient #11 was assessed after she reported the event. Personnel #1 stated she could not find any documentation.

On 03/10/16 at 1315 Personnel #11 was interviewed by telephone. Personnel #11 stated he wrote up the event on a complaint form and it was reported to the Director of Nurses. Personnel #11 was asked if he assessed the patient and/or documented in her medical record the event. Personnel #11 stated he did not.

The policy and procedure entitled, "Abuse, Neglect, Exploitation: Assessment and Reporting" with an issue date of 08/11/14 reflected, "Patient abuse, neglect...by any health care providers are prohibited behaviors...the patient must be the focus of the assessment and his/her ultimate care the priority of interventions..."
VIOLATION: NURSING CARE PLAN Tag No: A0396
Based on interview and record review the hospital failed to ensure 1 of 11 patients (Patient #11's) nursing care plan was current and addressed Patient #11's outcry of being sexually assaulted by a hospital employee.

Findings included:

The Initial Treatment Plan dated 01/28/16 reflected, "Problems to be addressed...Depression...self-harm..." The treatment plan was not updated to address Patient #11's allegation of being sexually assaulted by a hospital employee.

The psychiatric evaluation dated 01/30/16 reflected, "Transferred from...after drinking alcohol and overdosing on Restoril...two year anniversary of her daughters homicide...still having difficulty with her passing and grieving her death..."

The nursing shift assessment and progress note dated 02/02/16 timed at 0900 reflected, "States she does not feel safe here..."

The Behavioral Healthcare Therapy Note dated 02/04/16 timed 0930 to 1030 reflected, "Patient reports being sexually assaulted and concerned for other patient safety..."

On 03/10/16 from 1250 to 1310 Personnel #10 was interviewed by telephone. Personnel #10 was asked to review Patient #11's medical record which included Patient #11's treatment plan. Personnel #10 stated Patient #11's treatment plan did not address Patient #11's allegation of being sexually assaulted by a hospital employee.