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 Feb. 9, 2016
VIOLATION: POSTING OF SIGNS Tag No: A2402
Based on observation and interview, the hospital failed to post a sign specifying the rights of individuals with respect to examination and treatment for emergency medical conditions and women in labor, and information indicating whether or not the hospital participated in the Medicaid program under a State plan approved under Title XIX.



Findings included:

Hospital A Employee #6 was interviewed on 02/05/16 at 14:30 and confirmed that the Hospital A lobby was the waiting area for patients who came for assessments.

A tour of Hospital A's main entrance and lobby area on 02/05/16 at 15:00 did not reflect EMTALA signage.

Hospital A Employees #4 and #6 acknowledged the finding on 02/05/16 at approximately 15:05.
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
Based on record review, observation, and interview, Hospital A did not comply with 489.24(a)(c) (q)(r) in the care of one of 27 patients (Patient #1) who arrived at Hospital A on an emergency detention order after she made a suicidal statement in front of a Police Officer.

1) The hospital did not display the required EMTALA post.
2) The hospital failed to maintain a central log for Patient #1.
3) The hospital failed to provide an appropriate medical screening for Patient #1.

Findings included:

1) Hospital A Employee #6 was interviewed on 02/05/16 at 14:30 and confirmed that the Hospital A lobby was the waiting area for patients who came for assessments.

A tour of Hospital A's main entrance and lobby area on 02/05/16 at 15:00 did not reflect EMTALA signage.

Hospital A Employees #4 and #6 acknowledged the finding on 02/05/16 at approximately 15:05.

2) Notification of Emergency Detention dated 01/29/16 at 20:54 reflected Patient #1 was "a risk of serious harm to herself" based on her statement made to the Deputy that she wanted to die.

Review of Hospital A's Central Intake log dated 01/29/16 did not reflect Patient #1's name.

During an interview on 02/05/16 at 14:10, Hospital A Employee #7 stated on the evening of 01/29/16, a pre-adolescent patient came to the hospital with Police and "Intake (staff) explained to them that we were full and...[could] not accept the patient..."

Hospital A Employee #8 was interviewed on 02/05/16 at 15:05 and denied that Patient #1's name was placed on the hospital's Intake Central log.

3) Hospital A Employee #8 was interviewed on 02/05/16 at 15:05 and stated a patient on an emergency detention order was brought to the hospital lobby on the evening of 01/29/16. Employee #8 stated the hospital did not have a bed available for Patient #1 and "...did not actually receive her." Employee #8 confirmed that the patient did not get assessed and the on-call physician was not notified.

Hospital A Employee #7, was interviewed on 02/05/16 at 14:10 and stated the patient was not assessed or screened because "it was not a life-threatening situation, although the Police Officer said it was."


During an interview on 02/09/16 at 12:29 Hospital A Employee #4 acknowledged that the staff members involved in the incident did not have EMTALA training on 01/29/16.

Review of the Hospital A's COBRA/EMTALA Violations policy dated 10/15/11 reflected that "when a prospective patient or an individual making a request on behalf of a prospective patient...and he/she presents on the hospital property and request examination or treatment, a qualified staff shall provide medical screening to determine if an emergency medical condition exists as appropriate."

Hospital B's Physician's Notes dated 01/30/16 at 00:50 reflected Patient #1 was hospital admitted and screened under emergency detention. The patient had a history of Bipolar Illness and took Clonidine and Zoloft. The physician's diagnoses included Intermittent Explosive Disorder and Acute Exacerbation of Mood.

Patient #1 was discharged from Hospital B on 01/30/16 at 01:07 according to Hospital B's Patient Demographics.
VIOLATION: EMERGENCY ROOM LOG Tag No: A2405
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview, Hospital A failed to maintain a central log for one of 27 patients (Patient #1) who was emergently detained and brought to the hospital by Police after she made a suicidal statement on 01/29/16.

Findings included:

Notification of Emergency Detention dated 01/29/16 at 20:54 reflected Patient #1 was "a risk of serious harm to herself" based on her statement made to the Deputy that she wanted to die.

Review of Hospital A's Central Intake log dated 01/29/16 did not reflect Patient #1's name.

During an interview on 02/05/16 at 14:10, Hospital A Employee #7 stated on the evening of 01/29/16 a pre-adolescent patient came to the hospital with Police and "Intake (staff) explained to them that we were full and...[could] not accept the patient..."

Hospital A Employee #8 was interviewed on 02/05/16 at 15:05 and stated she met the Police Officer and the patient in the hospital lobby. Employee #8 informed the officer that the hospital did not have a bed for the [AGE] year old patient. Employee #8 denied that Patient #1's name was placed on the hospital's Intake Central log.
VIOLATION: MEDICAL SCREENING EXAM Tag No: A2406
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview, the hospital failed to provide an appropriate medical screening examination for one of 27 patients (Patient #1) who arrived at Hospital A on an emergency detention order after she made a suicidal statement in front of a Police Officer. The pre-adolescent female patient sat in hand-cuffs for about one hour in the hospital lobby before she was taken by Police to Hospital B where she was diagnosed with Intermittent Explosive Disorder.

Findings included:

Notification of Emergency Detention dated 01/29/16 at 20:54 reflected Patient #1 was "a risk of serious harm to herself" based on her statement made to the Deputy that she wanted to die.

Review of Hospital A's central Intake log dated 01/29/16 did not reflect Patient #1's name.

Hospital A Employee #8 was interviewed on 02/05/16 at 15:05 and asked about an incident on 01/29/16. Unable to recall the patient's name, Employee #8 stated the patient was legally held on an emergency detention. The employee met the Police Officer and the patient in the hospital lobby. Employee #8 informed the officer that the hospital did not have a bed for the [AGE] year old patient. When asked why Patient #1 was not evaluated at the hospital, Employee #8 stated, "The Police Officer had her in cuffs and kept her safe." Employee #8 denied that Patient #1's name was placed on the hospital's Intake Central log. Employee #8 confirmed that the patient did not get screened and the on-call physician was not notified.

During an interview on 02/05/16 at 14:10, Hospital A Employee #7 stated on the evening of 01/29/16, a pre-adolescent patient came to the hospital with Police and "Intake (staff) explained to them that we were full and...[could] not accept the patient...it was not a life-threatening situation here although the Police Officer stated that it was life-threatening."

During an interview on 02/05/16 at 14:30 Hospital A Employee #6 stated staff informed him that the Police Officer "was belligerent" when he pointed out that it was the hospital's responsibility to evaluate the patient. The officer "made a scene and refused to leave ...unit was full." The officer and the patient left after about an hour.

During an interview on 02/09/16 at 12:29 Hospital A Employee #4 acknowledged that the staff members involved in the incident did not have EMTALA training on 01/29/16.

Review of the Hospital A's COBRA/EMTALA Violations policy dated 10/15/11 reflected that "when a prospective patient or an individual making a request on behalf of a prospective patient has an appointment of Intake Service evaluation and he/she presents on the hospital property and request examination or treatment, a qualified staff shall provide medical screening to determine if an emergency medical condition exists as appropriate."

Hospital B's Physician's Notes dated 01/30/16 at 00:50 reflected Patient #1 was hospital admitted and screened under emergency detention. The patient had a history of Bipolar Illness and took Clonidine and Zoloft. The physician's diagnoses included Intermittent Explosive Disorder and Acute Exacerbation of Mood.

Patient #1 was discharged from Hospital B on 01/30/16 at 01:07 according to Hospital B's Patient Demographics.