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 Nov. 10, 2016
VIOLATION: TIMELY DISCHARGE PLANNING EVALUATIONS Tag No: A0810
Based on record review, interview the hospital failed, to complete make appropriate arrangements for 1 of 1 patient (Patient #10) for post hospital care and to avoid unneccessary delays in discharge.

Findings Include:

During an interview and record review with Personel #1, #4, and #6 all verified Patient #10 signed an AMA on 11/06/16 at 1430.

During an interview and record review with Personel #1, #4, and #6 all verfied Patient #10 gave them a verbal order to remove the AMA on 11/08/16. This was well past the 4 hours for discharge of Patient # 10.

Policy
The hospital Discharge Planning Policy dated 08/11/14 reflected, " Discharge planning begins on admission and is provided for Behavioral Health Service inpatients by the interdisciplinary treatment team (IDT), with the involvement of the patient and or the patient ' s legally authorized representative (LAR) ... "

The hospital Transfer Policy dated 08/11/14 reflected, " To comply with TAC 134.43 regarding the transfer of a patient to another facility in the event of medical or psychiatric emergency and The Texas Department of Mental Health and Mental Retardation 411.468 Sundance Hospital has developed a written plan describing the specific and appropriate action to be taken by hospital staff to evaluate for and stabilize each identified potential emergency medical condition ... "

The hospital Patient Rights Policy dated 09/2016, " All patients receiving mental health services at Sundance Hospital will be granted the following rights: The rights, benefits, responsibilities, and privileges ...The right to presumption of mental competency in the absence of a judicial determination to the contrary ...The right to appropriate treatment in the least restrictive appropriate setting available consistent with the protection of the individual ...The right to be informed of those rules and regulations of the hospital relating to expectations of the individual ' s conduct ...The right to explanations of the care, procedures and treatment to be provided; the risks, side effects, and benefits of all medications and treatment procedures to be. " used. Including those that are unusual or experimental; the alternate procedures that are available; and the possible consequences of refusing the treatment or procedure ...The right to information, upon request, pertaining to the cost of services rendered ...The right to be free from unnecessary or excessive medication, which includes the right to give or withhold informed consent to treatment with psychoactive medication, unless the right has been limited by court order or in an emergency ...All persons voluntarily admitted to inpatient services for treatment of mental illness or chemical dependency have to the right to be discharged within four hours of a request for release unless the individuals treating physician determines that there is cause to believe that the individual might meet the criteria for court-ordered mental health services or emergency detention. "
VIOLATION: TRANSFER OR REFERRAL Tag No: A0837
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**






Based on record review and interview the hospital failed to refer 1 of 1 patients (Patient #10), to appropriate failicities, for follow-up or ancillary care.

Findings Included

1.) The hospital Progress Note dated 11/08/16 at 1400 reflected, " She is requesting to be transferred to the Seay Center. "

2.) In an interview with Personnel #6,on 11/10/16 at 12:00, "Patient # 10 when she arrived here she wanted to be transferred out of the hospital on [DATE]. The patient was not able to provide the hospital with a different location to attend until her husband provided her with Seay Center."