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 Feb. 6, 2018
VIOLATION: PATIENT RIGHTS: INFORMED CONSENT Tag No: A0131
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review the hospital failed to ensure 1 of 1 patient (Patient #3's) legal guardian was allowed to make informed decisions regarding patient care, which included patient needs, treatment and discharge.

Findings included:

The Notification of Emergency Detention dated 07/04/17 timed at 1205 for Patient #3 reflected, "Aggressive behavior to herself she is not taking her medication...attempted to assault her mother and sister...not showering and eating..."

The...County...Probate Court dated 28th day of February, 2017 Letter of Guardianship reflected, "Non Personnel #30...qualified according to law as Guardian of...Patient #3, Incapacitated Person...appointment shall remain in full force and effect until the expiration of one year and four months from 21st day of November, 2016 with full powers and authority set out in the Texas Estates Code..."

The Hospital Consent for Treatment dated 07/04/17 signed by Patient #3's (legal guardian).

The Assessment Service Statement and Consent to assessment dated [DATE] reflected, "I certify I am...biological parent with authority to consent for treatment...legal guardian."

The Approved Phone Contact List and Approved Visitation List dated 07/04/17 reflected, "Guardian and...sister listed..."

The Consent to Release/Obtain Information Form dated 07/04/17 reflected, "Health professional Dr ...MHMR ...(signed by) legal guardian..."

The Consent to Release/Obtain Information dated 07/06/17 reflected, "Non Personnel #28...phone number...Patient #3 signed and staff witness Personnel #10." The document was not signed by the Legal Guardian.

The Therapy note dated 07/06/17 timed at 1400 signed by Personnel #10 reflected, "Returned call from Non Personnel #27...stated he wants to meet with patient on 07/07/17 at 0830...also stated he would provide an interpreter...therapist stated she was making report but Non Personnel #27 told her it was not necessary because patient has an open case..."

The Therapy Note dated 07/07/17 timed at 0830-1000 signed by Personnel #10 reflected, "Patient met with therapist, Non Personnel #27, Non Personnel #28...patient asked about alleged abuse by...stated her mother steals her money, denies her access to her video phone for communication, does not respect her privacy in her apartment...stated she is fearful to return to her apartment because her mother has access to the apartment...Non Personnel #27 stated he did not want patient to return to her apartment while investigation is pending...instructed Hospital staff to not alert her (Guardian) or be in contact with her when patient is discharged ...therapist explained patient would be discharged this afternoon because she does not have adequate access to means of communication ...during conversation Non Personnel #29 provided...and therapist with her address and phone number and stated Patient #3 can stay at her house until...is able to find alternate living arrangement..." It was noted no legal paperwork was provided by Non Personnel #27 to the hospital or Legal Guardian which allowed the discharge of Patient #3 to someone other than the Legal Guardian.

The Therapy Note dated 07/06/17 timed at 1400-1445 reflected, "Patient met with therapist, Non Personnel #28 and her interpreter...requested meeting to help provide therapist with more details leading up patient's admission to the hospital and express her concern that patient is not being provided with an interpreter or video phone for communication while she is inpatient...therapist stated she would make an...report and update patient and Non Personnel #28 with any discharge plans...." No contact was made with the legal guardian.

The 07/07/17 Physician's Orders "Discharge routine to home Bipolar Manic Severe with Psychosis...prescriptions called into pharmacy..." The legal guardian was not notified.

The Discharge/Aftercare Plan dated 07/07/17 reflected, "Patient verbalized understanding...[DIAGNOSES REDACTED] resource specialist...to reside with Non Personnel #29...by car..." Legal Guardian did not sign document and was unaware of discharge.

The Nursing Shift Assessment and Progress Note dated 07/07/17 timed at 1430 reflected, "Discharger asked about discharge states to be discharged to her friend...at 1440...discharge time of 1830 given for pick up...1800 call to friend to find out pharmacy to call scripts to...use of interpreter for pharmacy information...instructed not able to give any medical information due to her not being on release of information..." No nursing assessment of patient was found when discharged . The patients actual discharge time and pertinent information was not documented nor was actual time patient was discharged documented.

The Patient Rounding: Hourly, 15 minute and 1:1 Precaution Checklist dated 07/07/17 reflected, "discharged 2100..."

The Physician Discharge Summary dated 08/05/17 reflected, "She was initially able to adjust adequately to treatment environment...denying aggressive outbursts towards parents...patient able to indicate adequate renewed improvement in mood as well as in baseline, discharged [DATE]...to follow-up resource specialist...discharged to care of friend..."

The 07/10/17 Therapy Note timed at 1054 reflected, "Hospital Personnel contacted Non Personnel #27 and left a message to please return voicemail or text as soon as possible regarding the directive to not discharge patient to (guardian)..."

The 07/10/17 Therapy Note timed at 1500 reflected, "Therapist initiated phone call with Non Personnel #28 regarding discharge follow-up...stated she went with Non Personnel #29 to the police station to explain their side of the story...Non Personnel #28 said the police let Non Personnel #29 go home and did not voice any concerns...Non Personnel #28 stated she did not feel comfortable disclosing patients location..."

On 01/11/18 at 1550 Non Personnel #30 was interviewed. Non Personnel #30 stated she was the Legal Guardian of Patient #3. Non Personnel #30 stated Patient #3 stopped taking her medication for Bipolar Disorder so Patient #3 was admitted to the hospital. Non Personnel #30 stated only herself and other daughter was allowed to contact and visit Patient #3. She stated she clarified this with the facility and wanted to make sure only herself (Guardian) and daughter would be provided information on the patient. Non Personnel #30 stated the facility discharged her daughter to someone else who was not her Guardian.

On 01/31/18 at approximately 1227 Non Personnel #30 was interviewed and stated the hospital did not communicate with her even though she had provided legal guardianship paperwork when Patient #3 was admitted . Non Personnel #30 stated she did not even know Patient #3 was discharged at the time.

On 01/30/18 at 1202 Non Personnel #27 was interviewed. Non Personnel #27 was asked if he remembered Patient #3. Non Personnel #30 stated at the time Patient #3 was admitted to the facility his agency had and open case. He stated he went to the hospital to speak with the patient and felt the situation with her legal guardian was not good for her. Non Personnel #27 was asked if he instructed the hospital to discharge Patient #3 to her friend Non Personnel #29. Non Personnel #27 stated he could not legally tell the hospital who to discharge the patient to.

On 01/30/18 at 1300 Personnel #10 was interviewed. Personnel #10 stated she was unaware that Patient #3 had a legal guardian. Personnel #10 stated Non Personnel #27 was concerned about Patient #3's safety if discharged home. Patient #3 was discharged to a friend instead. Personnel #10 was asked if anyone provided legal documentation that the patient could be released to her friend. Personnel #10 stated again she did not know the patient had a legal guardian.

The policy and procedure entitled, "Patient Rights" with a revision date of 09/26/16 reflected, "The right to explanation of the care, procedures, and treatment to be provided; the risks, side effects, and benefits...treatment...this right extends to legal guardian of the person...the right to give or withhold informed consent...right to participate actively in the development of a discharge plan addressing aftercare issues...right extends to legal guardian..."
VIOLATION: MEDICAL STAFF ACCOUNTABILITY Tag No: A0347
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review the hospital failed to ensure medical staff (Personnel #7) ensured quality care was provided for 1 of 1 patient (Patient #3') in that Patient #3's Legal Guardian was not involved in Patient #3's care and treatment. The physician discharged the patient to someone other than the Legal Guardian.

Findings included:

The Notification of Emergency Detention dated 07/04/17 timed at 1205 for Patient #3 reflected, "Aggressive behavior to herself she is not taking her medication...attempted to assault her mother and sister...not showering and eating..."

The...County...Probate Court dated 28th day of February, 2017 Letter of Guardianship reflected, "Non Personnel #30...qualified according to law as Guardian of...Patient #3, Incapacitated Person...appointment shall remain in full force and effect until the expiration of one year and four months from 21st day of November, 2016 with full powers and authority set out in the Texas Estates Code..."

The Hospital Consent for Treatment dated 07/04/17 signed by Patient #3's (legal guardian).

The Assessment Service Statement and Consent to assessment dated [DATE] reflected, "I certify I am ...biological parent with authority to consent for treatment...legal guardian."

The Approved Phone Contact List and Approved Visitation List dated 07/04/17 reflected, "Guardian and two sisters listed..."

The Behavioral Health Integrative Psychiatric assessment dated [DATE] timed at 1246 reflected, "Legal Guardian...patient has been combative and aggressive towards her and sisters...stood over mother during assessment and closed fist and hit table with palm of her hand ...mother reports patient moved an unknown male into her apartment...threw chair at mother ...will not communicate with family...cochlear implants no longer wears...needs alternate living arrangements...group housing...assessment (reviewed by MD 07/05/17)."

The Consent to Release/Obtain Information Form dated 07/04/17 reflected, "Health professional Dr ...MHMR ...(signed by) legal guardian..."

The Therapy Note dated 07/07/17 timed at 0830-1000 signed by Personnel #10 reflected, "Patient met with therapist, Non Personnel #27, Non Personnel #28...patient asked about alleged abuse by her mother...stated her mother steals her money, denies her access to her video phone for communication, does not respect her privacy in her apartment...stated she is fearful to return to her apartment because her mother has access to the apartment...Non Personnel #27 stated he did not want patient to return to her apartment while investigation is pending...instructed Hospital staff to not alert her (Guardian) or be in contact with her when patient is discharged ...therapist explained patient would be discharged this afternoon because she does not have adequate access to means of communication...during conversation Non Personnel #29 provided...and therapist with her address and phone number and stated Patient #3 can stay at her house until...is able to find alternate living arrangement..." No contact was made with the legal guardian.

The 07/07/17 Physician's Orders "Discharge routine to home Bipolar Manic Severe with Psychosis...prescriptions called into pharmacy..." The legal guardian was not notified and not involved in the discharge process.

The Discharge/Aftercare Plan dated 07/07/17 reflected, "Patient verbalized understanding...[DIAGNOSES REDACTED] resource specialist...to reside with Non Personnel #29...by car..." Legal Guardian did not sign document and unaware of discharge.

The Patient Rounding: Hourly, 15 minute and 1:1 Precaution Checklist dated 07/07/17 reflected, "discharged 2100..."

On 02/06/18 at 1400 Personnel #7 was interviewed. Personnel #7 was asked to review the patient's medical record. Personnel #7 was asked why he discharged the patient to her friend instead of her legal guardian. Personnel #7 stated he did not know the patient had a legal guardian.
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 Nurse evaluated and/or reassessed 1of 1 patient (Patient #3) prior to discharge.

Findings included:

The Notification of Emergency Detention dated 07/04/17 timed at 1205 for Patient #3 reflected, "Aggressive behavior to herself she is not taking her medication...attempted to assault her mother and sister...not showering and eating..."

The...County...Probate Court dated 28th day of February, 2017 Letter of Guardianship reflected, "Non Personnel #30...qualified according to law as Guardian of...Patient #3, Incapacitated Person...appointment shall remain in full force and effect until the expiration of one year and four months from 21st day of November, 2016 with full powers and authority set out in the Texas Estates Code..."

The Behavioral Health Integrative Psychiatric assessment dated [DATE] timed at 1246 reflected, "Legal Guardian...patient has been combative and aggressive towards her and sisters...stood over mother during assessment and closed fist and hit table with palm of her hand ...mother reports patient moved an unknown male into her apartment...threw chair at mother ...will not communicate with family...cochlear implants no longer wears...needs alternate living arrangements...group housing...assessment (reviewed by MD 07/05/17)."

The Therapy Note dated 07/07/17 timed at 0830-1000 signed by Personnel #10 reflected, "Patient met with therapist, Non Personnel #27, Non Personnel #28...patient asked about alleged abuse by her mother...stated her mother steals her money, denies her access to her video phone for communication, does not respect her privacy in her apartment...stated she is fearful to return to her apartment because her mother has access to the apartment...Non Personnel #27 stated he did not want patient to return to her apartment while investigation is pending...instructed Hospital staff to not alert her (Guardian) or be in contact with her when patient is discharged ...therapist explained patient would be discharged this afternoon because she does not have adequate access to means of communication ...during conversation Non Personnel #29 provided...and therapist with her address and phone number and stated Patient #3 can stay at her house until...is able to find alternate living arrangement..."

The Therapy Note dated 07/06/17 timed at 1400-1445 reflected, "Patient met with therapist, Non Personnel #28 and her interpreter...stated she would make report and update patient and Non Personnel #28 with any discharge plans..."

The 07/07/17 Physician's Orders "Discharge routine to home Bipolar Manic Severe with Psychosis...prescriptions called into pharmacy..." The legal guardian was not notified.

The Discharge/Aftercare Plan dated 07/07/17 reflected, "Patient verbalized understanding...[DIAGNOSES REDACTED] resource specialist...to reside with Non Personnel #29...by car..." Legal Guardian did not sign document and unaware of discharge.

The Nursing Shift Assessment and Progress Note dated 07/07/17 timed at 1430 reflected, "Discharger asked about discharge states to be discharged to her friend...at 1440...discharge time of 1830 given for pick up...1800 call to friend to find out pharmacy to call scripts to...use of interpreter for pharmacy information...instructed not able to give any medical information due to her not being on release of information..." No nursing assessment of patient was found when discharged . The patients actual discharge time and pertinent information was not documented nor was the actual time patient was discharged documented.

On 01/31/18 at 2000 Personnel #11 was interviewed. Personnel #11 stated she did not know Patient #3 had a legal guardian. Personnel #11 stated she signed the discharge paperwork but was not present when the patient was discharged later in the evening. Personnel #11 stated she did not see/assess the patient when she was discharged and verified no nurse assessment documentation was completed. The surveyor asked why she signed the paperwork when she did not actually discharge the patient. Personnel #11 stated she was called away off the unit so someone else on the evening shift discharged the patient.. The surveyor read the documentation to her and questioned where the nursing assessment of the patient was. Personnel #10 stated she completed discharge paperwork but did not see the patient when she was discharged .
VIOLATION: IMPLEMENTATION OF A DISCHARGE PLAN Tag No: A0820
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review the hospital failed to ensure the legal guardian for 1 of 1 patient (Patient #3) was involved, informed of discharge plans for Patient #3. Patient #3 was discharged to someone other than legal guardian.

Findings included:

The...County....Probate Court dated 28th day of February, 2017 Letter of Guardianship reflected, "Non Personnel #30...qualified according to law as Guardian of...Patient #3, Incapacitated Person...appointment shall remain in full force and effect until the expiration of one year and four months from 21st day of November, 2016 with full powers and authority set out in the Texas Estates Code..."

The Hospital Consent for Treatment dated 07/04/17 signed by Patient #3's (legal guardian).

The Assessment Service Statement and Consent to assessment dated [DATE] reflected, "I certify I am...biological parent with authority to consent for treatment...legal guardian."

The Behavioral Health Integrative Psychiatric assessment dated [DATE] timed at 1246 reflected, "Legal Guardian...patient has been combative and aggressive towards her and sisters...stood over mother during assessment and closed fist and hit table with palm of her hand ...mother reports patient moved an unknown male into her apartment...threw chair at mother ...will not communicate with family...cochlear implants no longer wears...needs alternate living arrangements...group housing...assessment."

The Consent to Release/Obtain Information Form dated 07/04/17 reflected, "Health professional Dr ...MHMR ...(signed by) legal guardian..."

The Therapy Note dated 07/07/17 timed at 0830-1000 signed by Personnel #10 reflected, "Patient met with therapist, Non Personnel #27, Non Personnel #28...patient asked about alleged abuse by her mother...stated her mother steals her money, denies her access to her video phone for communication, does not respect her privacy in her apartment...stated she is fearful to return to her apartment because her mother has access to the apartment...Non Personnel #27 stated he did not want patient to return to her apartment while investigation is pending...instructed Hospital staff to not alert her (Guardian) or be in contact with her when patient is discharged ...therapist explained patient would be discharged this afternoon because she does not have adequate access to means of communication ...during conversation Non Personnel #29 provided...and therapist with her address and phone number and stated Patient #3 can stay at her house until...is able to find alternate living arrangement..."

The 07/07/17 Physician's Orders "Discharge routine to home Bipolar Manic Severe with Psychosis...prescriptions called into pharmacy..." The legal guardian was not notified.

The Discharge/Aftercare Plan dated 07/07/17 reflected, "Patient verbalized understanding...[DIAGNOSES REDACTED] resource specialist...to reside with Non Personnel #29...by car..." Legal Guardian did not sign document and unaware of discharge.

The Patient Rounding: Hourly, 15 minute and 1:1 Precaution Checklist dated 07/07/17 reflected, "discharged 2100..."

On 01/30/18 at 1300 Personnel #10 was interviewed. Personnel #10 stated she was unaware that Patient #3 had a legal guardian. Personnel #10 stated Non Personnel #27 was concerned about Patient #3's safety if discharged home. Patient #3 was discharged to a friend instead. Personnel #10 was asked if anyone provided legal documentation that the patient could be released to her friend. Personnel #10 stated again she did not know the patient had a legal guardian.

The policy and procedure entitled, "Discharge Planning" with a revision date of 09/26/16 reflected, "Discharge planning begins on admission with the involvement of the patient and/or patient's legally authorized representative...recommending and/or arranging services and supports needed by the patient...including placement...the legally authorized representative will be involved in discharge planning..."