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 Sept. 14, 2017
VIOLATION: REASSESSMENT OF A DISCHARGE PLAN Tag No: A0821
Through record review, interview hospital failed to meet the needs of 1 patient (Patient #6) by failing to reassess the patient's discharge plan that may affect continuing care needs or the appropriateness of the discharge plan.

Findings Included:

During record review the hospital failed to complete a home safety precaution plan for Patient #6. The documentation was found in the file blank.

During record review the hospital failed to complete a discharge/aftercare plan when Patient #6 needed continued care. The supporting documentation was a blank discharge/aftercare plan in the patient medical record.

During record review the hospital failed review the Physician's Daily Progress Note on 09/02/17 date of discharge that reflected Justification for continued stay "Mood Stabilization," assessment of Progress towards treatment goals and response to treatment; "No Improvement."

During Interview with Personnel #1, revealed that the family had an attorney and threatened to sue the hospital if the patient was not discharged .

During Interview with Personnel #3, Personnel #3 was unable to answer why forms were left blank prior to the patient being discharged , and or why was there not a home safety plan provided for the patient and family at discharge.

Policy
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."

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."

The hospital Nursing Services Policy dated 08/11/14 reflected, "Sundance Hospital maintains an organized plan for nursing service that provides 24-hour nursing service as needed. Nursing service is under the authority of the Chief Nursing Officer ...a valid and current license while employed at the facility ...A registered nurse (RN) shall be available to provide care for any patient as needed."

The hospital Discharge/Aftercare Planning policy dated 09/26/16 reflected, "The development of a Discharge Plan begins on admission. As a component of the assessment process. The patient's demonstrated readiness for discharge should be linked to the achievement of inpatient treatment goals ...Discharge goals represent the achievements expected for the identified problem by the time of discharge when the patient is ready to move into a less intensive level of care."
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Through interview and record review the hospital failed to promote the patient's rights of 2 of 2 Patient's (Patient #6 and Patient #9) by providing care in a safe setting.

Findings Include:

During record review Patient #6 was admitted into the hospital on APOWW (Apprehension without a Warrant) status. Patient #6 was not taken to court with in the first 72 to hours of admission into the hospital. Patient #6 did not sign into the hospital as they were under APOWW status. The patient was being held in the hospital against their will.

During record review Patient #9 did not receive a blanket or pillow until the third day of admission into the hospital.

During interview Personnel #8 reported that Patient #6 did not go to court, because the doctor wanted to wait and see how the patient would do once they became medication compliant. Patient #6 did not become medication compliant.

During an interview with Personnel #6 reported that Patient #9 did not have a blanket or pillow until she spoke to the parent on the telephone and informed them she now has a blanket and pillow.


Policy
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."

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."

The hospital Nursing Services Policy dated 08/11/14 reflected, "Sundance Hospital maintains an organized plan for nursing service that provides 24-hour nursing service as needed. Nursing service is under the authority of the Chief Nursing Officer ...a valid and current license while employed at the facility ...A registered nurse (RN) shall be available to provide care for any patient as needed."

The hospital Discharge/Aftercare Planning policy dated 09/26/16 reflected, "The development of a Discharge Plan begins on admission. As a component of the assessment process. The patient's demonstrated readiness for discharge should be linked to the achievement of inpatient treatment goals ...Discharge goals represent the achievements expected for the identified problem by the time of discharge when the patient is ready to move into a less intensive level of care."