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 31, 2017
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 Registered Nurses completed a nursing admission assessment, obtained vital signs and/or evaluated 1 of 1 (Patient #1) who was administered multiple doses of emergent psychoactive medication and who demonstrated episodes of lethargy during his inpatient stay.

Findings included:

1) Patient #1's Nursing assessment dated [DATE] timed at 2250 reflected, "Pages 2 through page 10 was left incomplete. Page 13 admission summary revealed patient brought to adult unit restless, jumping and cursing refused vital signs, skin assessment unable to communicate needs...at 2230...patient actively psychotic unable to complete assessment at this time..." No further documented attempts were found in the clinical record which indicated the nursing assessment was completed.

The physician's orders dated 03/22/16 timed at 2210 reflected, "Ativan 1 mg (milligrams) IM (intramuscular) now times one...Haldol 5 mg IM now times one dose, Benadryl 25 mg IM now times one dose..."

The Nursing Progress Notes dated 03/23/16 timed at 1020 reflected, "Patient was loud, impulsive and disruptive...urgent intra-muscular medication was ordered..." No follow-up assessment and/or vital signs were obtained.

The Behavioral Health Integrative Psychiatric assessment dated [DATE] timed at 1340 reflected, "Patient has a history of schizophrenia and mild autism and mental retardation...believes he hears songs...has a history of self-harm, cutting..."

The physician's orders dated 03/23/16 reflected, "Haldol 5 mg, Benadryl 25, Ativan 1 mg now for agitation..."

The physician's orders dated 03/24/16 reflected, "Haldol 10 mg, Ativan 2 mg, Benadryl 5 mg times one dose for aggressive behavior..."

The Nursing Progress Notes dated 03/25/16 timed at 0100 reflected, "Patient comes toward nursing station at this time...patient tried to grab MHT (mental health technician) and became physically aggressive and throwing things...Haldol 10 mg/Benadryl 50 mg, Ativan 2 mg ordered and administered at this time..." No vital signs were documented.

The Nursing Progress Notes dated 03/25/16 timed at 0814 reflected, "Patient looked very distracted...frequently needs redirection...patient looked sedated..." No follow-up assessment was documented and/or vital signs obtained.

The Nursing Progress Notes dated 03/26/16 timed at 0130 reflected, "Patient cursing and physically aggressive...Dr. notified Haldol, Benadryl, Ativan ordered and administered at this time..." No vital signs were documented.

The Hospital Healthcare Therapy Note dated 03/26/16 timed from 1500-1600 reflected, "Presented as lethargic, distracted and flat in group...difficulty completing tasks, following directions..." No nursing intervention and/or assessment was documented.

The 03/27/16 Nursing Progress Notes timed at 0305 reflected, "Patient started being aggressive, agitated, oppositional to staff...started slamming the nursing station door...at 0315 Dr. notified...ordered Haldol 10 mg, Ativan 2 mg, Benadryl 50 mg IM times one dose..." No vital signs were documented.

The 03/27/16 Hospital Behavioral Healthcare Therapy Note timed at 1130-1230 reflected, "Inability to focus on activity and was observed as having slurred or poverty of speech..." No nursing intervention and/or assessment was documented.

The 03/27/16 Nursing Progress Notes timed at 2035 reflected, "Patient standing in day area, appeared lethargic..." No vital signs and/or follow-up assessment was documented.

The 03/28/16 Nursing Progress Notes timed at 0340 reflected, "Patient became physically aggressive and agitated...hitting the door on the nursing station...Dr. notified...Benadryl 50 mg, Ativan 2 mg, Haldol 10 mg IM times one dose ordered and administered..." No vital signs and/or follow-up assessment was documented.

The physician's orders dated 03/29/16 timed at 0104 reflected, "Haldol 5 mg, Ativan 2 mg, Benadryl 50 mg IM times one dose for aggressive behavior/agitation..."

The 03/29/16 Nursing Progress Note timed at 0140 reflected, "Patient became very aggressive and disruptive...redirection failed...Dr. notified...Haldol 5 mg, Benadryl 50 mg, Ativan 2 mg IM times one dose..." No vital signs and/or follow-up assessment was documented.

The 03/29/16 Nursing Progress Note timed at 0851 reflected, "Patient looked very lethargic..." No vital signs and/or follow-up assessment.

The physician daily progress notes dated 03/29/16 timed at 0755 reflected, "verbally/physically aggressive, jumped over nurses station/attempted to...required emergency medications..."

The physician's orders dated 03/29/16 timed at 1700 reflected, "Haldol 5 mg, Ativan 1 mg, Benadryl 25 mg IM times one for acting out, severe agitation..."

The physician's orders dated 03/30/16 timed at 0250 reflected, "Haldol 5 mg IM, Ativan 1 mg IM, Benadryl 25 mg IM times one dose for agitation/aggression..."

The Healthcare Therapy Note dated 03/30/16 timed at 1330-1430 reflected, "Patient was very psychotic and delusional at points and also appeared very lethargic...poor boundaries."

The Nursing Progress Notes dated 03/30/16 timed at 2225 reflected, "Patient noticed with sluggish movement out in the hallway...patient aggressive and assaultive."

The Nursing Progress Notes dated 03/31/16 timed at 0100 reflected, "Patient is oppositional and enable to adhere to redirection given...Ativan 2 mg IM ordered and administered." No vital signs and/or follow-up assessment was documented.

The 04/01/16 Nursing Progress Notes timed at 1401 reflected, "Patients guardian signed all his discharge documents before leaving the facility...collected all his belongings..." No patient assessment was documented before discharge.

The Policy and Procedure entitled, "Assessment and Reassessments of Patients" with a revision dated 09/26/16 reflected, "An accurate record of the patient's condition, care, and treatment is provided throughout the hospital visit ...admission assessments and histories are completed upon arrival to the hospital ...reassessments are documented when there is a significant change in patient status, post procedure ...or as warranted or recommended.

On 05/31/17 at 1240 Personnel #3 was interviewed. Personnel #3 reviewed Patient #1's medical record. Personnel #3 verified vital signs and follow-up nursing assessments were not completed for emergent psychoactive medication administered to Patient #1 and for episodes of lethargy. Personnel #3 was asked by the surveyor to review the medical record and provide evidence the nursing staff completed a Nursing Assessment for Patient #1. Personnel #3 verified the patient nursing assessment was left incomplete and never completed.