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. 23, 2016
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review the hospital failed to ensure a safe environment was provided for 2 of 10 patients (Patient #1 and #4).

1) Patient #1 was attacked by Patient #4 and sustained an injury to his mouth.

2) Patient #4 demonstrated multiple acts of aggression towards staff and peers. Patient #4 further attempted self-harm. Patient #4 tied a blanket around his neck attempting to choke himself. No higher level of care was initiated. Additionally Patient #4's 15 minute observation rounds record for 10/15/16 was left blank for 30 minutes.

Findings included:

1) Patient #1's Behavioral Health Integrative Psychiatric assessment dated [DATE] timed at 0121 reflected, "Presents with increased aggression and assault...threats to harm his mother, father and sister...history of several hospitalization s...history of Aspergers, ADHD (Attention Deficit Disorder), Anxiety and Depression..."

The 10/05/16 Nursing Progress Notes timed at 1630 reflected, "Patient involved with another patient in a physical altercation in the cafeteria...states he was punched in the mouth and nose...laceration around lip area...cleaned and ice pack applied...Dr...notified...at 1800 laceration area still swollen..."

The 10/05/16 Physician's Orders reflected, "Ibuprofen 400 mg (milligrams) po (by mouth) every six hours prn (as needed) for pain..."

The 10/06/16 Nursing Progress Notes timed at 0700, 1200 and 1804...continues on neuro-checks...at 1804...complains of toothache rate pain 4 on the scale of 1-10 Ibuprofen given as ordered..." No documentation was found regarding the laceration to the patients mouth, condition of his mouth size of laceration, color of skin and/or whether the patients tooth was loose related to being punched in the mouth 10/05/16.

On 11/22/16 from 1135 to 1200 Personnel #2 was interviewed. Personnel #2 was asked to review Patient #1's medical record. Personnel #2 verified Patient #1 was assaulted by Patient #4 and sustained a laceration to the mouth.

2) Patient #4's Risk Notification Alert dated 10/04/16 reflected, "High Risk Factors, assaultive, homicidal indicators ..violent behavior, homicidal ideation's and destructive..."

The Pre-admission exam and certification form dated 10/04/16 timed at 1940 reflected, "Per intake staff patient was brought to inpatient for (sic) from...outpatient for putting a staff member in a choke hold...reports that he has been having homicidal deation...paranoia about the world ending...anxious, having anger outbursts, paranoid, aggressive towards others...precautions assaultive every fifteen minutes...level of observation."

The 10/05/16 physician orders and directions timed at 0823 reflected, "Haldol 5 mg (milligrams) IM (intramuscular) times one dose now...benadryl 50 mg IM timed one dose now...aggression/agitation."

The 10/05/16 Nursing Progress Notes timed at 0835 reflected, "Patient became aggressive (physically) with another patient...continued to make threats...received haldol...Benadryl...at 0930 (late entry for 0835)...patient struck another patient."

The 10/05/16 Nursing Progress Notes timed at 1650 reflected, "Patient got involved with another patient by physically hitting another patient on his nose and mouth...staff was able to deescalate the situation..."

The 10/07/16 Nursing Progress Notes timed at 10/07/16 timed at 2045 reflected, "Patient presented with anger outburst...patient punched another patient...Haldol, Benadryl given...Q fifteen checks."

The 10/08/16 Physician Progress Notes timed at 0718 reflected, "Has trouble getting along with peers and physical outbursts..."

The 10/08/16 Nursing Progress Notes dated 10/08/16 timed at 1730 reflected, "Patient back to unit due to incident in cafeteria...became very aggressive and attempting to fight and throws water...received Haldol, Benadryl...1900 patient continues to be unpredictable..."

The 10/09/16 Physician's Orders and Directions timed at 0700 reflected, "Place patient on Unit restrictions due to anger and violent behavior..."

The 10/09/16 Nursing Progress Notes timed at 1750 reflected, "Patient was wrestling with another patient...staff requested patient to stop...went to room...staff checked on him...and he had tied a blanket around his neck/choking self...called to room and requested patient to stop...did not...I started to take blanket from patient and patient attempted to assault me code called taken to quiet room..." No physician's orders and/or documentation was found which indicated the patient was placed on a 1:1 during his inpatient stay. Multiple acts of aggression to staff and peers was documented. The patient further attempted to choke himself. The hospital failed to initiate a higher level of observation for the patient.

The 10/10/16 Nursing Progress Notes timed at 1520 reflected, "Patient seen in dayroom playing with another patient...incident later turned aggressive...patient raised his hands and slapped the other patient...at 1900...patient charged at peer once he returned onto the unit...cursing and yelling at peer and attempted to hit peer several times...continued to act combative with staff and peers...continued to threaten peer by saying it ain't over I will get your...haldol, benadryl for agitation...patient room moved to opposite hall."

The 10/13/16 Nursing Progress Notes timed at 2140 reflected, "Patient was verbally and physically aggressive to other two patients, that led to both patients engaging into a fight...patient was bleeding from his nose, his nose was cleaned, after 15 minutes bleeding stopped, his pink eye was clear..."

The 10/15/16 Patient Rounding: Hourly, 15 Minute and 1:1 Precaution Checklist reflected, "Aggression, observation/eval..." The 1015 and 1030 behavior and location was left blank with no staff documentation.

The Precaution/Patient Monitoring One-on-One Care policy and procedure with a revision date of 09/26/16 reflected, "The use of one-on-one patient monitoring is an accepted psychiatric intervention...for significantly high risk patients who have been identified as acutely dangerous to themselves or others, and in which continuous monitoring is required for patient safety...patients with prominent psychiatric disturbances so as to provide safe care during the inpatient hospitalization ...criteria for 1:1 care...patient is at immediate risk of self-harm, harm to others, or is an extreme disruption to the therapeutic mileu...infringing on the rights of other patients...less restrictive interventions have failed or are not appropriate..."

On 11/22/16 at approximately 1230 Personnel #2 was interviewed. Personnel #2 was asked to review Patient #4's medical record. Personnel #2 verified Patient #4's aggressive behaviors to peers and staff and his attempt to choke himself with a blanket. Personnel #2 verified Patient #4 level of observation should have been increased. Personnel #2 stated the patient rounds record was left blank for 30 minutes with no documentation on patient behavior and location.

On 11/22/16 at 1309 Personnel #6 was interviewed. Personnel #6 stated Patient #4 attempted to choke himself when he tied a blanket around his neck. Personnel #6 stated Patient #4 should have been put on a 1:1 for safety.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review the hospital failed to ensure the RN evaluated and/or reassessed 2 of 10 patients (Patient #1) after he sustained a laceration to the mouth when a peer punched him in the mouth and, 2) Patient #7 had chest pains and the RN did not reassess Patient #7 after administering Nitroglycerin.

Findings included:

1) Patient #1's Behavioral Health Integrative Psychiatric assessment dated [DATE] timed at 0121 reflected, "Presents with increased aggression and assault...threats to harm his mother, father and sister...history of several hospitalization s...history of Aspergers, ADHD (Attention Deficit Disorder), Anxiety and Depression..."

The 10/05/16 Nursing Progress Notes timed at 1630 reflected, "Patient involved with another patient in a physical altercation in the cafeteria...states he was punched in the mouth and nose...laceration around lip area..cleaned and ice pack applied...Dr...notified...at 1800 laceration area still swollen..."

The 10/05/16 Physician's Orders reflected, "Ibuprofen 400 mg (milligrams) po (by mouth) every six hours prn (as needed) for pain..."

The 10/06/16 Nursing Progress Notes timed at 1804...complains of toothache rate pain 4 on the scale of 1-10 Ibuprofen given as ordered..." No documentation was found regarding the laceration to the patients mouth, condition of his mouth size of laceration, color of skin and/or whether the patients tooth was loose related to being punched in the mouth 10/05/16.

The 10/07/16 Nursing Progress Notes timed at 0035, 0940 and 2000 revealed no assessment/reassessment of the laceration to patients mouth.

On 11/22/16 from 1135 to 1200 Personnel #2 was interviewed. Personnel #2 was asked to review Patient #1's medical record. Personnel #2 verified no follow-up assessment and/or reassessment of Patient #1's mouth injury was conducted.

2) Patient #7's 10/29/16 timed at 1300 Behavioral Health Integrative Psychiatric Assessment reflected, "Patient threatened his father with a razor knife...drug use."

The Nursing Progress Notes dated 11/07/16 timed at 1915 reflected, "Patient is seen lying on the floor...complained of feeling dizzy, chest pain and shortness of breath...blood pressure 149/73, pulse 102...Dr. notified...new order Nitro (Nitroglycerin) 0.4 mg (milligrams) sublingual times one given...relief of chest pain...pulse ox (oxygenation)
100%."

The physician orders and directions dated 11/07/16 reflected, "Nitroglycerin 0.4 mg po (by mouth) for chest pains times one."

The Nursing Progress Notes dated 11/07/16 timed at 1917 reflected, "To (hospital)..."
No further documentation was found which indicted Patient #7's blood pressure and pulse was recheck after Patient #7 received Nitroglycerin. No further entries were found which addressed Patient #7's complaint of chest pain.

The Hospital policy and procedure entitled, "Assessment and Reassessments of Patients" with a revision dated of 09/26/16 reflected, "An accurate record of the patient's condition, care, and treatment is provided throughout the hospital visit...reassessments are documented when there is a significant change in patient status, post procedure...information will be documented in the patient's medical record...RN will reassess the patient based on the patient's needs..."

On 11/22/16 at 1109 Personnel #2 was interviewed. Personnel #2 was asked to review Patient #7's medical record for documentation which addressed Patient #7's vital signs and reassessment was performed after being administered Nitroglycerin sublingual. Personnel #2 verified no reassessment was completed.
VIOLATION: NURSING CARE PLAN Tag No: A0396
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review, the hospital failed to ensure 1 of 10 patients (Patient #1's) nursing care plan addressed a mouth injury sustained while inpatient.

Findings included:

Patient #1's Behavioral Health Integrative Psychiatric assessment dated [DATE] timed at 0121 reflected, "Presents with increased aggression and assault...threats to harm his mother, father and sister...history of several hospitalization s...history of Aspergers, ADHD (Attention Deficit Disorder), Anxiety and Depression..."

The 10/05/16 Nursing Progress Notes timed at 1630 reflected, "Patient involved with another patient in a physical altercation in the cafeteria...states he was punched in the mouth and nose...laceration around lip area ..cleaned and ice pack applied...Dr...notified...at 1800 laceration area still swollen..."

The 10/05/16 Physician's Orders reflected, "Ibuprofen 400 mg (milligrams) po (by mouth) every six hours prn (as needed) for pain..."

The 10/06/16 Nursing Progress Notes timed at 0700, 1200 and 1804...continues on neuro-checks...at 1804...complains of toothache rate pain 4 on the scale of 1-10 Ibuprofen given as ordered..."

The Multidisciplinary Treatment Plan dated 10/04/16 reflected, "Disruptive Mood Dysregulation Disorder...precautions Q (every) 15 minute Assaultive...emergency behavior management (IM) Intramuscular...date revised 10/06/16...problems Disruptive Behavior...demonstrates inability to respond well to negative stimuli...estimated discharge date [DATE]..." The treatment plan revealed no documentation which addressed the injury to Patient #1's mouth.

The Hospital policy and procedure entitled, "Treatment Plan: Interdisciplinary Treatment Planning/Master Treatment Plan" with a revision date of 09/26/16 reflected, "The treatment planning process is ongoing, beginning at the time of admission and continuing through discharge...the treatment plan shall be appropriate to the interests of the patient and directed toward restoring and maintaining optimal level of physical and psychological functioning...goals and objectives are established...interdisciplinary team shall include the patient's treating physician, the patient, the patient's legally authorized representative..."

On 11/22/16 from 1135 to 1200 Personnel #2 was interviewed. Personnel #2 was asked to review Patient #1's medical record. Personnel #2 verified Patient #1's treatment plan did not address the laceration Patient #1 sustained to his mouth.

On 11/22/16 at approximately 1230 Personnel #2 was interviewed. Patient #2 was asked to review Patient #4's medical record. Personnel #2 verified Patient #4's aggressive behaviors to peers and staff and his attempt to choke himself with a blanket. Personnel #2 verified Patient #4 level of observation should have been increased.

On 11/22/16 at 1309 Personnel #6 was interviewed. Personnel #6 stated Patient #4 attempted to choke himself when he tied a blanket around his neck. Personnel #6 stated Patient #4 should have been put on a 1:1 for safety.