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 Jan. 25, 2017
VIOLATION: CONTENT OF RECORD - DISCHARGE SUMMARY Tag No: A0468
Based on interview and record review the hospital failed 1 of 11 patients, patient #1 in the completion of Discharge Summary that documented the hospitalization , disoposition of care and provisions for follow-up care.

Findings Included

During an interview with hospital Personnel #1, stated that she was aware the record did not have a completed Discharge Summary.

During an interview with hospital Personnel #8, stated that there was not a discharge summary because the record was placed in the administrative office.
VIOLATION: THERAPEUTIC DIETS Tag No: A0629
Based on interivew, record review, the hospital failed 1 of 11 Patients, Patient #1 in that, Patient #1 did not receive the Individual patient nutrional needs in accordance with dietary practices.

Findings Included

During record review Patient #1's record revealed that a Nutrient Assessment was completed on 09/25/16. The record documentation revealed that Patient #1 only received Ensure/Boost on 01/28/16 and 01/29/16.

During an interview on 01/25/16 Personnel #1 was asked if the hospital could explain why there was only documentation that Patient #1 received the Ensure/Boost 2 out of the 5 remaining days the patient was hospitalized .
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on record review and interview, the facility failed to ensure that a registered nurse was supervising and/or evaluating the nursing care of 1 of 1 patient (Patient #1).

Findings included:


1. M. D. order to monitor vital signs of Patient #1 every four hours while awake. M. D. orders were not followed by the nursing staff. Patient did not have vital signs monitored and recorded every 4 hours.

Vital Signs:
9/24/2016
0900 142/81,96,16,98.1
1400 128/70,70, 16, 97.8,
2000 111/74, 97, 17, 96.6

9/25/2016
0800 160/82; 97; 18; 97.8
2000 141/85; 123; 97.5; 22

9/26/2016 2000 160/78; 114; 18; 97.6

9/27/2016:
1415 143/79; 147; 98%
1434 143/79; 157; 98%
1437 116/69; 137; 95%
1446 124/79; 116; 97%

9/28/2016
0435 121/61; 145
0540 129/71; 115
0855 131/65; 95
2100 116/69; 86; 20; 97.7

9/29/2016:
0850 128/67; 123; 20; 97.6
2000 143/66; 110; 16; 97.0

9/30/2016
No vital signs recorded


2. Registered Dietician/M. D. orders for Patient #1 to have Boost/Ensure TID. Patient #1 did not receive Boost as ordered.

Order written 9/27/2016 at 1300.

9/27/2016 No Boost/Ensure given

9/28/2016 0855 1 can Boost

9/29/2016 0850 1 can Boost
9/29/2016 2030 Boost not available.

9/30/2016 No documentation of any Boost/Ensure administered this date.


3. 9/27/2016 Code Blue was called at 1425. Crash cart brought to room. No code sheet could be produced. Patient with chest pain and heart rate ranging from 130-170. Patient was given ordered medications. Patient was not transferred to the emergency room to be evaluated.


4. Nursing documentation is incomplete.

9/25/2016 AM Nursing shift Assessment Not Signed or date/timed.

9/26/2016 Nursing Assessment: Time _____(not documented)

9/28/2016 0855 Nursing Assessment: No vital signs recorded. Nursing assessment not signed, dated or timed

9/30/2016 2000 Nursing Shift Assessment
"MHT 1:1 sitter reports that patient is found bleeding. Staff seen that patient is on a pool of blood, bleeds from the nose. Staff tried to wake this patient up, found that he is unresponsive, able to open his eyes, but was not able to talk, staring at his ceiling. Staff cleaned him up, changed clothes. (Patient urinated on the bed.) Vital signs 159/99; 133; 81; 18; 97.6) unsteady gait, unable to stand. Tried to reach on call doctor, left message, house supervisor notified (left message to call back.) Patient had no breathing difficulty, 02 on room air 96%. Called 911 and sent out to Baylor Garland ER. Parents notified. The morning shift reported that patient is not eating his lunch and dinner and has been sleeping all day. No meds. administered during this day. Staff accompanied with this patient to ER. Will update with the staff."


5. Emergency medications ordered and administered without documented reasons for the "Now/STAT" medications and/or reassessment after medication to document patient's response to medication.

Emergency Medications Administered:
9/ 6 1530 Verbal order received from Dr. Gautam for Ativan 1 mg. IM, Benadryl 50 mg. IM and Haldol 5 mg. IM stat, same administered. Order not signed.

9/26/2016 Time _____(not documented)
124/95; 99; 14; 97.6 "Patient received walking up and down the hall non-stop back and forth. Not bothering anyone, not speaking; only responds to his name. Patient at times stripping naked walking down hall without clothes, very psychotic, posing in one position for lengths of time, picking his nose, wiping mucous on his clothing. Not speaking in conversation, but answering short questions with short answers and at times no answering at all. Patient is not combative, but has to be observed closely.
11:00 AM Patient now being observed by Tech in a 1:1 until Dr. Bhatia gives further instructions and for Pt. safety.
1325 PM Patient getting very hard to handle with 1:1 and Tech. Trying to bang his head into the wall
1340 Called Dr. Bhatia for ER meds. Left Message in phone.
1342 Dr. Bhatia called again for meds.
1355 Telephone order to give 5 mg Haldol and 50 mg. Benadryl. IM Now
1410 Given 5 mg. Haldol and 50 mg. Benadryl right hip.
1500 Patient much quiet but still continues strange behavior.
1630 Recreational therapist here; Line of Sight
1630 Recreational therapist with patient came to report patient tongue look like it is swollen deep red/purplish.
1632 Patient had tongue hanging out of his mouth drooling on himself. Patient looks as if he bit his tongue. Small amount of blood mixed in with saliva. Dr. Bhatia here on floor asked what does he want to do. Robert, Recreational Therapist also stated he spoke with patient and patient admits that he did bath salts and pills, but type of pills are unknown.
1640 T/O from Dr. Bhatia. Give Cogentin 1 mg IM, read back.
1650 Given Cogentin 1 mg. IM in right hip with the assistance of Brantly and Robert, Recreational Therapist for swollen tongue will continue to observe for change.

9/27/2016
8:03 AM Physician Progress Notes: "Patient seen, chart reviewed and discusses with staff. Sleep decreased. Appetite normal; no somatic symptoms reported. Pacing around, irritable. Residual psychosis, give Cogentin for probable EPS." Signed Dr. Bhatia 9/27/2016 1000

MD Orders: 9/26/2016 Order not timed
1. Monitor VS Q4 hours while awake
2. EKG (NOT IN THE MEDICAL RECORD; NO NOTES BY PHYSICIAN THAT HE REVIEWED THE EKG)
3. Discontinue Seroquel
4. Risperedal 1 mg. q AM 2mg q HS get consent before starting.

9/27/2016 1000 133/67: 169; 20
1030 "Writer observed patient pacing the hallway pants torn, he appeared to have a flat affect not responding to his name. He soon returned to room and appeared to be stretching on his bed, drooling. He soon responded, got up from bed and walked out of room, pacing the hallways. A female tech was asked to watch him closely as he appeared to have unsteady gait.
1415 Patient in bed, eyes open, responding to name by grunting, like he was in pain. When asked to touch area of pain, he touched the lower part of his left shoulder. He continues to drool. Writer informed patient was unable to swallow food earlier and food had to be taken out of his mouth as he appeared to be choking on it. Vital signs elevated but kept fluctuating up and down. Dr. Taylor was notified of this finding. He asked if patient received scheduled BP meds and patient had per nurse.
He was soon seen by Dr. Bhatia who ordered Ativan 1 mg. and Cogentin 1 mg. both administered. Patient soon fell asleep. Will continue to monitor for safety."

9/29/2016 2200 138/66; 100; 18; 97.8 "Patient continues to be almost catatonic. No verbal responses. Drooling from mouth. Taking medications as ordered. Slowed voluntary movements. Unable to determine risks. Blank stare.
Continue to monitor 1:1 close observation."

9/30/2016 0745 Nursing Shift Assessment: No Vital signs recorded.
0745: "Received Patient awake but lethargic, Patient is [AGE] year old WM who snorted bath salts and took pills unknown quantity or name. Patient has been psychotic almost catatonic, but patient does and can answer to his name, obeys command, but needs lots of 1:1 help. Patient is sitting up in chair and trying to stand. Spoke with patient to tell him that, not to stand up or he may fall and hurt himself. Patient is on 1:1 for his safety.
0945 Medication Nurse attempted to give patient medication several times but asleep, unable to swallow at this time. Will attempt later.
1130 Awaken to eat lunch, but patient asleep, breathing unlabored on his side. No distress noted.
1325 Asked MHT (Mental health tech) had patient tried to eat, MHT stated no, also patient refused to drink H2O. Encouraged MHT to encourage Patient to at least take some H20 or juice.
1420 Patient refused juice and refused once again medication.
1720 Patient on left side remains asleep. Breathing unlabored. Attempted to give H20. Patient refused H20."
9/30/2016 2000 Nursing Shift Assessment
"MHT 1:1 sitter reports that patient is found bleeding. Staff seen that patient is on a pool of blood, bleeds from the nose. Staff tried to wake this patient up, found that he is unresponsive, able to open his eyes, but was not able to talk, staring at his ceiling. Staff cleaned him up, changed clothes.
(Patient urinated on the bed.) Vital signs 159/99; 133; 81; 18 97.6) unsteady gait, unable to stand. Tried to reach on call doctor, left message, house supervisor notified (left message to call back.) Patient had no breathing difficulty, 02 at room air 96%. Called 911 and sent out to Baylor Garland ER. Parents notified. The morning shift reported that patient is not eating his lunch and dinner and has been sleeping all day. No meds. administered during this day. Staff accompanied with this patient to ER. Will update with the staff.
2130 The staff accompanied with this patient to this ER informed that patient being transferring to Children's Medical Center for further evaluation and higher level medical.
10/1/16 0100 Staff notified that patient is being admitted in Children's Medical Center."

Interview:
An interview was conducted on 11/1/2017 at 10:00 with Personnel #2. Personnel #2 has been at Sundance since July, 2017. She stated that she was not at Sundance when this patient was here. Nursing Documentation is one area that she feels needs to be improved. She stated that there needed to be more detailed documentation. Also, the staff need to give Patients alternatives other than to be given IM stat medications. Personnel #2 stated that Human Resources (HR) have not been doing a very good job of screening their nurses. They have hired a new Human Resources Director. When I requested to interview nurses that was listed on the patient's chart, Personnel #2 stated the nurse did not work here anymore. Personnel #2 stated they have let a lot of nurses go and have hired and are training their staff a lot better. Personnel #2 and I walked through each day of the medical record. There were days that were incomplete with no vital signs, no nurse signature, no date and time of nursing documentation. During the chart review, there was an order for an EKG but no EKG was in the chart. No notes from the Dr. that he reviewed the EKG.Personnel #2 confirmed there was no EKG documented in the Patient #1 chart. On 9/27/2016, the patient had chest pain and elevated heart rate (130-170) a Code was called and one nurse went for the crash cart and the other nurse stayed with the patient. Personnel #2 stated that this patient should have been sent out to the emergency room . However, the patient was medicated and was not sent for emergency medical attention.

Policy Review:

Assessment and Reassessments of Patients Date Revised: 9/26/2016
" RN will reassess the patient based on the patient's needs, but at least every 12 hours after the initial comprehensive nursing assessment has been completed...Patient problems, interventions, responses to treatment, and changes in patient condition are identified and documented each shift by a licensed nurse. Any new/abnormal findings or changes in the patgient's condition are documented in the medical record. Such findings are reported to the RN/Charge Nurse if identified by other than RN staff...The physician is notified, as appropriate and nursing interventions and physician's orders are implemented...Nursing reassessment will occur when there is a change in the patient's condition, physical complaint, with any procedures, with medication side effects, etc...Documentation provides a complete, current, and concise description of the patient status, changes in condition, and treatments given with the least duplication of information possible...Abnormal, unexpected, or non-standard responses and treatments are documented in detail."