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 July 12, 2017
VIOLATION: PATIENT RIGHTS: PERSONAL PRIVACY Tag No: A0143
Based on Record review and interview the hospital failed to provide privacy to one of one patient (Patient #8). The hospital has failed to follow its own policy.

Findings Included;

Based on a complaint written by Patient #8 reflected a hospital physician would meet with Patient #8 in the hallway.

During an Interview with Personnel #1 it was verified the doctor did have a habit of meeting with the patients in the hallway.

Policy
The hospital HIPAA Privacy Policy date 01/05/15 reflected, "It is the policy of the Facility to make a reasonable effort to use or disclose, or to request from another health care provider, the minimum amount of Protected Health Information to achieve the particular use or disclosure unless an exception applies.
VIOLATION: MEDICAL STAFF RESPONSIBILITIES Tag No: A0359
Based on record review, interview and the hospital failed to ensure that an updated examination of the 1 of 2 patients (Patient #1 and Patient #7), including any changes in the patient's condition assessment reassessment.

Findings Included"

During record review in a complaint patient #1 reported to the Recreational Therapist that Patient #7 "fucked him in the ass last night."
During record review there was no in hospital documentation that patient #1 was assessed by hospital staff. The hospital failed to follow its own policy and assess a patient if there is a change of condition.

Record Review of patient #1's medical record reflected no assessment in the chart.

During an interview with Personnel #16 the medical record was reviewed and the there was no record of an assessment reassessment.

Policy
The hospital Policy on Assessment and Reassessment of Patients dated 01/23/17, reflected, "An accurate record of the patient's condition, care, and treatment is provided throughout the hospital visit. Screening and admission assessments and histories are completed upon arrival ...Reassessments are documented when there is a significant change in patient status."
VIOLATION: ADMINISTRATION OF DRUGS Tag No: A0405
Based on interview and record review the hospital failed to administer medication to one of one patient (Patient #8) in accordance with the Federal and State laws, the orders of the practitioner or practitioners responsible for the patient's care as specified under 482.12 (c) and accepted standards of practice.

Findings Included

During the record review Patient #8 reported the medication (Levothyroxine) should be taken daily at least 30 minutes prior to morning meals.

During the record review of Patient #8's Medication Administration Record on the 16th and 17th the patient did not receive her medication.

During interview with Personnel #20 and Personnel #21 verified the patient should receive her medication on an empty stomach first thing in the morning.

During interview with Personnel #20 it was verified in the medical record that Patient #8 did not receive her medication on the 16th, and 17th.

Policy

The hospital HIPAA Privacy Policy date 01/05/15 reflected, "It is the policy of the Facility to make a reasonable effort to use or disclose, or to request from another health care provider, the minimum amount of Protected Health Information to achieve the particular use or disclosure unless an exception applies.