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 | Oct. 11, 2017 |
| VIOLATION: PATIENT RIGHTS: NOTICE OF RIGHTS | Tag No: A0117 | |
| Based on Interview, Record Review the hospital failed 1 of 1 Patient (Patient #1) their rights by discontinuing care whenever possible. The hospital discharged Patient #1 prior to notifiying their legal guardian. Findings Include: During an Interview with Personnel #11 it was verified that the hospital did not notify Patient #1's legal guardian and allowed Patient #1 to be discharged from the hospital. During Record review of Patient #1's medical chart the Discharge/Aftercare Plan dated 08/28/17 at 1:30 PM was signed by Personnel #11. The information for who the patient was released to was not signed but the destination. The hospital Discharge Policy dated 09/26/2016 reflected, "Discharge planning begins on admission and is provided for Behavioral Health Service inpatients by the interdisciplinary treatment team (IDT), with the involvement of the patient and/or the patient's legally authorized representative (LAR)." The hospital Discharge/Aftercare Planning dated 09/26/16 reflected, "The development of discharge Plan begins on admission ...The patient's demonstrated readiness for discharge should be linked to the achievement of inpatient treatment goal ...The Discharge plan may include but not be limited to recommendations that: prepare the patient and family/significant other(s) for the transition to the next level of care. The hospital Admission, Discharge, and Continued Stay Criteria dated 09/26/16 reflected, "Sundance Hospital seeks to provide quality mental health services to patients admitted for inpatient treatment ...Releasing or transferring the patient to a less intensive level of care does not pose a threat to him/her, others or property ...Patients and family will be involved in treatment team and discharge. The hospital policy Patient Rights dated on 09/26/16 reflected, "All patients receiving mental health services at Sundance Hospital will be granted the following rights: The right to explanations of the care, procedures, and treatment provided ...The right to be transported to, from ...facilities (including community-based services) community centers, and psychiatric hospitals in a way that protects the dignity and safety of individuals." The hospital Policy Abuse Neglect and Exploitation dated 08/01/14 reflected, "Sundance Hospital prohibits the abuse, neglect, and exploitation of patients and or program or services participants ...Neglect ...includes, but is not limited to failure to provide one's self the goods or services ...which are necessary to avoid physical or emotional harm or the failure of a caretaker to provide such goods and services." |
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| VIOLATION: REASSESSMENT OF DISCHARGE PLANNING PROCESS | Tag No: A0843 | |
| Based on Interview, Record Review the hospital failed 1 of 1 Patient (Patient #1) their rights by not reviewing its discharge planning process to ensure it was responsive to the discharge needs. The hospital discharged Patient #1 prior to notifiying their legal guardian. Findings Include: During an Interview with Personnel #11 verified that the hospital did not notify Patient #1's legal guardian and allowed Patient #1 to be discharged from the hospital. During Record review of Patient #1's medical chart the Discharge/Aftercare Plan dated 08/28/17 at 1:30 PM was signed by Personnel #11. The information for who the patient was released to was not signed but the destination. The hospital Discharge Policy dated 09/26/2016 reflected, "Discharge planning begins on admission and is provided for Behavioral Health Service inpatients by the interdisciplinary treatment team (IDT), with the involvement of the patient and/or the patient's legally authorized representative (LAR)." The hospital Discharge/Aftercare Planning dated 09/26/16 reflected, "The development of discharge Plan begins on admission ...The patient's demonstrated readiness for discharge should be linked to the achievement of inpatient treatment goal ...The Discharge plan may include but not be limited to recommendations that: prepare the patient and family/significant other(s) for the transition to the next level of care. The hospital Admission, Discharge, and Continued Stay Criteria dated 09/26/16 reflected, "Sundance Hospital seeks to provide quality mental health services to patients admitted for inpatient treatment ...Releasing or transferring the patient to a less intensive level of care does not pose a threat to him/her, others or property ...Patients and family will be involved in treatment team and discharge. The hospital policy Patient Rights dated on 09/26/16 reflected, "All patients receiving mental health services at Sundance Hospital will be granted the following rights: The right to explanations of the care, procedures, and treatment provided ...The right to be transported to, from ...facilities (including community-based services) community centers, and psychiatric hospitals in a way that protects the dignity and safety of individuals." The hospital Policy Abuse Neglect and Exploitation dated 08/01/14 reflected, "Sundance Hospital prohibits the abuse, neglect, and exploitation of patients and or program or services participants ...Neglect ...includes, but is not limited to failure to provide one's self the goods or services ...which are necessary to avoid physical or emotional harm or the failure of a caretaker to provide such goods and services |
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