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.

Based on record review, interview the hospital failed to provide to provide patient (Patient #3) with the right to receive care in a safe setting.

Findings Include:

During record review the hospital Behavior Intervention Response Plan notes on 08/11/17 at 2033 reflected, "Patient involved in a small incident between another peer Curtis. He was hit by peer during an argument."

During the interview with the hospital personnel #12 stated, "I was told the Patient #25 struck Patient #3 in the face with his hand."

The hospital Patient Rights Policy dated 09/2016, "All patients receiving mental health services at Sundance Hospital will be granted the following rights: The rights, benefits, responsibilities, and privileges ...The right to presumption of mental competency in the absence of a judicial determination to the contrary ...The right to appropriate treatment in the least restrictive appropriate setting available consistent with the protection of the individual ...The right to be informed of those rules and regulations of the hospital relating to expectations of the individual's conduct ...The right to explanations of the care, procedures and treatment to be provided; the risks, side effects, and benefits of all medications and treatment procedures to be." used. Including those that are unusual or experimental; the alternate procedures that are available; and the possible consequences of refusing the treatment or procedure ...The right to information, upon request, pertaining to the cost of services rendered ...The right to be free from unnecessary or excessive medication, which includes the right to give or withhold informed consent to treatment with psychoactive medication, unless the right has been limited by court order or in an emergency ...All persons voluntarily admitted to inpatient services for treatment of mental illness or chemical dependency have to the right to be discharged within four hours of a request for release unless the individuals treating physician determines that there is cause to believe that the individual might meet the criteria for court-ordered mental health services or emergency detention."
Based on interview and record review the hospital failed one of one patient (Patient #3). Patient #3 did not have an updated examination after the changes in the patient's condition after being struck in the face by another patient.

Findings Included:

During record review of Patient #3's medical record the hospital failed to assess Patient #3 after being struck in the face by another patient.

During record review the hospital failed to complete an incident report.

During the interview process Personnel #12 stated, "It would have been me who wrote the incident report."

During the interview process Personnel #12 stated, "the medical record was not documented because an assessment was not completed because there were no visible marks or bruising noted and there was no information for the record for the doctor to follow up with the patient."


The hospital Assessment and Reassessments of Patients Policy dated 08/11/14 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 to the hospital and during the admission process on the inpatient units. Reassessments are documented when there is a significant change in patient status, post procedure ...Patient information obtained during reassessments will be documented in the patient's medical record. The family, guardian and or legally authorized representative will be assisted to be involved throughout the assessment process and in the provision of care of the patient ...A registered nurse (RN) is designated as admitting nurse and is responsible for ensuring the completion of the comprehensive nursing admission assessment ... The RN Nursing Admission is completed within 8 hours of admissions ...An 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 ...An initial Plan of Care is generated from the from the Admission Assessment and begins at the time of admission. The plan of care is individualized, interdisciplinary, and addresses identified patient needs ...Patients and or their legal authorized representative(s), and significant others are authorized through consent, are to be involved in the treatment planning and discharge planning process."