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 May 4, 2017
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
Based on interview and record review, the hospital failed to ensure 1 of 1 patient (Patient #1) a minor who demonstrated active/worsening EPS symptoms was evaluated, re-assessed and a plan of care determined. Patient #1 was discharged home with active/worsening EPS symptoms with no documentation for plan of care and/or action plan.

Findings included:

Patient #1's Risk Notification Alert dated 06/10/16 timed at 1058 reflected, "Self-harm indicators...hits head on the floor, used knife to go after mom, physically aggressive..."

The physician's pre-admission examination orders and preliminary plan of care dated 06/10/16 reflected, "Medications...Catapress 0.1 mg (milligrams) by mouth TID [three times a day], Ritalin 20 mg TID, Zyprexia 7.5 mg at bedtime, Risperdal 0.5 BID [twice daily]....to continue..."

The physician's orders dated 06/11/16 timed at 1740 reflected, "Discontinue Zyprexia..."

The physician's orders dated 06/14/16 timed at 0830 reflected, "Cogentin 1 mg po BID (twice daily) for EPS..."

The 06/14/16 physician daily progress note timed at 0830 reflected, "Positive hand tremors..."

The 06/14/16 nursing progress note timed at 0940 reflected, "He was drooling and had some minor hand tremors, Cogentin 1 mg was given at 1845...mom expressed concern for the EPS and hand tremors..."

The 06/14/16 Therapy Note timed at 1700 reflected, "Director of Clinical Services met with patient, mother and grandmother...concerns about patient drooling...mother stated this is not how he used to be...house supervisor met with family to address their concerns regarding patients medications." No documentation from the house supervisor was found.

The 06/15/16 nursing progress notes timed at 0918 reflected, "Patient had visible tremors and was drooling...at 1850...has slurred speech and involuntary hand movements..."

The Pharmacy Communication record dated 06/15/16 timed at 0931 reflected, "Therapeutic duplication with cogentin and benadryl...consider other antipsychotic if EPS not controlled with a single medication or consider discontinue of either medication and increasing the other...cogentin and Benadryl discontinued..."

The physician's orders dated 06/15/16 timed at 1310 reflected, "Benadryl 25 mg po (by mouth) BID for EPS..."

The physician's orders dated 06/15/16 timed at 1517 reflected, "Discontinue Cogentin...Clonazepam 0.25 po BID (severe EPS) give first dose now...06/16/16 at 1120...discontinue Benadryl."

The 06/17/16 therapy note timed at 0900 to 1000 reflected, "Patient shaking was visibly present throughout much of group, and hindered patients ability to use scissors or draw..."

The physician daily progress note dated 06/18/16 timed at 0830 reflected, "EPS...tremors..."

The 06/18/16 nursing progress note timed at 2000 reflected, "EPS tremors continue...requires assistance to take pills due to tremors...Klonopin given for EPS..."

The 06/19/16 nursing progress note timed at 0805 reflected, "Visible tremors and was drooling...ate breakfast with assistance..."

The physician daily progress note dated 06/19/16 timed at 0843 reflected, "EPS increased..."

The physician Discharge order dated 06/20/16 timed at 0945 reflected, "Klonopin 0.5 mg [milligrams] po [by mouth] BID [twice daily] for EPS [Extrapyramidal symptoms], anxiety, Catapress 0.1 mg po TID for impulsive behavior...Risperdal 0.5 mg po BID [twice daily] for mood stabilization, Trazadone 50 mg po at hour of sleep..."

The 06/20/16 nursing progress note timed at 1544 reflected, "Patient slipped in bathroom staff attempted to get hold of him...hit the ground...hit his nose...no injury noted continues with tremors and continuous movement...at 1910...discharged home with belongings and parents...parents requested to see supervisor..." No documentation was found indicating the Supervisor saw Patient #1's parents and no nursing re-assessment was found prior to discharge.

The physician discharge summary dated 07/25/16 timed at 1410 reflected, "Final diagnoses...disruptive mood dysregulation disorder, rule out intermittent explosive disorder, rule out autism spectrum disorder...physical status...medically stable with the patient appearing in no acute physical distress...medication tolerated and adjusted..."

On 05/04/17 at 1049 Personnel #11 was interviewed. Personnel #11 reviewed Patient #1's medical record. Personnel #11 stated the Patient #1's EPS symptoms worsened according to the medical record. Personnel #11was asked although the nurses were charting side effects the surveyor could find no documentation consistently notifying the physician of Patient #1's clinical changes. Personnel #11 stated the nursing staff should have notified the physician of their findings and verified Patient #1 was not re-assessed prior to discharge. Personnel #11 verified Patient # 1's condition worsened right up to discharge.

On 05/04/17 at 1137 Personnel #12 was interviewed. Personnel #12 was asked to review Patient #1's medical record. Personnel #12 stated she remembered reviewing the chart for orders for Benadryl and Cogentin ordered for Patient #1 and recommended the physician either change the psychoactive medication or order Cogentin or Benadryl not both. Personnel #12 stated she could not remember looking at anything further for Patient #1.

On 05/04/17 at 1351 Personnel #10 was interviewed. Personnel #10 stated he remembered Patient #1. Personnel #10 stated the patient had some tremors and he was not sure if it was due to EPS, or due to stopping neuroleptic medications. Questioned why the patient was discharged home with EPS symptoms worsening before and at discharge. Personnel #10 did not offer an explanation. Personnel #10 was asked why his plan of care was not documented. Personnel #10 was referred to the medical record where no documentation/assessment was performed prior to patient being discharged nor was any documentation found with specific information on the hospitals plan of care for the patient.
VIOLATION: MEDICAL STAFF ACCOUNTABILITY Tag No: A0347
Based on interview and record review the hospital failed to ensure 1 of 1 physician (Personnel #10) provided quality of medical care for 1 of 1 patient (Patient #1) a minor patient. Patient #1 had active worsening EPS (Extrapyramidal symptoms) throughout inpatient stay with no improvement in status. Patient #1 was discharged home with active/worsening EPS symptoms with no documentation for continued plan of care.

Findings included:

Patient #1's Risk Notification Alert dated 06/10/16 timed at 1058 reflected, "Self-harm indicators...hits head on the floor, used knife to go after mom, physically aggressive..."

The physician's pre-admission examination orders and preliminary plan of care dated 06/10/16 reflected, "Medications...Catapress 0.1 mg (milligrams) by mouth TID [three times a day], Ritalin 20 mg TID, Zyprexia 7.5 mg at bedtime, Risperdal 0.5 BID [twice daily]....to continue..."

The physician's orders dated 06/11/16 timed at 1740 reflected, "Discontinue Zyprexia..."

The physician's orders dated 06/14/16 timed at 0830 reflected, "Cogentin 1 mg po BID (twice daily) for EPS..."

The 06/14/16 physician daily progress note timed at 0830 reflected, "Positive hand tremors..."

The 06/14/16 nursing progress note timed at 0940 reflected, "He was drooling and had some minor hand tremors, Cogentin 1 mg was given at 1845...mom expressed concern for the EPS and hand tremors..."

The 06/14/16 Therapy Note timed at 1700 reflected, "Director of Clinical Services met with patient, mother and grandmother...concerns about patient drooling...mother stated this is not how he used to be...house supervisor met with family to address their concerns regarding patients medications." No documentation from the house supervisor was found.

The 06/15/16 nursing progress notes timed at 0918 reflected, "Patient had visible tremors and was drooling...at 1850...has slurred speech and involuntary hand movements..."

The Pharmacy Communication record dated 06/15/16 timed at 0931 reflected, "Therapeutic duplication with cogentin and benadryl...consider other antipsychotic if EPS not controlled with a single medication or consider discontinue of either medication and increasing the other...cogentin and Benadryl discontinued..."

The physician's orders dated 06/15/16 timed at 1310 reflected, "Benadryl 25 mg po (by mouth) BID for EPS..."

The physician's orders dated 06/15/16 timed at 1517 reflected, "Discontinue Cogentin...Clonazepam 0.25 po BID (severe EPS) give first dose now...06/16/16 at 1120...discontinue Benadryl."

The 06/17/16 therapy note timed at 0900 to 1000 reflected, "Patient shaking was visibly present throughout much of group, and hindered patients ability to use scissors or draw..."

The physician daily progress note dated 06/18/16 timed at 0830 reflected, "EPS...tremors..."

The 06/18/16 nursing progress note timed at 2000 reflected, "EPS tremors continue...requires assistance to take pills due to tremors...Klonopin given for EPS..."

The 06/19/16 nursing progress note timed at 0805 reflected, "Visible tremors and was drooling...ate breakfast with assistance..."

The physician daily progress note dated 06/19/16 timed at 0843 reflected, "EPS increased..."

The physician Discharge order dated 06/20/16 timed at 0945 reflected, "Klonopin 0.5 mg [milligrams] po [by mouth] BID [twice daily] for EPS [Extrapyramidal symptoms], anxiety, Catapress 0.1 mg po TID for impulsive behavior...Risperdal 0.5 mg po BID [twice daily] for mood stabilization, Trazadone 50 mg po at hour of sleep..."

The 06/20/16 nursing progress note timed at 1544 reflected, "Patient slipped in bathroom staff attempted to get hold of him...hit the ground...hit his nose...no injury noted continues with tremors and continuous movement...at 1910...discharged home with belongings and parents...parents requested to see supervisor..." No documentation was found indicating the Supervisor saw Patient #1's parents and no nursing re-assessment was found prior to discharge.

The physician discharge summary dated 07/25/16 timed at 1410 reflected, "Final diagnoses...disruptive mood dysregulation disorder, rule out intermittent explosive disorder, rule out autism spectrum disorder...physical status...medically stable with the patient appearing in no acute physical distress...medication tolerated and adjusted..."

On 05/04/17 at 1049 Personnel #11 was interviewed. Personnel #11 reviewed Patient #1's medical record. Personnel #11 stated the Patient #1's EPS symptoms worsened according to the medical record. Personnel #11was asked although the nurses were charting side effects the surveyor could find no documentation consistently notifying the physician of Patient #1's clinical changes. Personnel #11 stated the nursing staff should have notified the physician of their findings and verified Patient #1 was not re-assessed prior to discharge. Personnel #11 verified Patient # 1's condition worsened right up to discharge.

On 05/04/17 at 1351 Personnel #10 was interviewed. Personnel #10 stated he remembered Patient #1. Personnel #10 stated the patient had some tremors and he was not sure if it was due to EPS, or due to stopping neuroleptic medications. Questioned why the patient was discharged home with EPS symptoms worsening before and at discharge. Personnel #10 did not offer an explanation. Personnel #10 was asked why his plan of care was not documented. Personnel #10 was referred to the medical record where no documentation/assessment was performed prior to patient being discharged nor was any documentation found with specific information on the hospitals plan of care for the patient.
VIOLATION: PATIENT RIGHTS: INFORMED CONSENT Tag No: A0131
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview, the hospital failed to involve the patient in treatment planning in that 1 of 2 (Patient #20) did not have a Multidisciplinary Treatment Plan completed during their hospitalization .

Findings Included:

The admission paper work reflected Patient #20 was admitted inpatient on 10/16/16 for Psychosis, unspecified, not due to a substance or known physiological condition, and a discharge summary reflected a discharge date of [DATE]. An Initial Treatment Plan was initiated on 10/17/16. The undated Multidisciplinary Treatment Plan was blank.

On 05/04/17 at 1220 Personnel #1 and Personnel #3 were asked to review Patient #20's medical record. The Multidisciplinary Treatment Plan was blank.
VIOLATION: REASSESSMENT OF A DISCHARGE PLAN Tag No: A0821
Based on interview and record review, the hospital failed to ensure 1 of 1 patient (Patient #1) a minor who demonstrated active/worsening EPS (Extrapryamidal symptoms) was re-assessed and a discharge plan was initiated. Patient #1 was discharged home with active/worsening EPS symptoms with no documentation for plan of care and/or action plan.

Findings included:

Patient #1's Risk Notification Alert dated 06/10/16 timed at 1058 reflected, "Self-harm indicators...hits head on the floor, used knife to go after mom, physically aggressive..."

The physician's pre-admission examination orders and preliminary plan of care dated 06/10/16 reflected, "Medications...Catapress 0.1 mg (milligrams) by mouth TID [three times a day], Ritalin 20 mg TID, Zyprexia 7.5 mg at bedtime, Risperdal 0.5 BID [twice daily]....to continue..."

The physician's orders dated 06/11/16 timed at 1740 reflected, "Discontinue Zyprexia..."

The physician's orders dated 06/14/16 timed at 0830 reflected, "Cogentin 1 mg po BID (twice daily) for EPS..."

The 06/14/16 physician daily progress note timed at 0830 reflected, "Positive hand tremors..."

The 06/14/16 nursing progress note timed at 0940 reflected, "He was drooling and had some minor hand tremors, Cogentin 1 mg was given at 1845...mom expressed concern for the EPS and hand tremors..."

The 06/14/16 Therapy Note timed at 1700 reflected, "Director of Clinical Services met with patient, mother and grandmother...concerns about patient drooling...mother stated this is not how he used to be...house supervisor met with family to address their concerns regarding patients medications." No documentation from the house supervisor was found.

The 06/15/16 nursing progress notes timed at 0918 reflected, "Patient had visible tremors and was drooling...at 1850...has slurred speech and involuntary hand movements..."

The Pharmacy Communication record dated 06/15/16 timed at 0931 reflected, "Therapeutic duplication with cogentin and benadryl...consider other antipsychotic if EPS not controlled with a single medication or consider discontinue of either medication and increasing the other...cogentin and Benadryl discontinued..."

The physician's orders dated 06/15/16 timed at 1310 reflected, "Benadryl 25 mg po (by mouth) BID for EPS..."

The physician's orders dated 06/15/16 timed at 1517 reflected, "Discontinue Cogentin...Clonazepam 0.25 po BID (severe EPS) give first dose now...06/16/16 at 1120...discontinue Benadryl."

The 06/17/16 therapy note timed at 0900 to 1000 reflected, "Patient shaking was visibly present throughout much of group, and hindered patients ability to use scissors or draw..."

The physician daily progress note dated 06/18/16 timed at 0830 reflected, "EPS...tremors..."

The 06/18/16 nursing progress note timed at 2000 reflected, "EPS tremors continue...requires assistance to take pills due to tremors...Klonopin given for EPS..."

The 06/19/16 nursing progress note timed at 0805 reflected, "Visible tremors and was drooling...ate breakfast with assistance..."

The physician daily progress note dated 06/19/16 timed at 0843 reflected, "EPS increased..."

The physician Discharge order dated 06/20/16 timed at 0945 reflected, "Klonopin 0.5 mg [milligrams] po [by mouth] BID [twice daily] for EPS [Extrapyramidal symptoms], anxiety, Catapress 0.1 mg po TID for impulsive behavior...Risperdal 0.5 mg po BID [twice daily] for mood stabilization, Trazadone 50 mg po at hour of sleep..."

The 06/20/16 nursing progress note timed at 1544 reflected, "Patient slipped in bathroom staff attempted to get hold of him...hit the ground...hit his nose...no injury noted continues with tremors and continuous movement...at 1910...discharged home with belongings and parents...parents requested to see supervisor..." No documentation was found indicating the Supervisor saw Patient #1's parents and no nursing re-assessment was found prior to discharge.

The physician discharge summary dated 07/25/16 timed at 1410 reflected, "Final diagnoses...disruptive mood dysregulation disorder, rule out intermittent explosive disorder, rule out autism spectrum disorder...physical status...medically stable with the patient appearing in no acute physical distress...medication tolerated and adjusted..." No documentation was found which addressed specfic discharge plans which addressed Patient #1's EPS symptoms.

On 05/04/17 at 1049 Personnel #11 was interviewed. Personnel #11 stated Patient #1's EPS symptoms worsened according to the medical record. Personnel #11 stated the nursing staff should have notified the physician of their findings and verified Patient #1 was not re-assessed prior to discharge. Personnel #11 verified Patient # 1's condition worsened right up to discharge and the discharge paperwork did not address Patient #1's active EPS upon discharge.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0167
Based on record review and interview, the hospital failed to ensure a restraint was implemented in accordance with state law and/or hospital policy for one of one patient (Patient #11). Patient #11 was set to transfer to a different hospital. The physician ordered a transport jacket. The restraint order did not specify time limit, special consideration, and/or monitoring requirements for the patient who suffered from high blood pressure.

Findings included:

Patient #11's physician psychiatric evaluation dated 08/08/16 at 0920 reflected admission diagnoses that included Schizophrenia. The patient was noted to have "poor" judgment, suffered from auditory and visual hallucinations, and had suicidal thoughts of jumping off a bridge. Patient #11 had a history of high blood pressure.

Patient #11' physician orders dated 08/08/16 timed at 1450 reflected an order to transfer the patient to another hospital.

Nurses' notes dated 08/08/16 at 1600 reflected Patient #11's blood pressure to be 144/100 mmHg.

Patient #11's physician orders dated 08/08/16 at 1800 reflected to place the patient into a "transport jacket for safety" during the transfer to the receiving hospital. The order did not reflect a time limit, special considerations for the use of restraint, and/or instructions for monitoring Patient #11 during the restraint.

Hospital Policy titled "Transport Jacket for Transfer of Involuntary Patients" dated 04/21/16 defined the transport jacket as a restraint and reflected "all orders for restraint...have time limitations..."

25TAC 415.273(c1-5) reflected "the physician's order for the restraint shall specify...a time limit on the use of the restraint...any special considerations for the use of restraint...instructions for monitoring the individual."

During an interview on 05/04/17 at 1145 Personnel #1 acknowledged that the order did not have specifications.