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 Jan. 26, 2018
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on Interview, Record Review and Observation the hospital failed 1 of 1 Patient (Patient #2) by not providing care in a safe setting.

Findings Include;

During the Record Review of Patient #2's medical record there is no medical reassessment of Patient #2 until the next shift. The medical record reflected Patient #2 did remain on the floor once she was found. The change in condition was not assessed until the next shift and it was determined that Patient #2 should be referred out of further evaluation.

During Interview it was confirmed that Patient # 2 was dragged down the hallway by her wrist by hospital Personnel #10.

During the observation of the hospital video footage, the surveyor observed Personnel #10 grab patient #2 by her wrist and drag her down the hallway into her room.


POLICY

The hospital Policy on Patient Rights dated 09/2016 reflected, "All patients receiving mental health services at Sundance will be granted; the right to a humane treatment environment that ensures protection from harm ...The right to be free from mistreatment, abuse, neglect and exploitation ..."

The hospital Policy on Abuse, Neglect and/or exploitation of patients or participants is strictly forbidden. All allegations of abuse, neglect and/or exploitation shall be reported to the Texas Department of State Health Services and in the case of child abuse, the Texas Department of Protective and Regulatory Services.

The hospital Policy on Nursing Services Provisions of Care dated 10/11/16 reflected, "Sundance Hospital maintains an organized plan for nursing services that provides 24-hour nursing services as needed. Nursing service is under the authority of the Chief Nursing Officer. Nurses employed at Sundance Hospital will have and maintain a valid and current license while employed at the facility. Adequate numbers of staff shall be available to provide patient care. A registered nurse (RN) shall be available to provide care for any patient as needed. There shall be at least one RN in the building in which there is a patient care unit where patients need present.
IT is the policy of Sundance Hospital that clinical decisions be made to address exclusionary criteria that may prevent a patient admission to inpatient services.
VIOLATION: STAFFING AND DELIVERY OF CARE Tag No: A0392
Based on Interview, Record Review and Observation the hospital failed 1 of 1 Patient (Patient #2) by not providing nursing care to all patients as needed.

Findings Include;

During the Record Review of Patient #2's medical record there is no medical reassessment of Patient #2 until the next shift. The medical record reflected Patient #2 did remain on the floor once she was found. The change in condition was not assessed until the next shift and it was determined that Patient #2 should be referred out of further evaluation.

During Interview it was confirmed that Patient # 2 was dragged down the hallway by her wrist by hospital Personnel #10.

During the observation of the hospital video footage, the surveyor observed Personnel #10 grab patient #2 by her wrist and drag her down the hallway into her room.


POLICY

The hospital Policy on Patient Rights dated 09/2016 reflected, "All patients receiving mental health services at Sundance will be granted; the right to a humane treatment environment that ensures protection from harm ...The right to be free from mistreatment, abuse, neglect and exploitation ..."

The hospital Policy on Abuse, Neglect and/or exploitation of patients or participants is strictly forbidden. All allegations of abuse, neglect and/or exploitation shall be reported to the Texas Department of State Health Services and in the case of child abuse, the Texas Department of Protective and Regulatory Services.

The hospital Policy on Nursing Services Provisions of Care dated 10/11/16 reflected, "Sundance Hospital maintains an organized plan for nursing services that provides 24-hour nursing services as needed. Nursing service is under the authority of the Chief Nursing Officer. Nurses employed at Sundance Hospital will have and maintain a valid and current license while employed at the facility. Adequate numbers of staff shall be available to provide patient care. A registered nurse (RN) shall be available to provide care for any patient as needed. There shall be at least one RN in the building in which there is a patient care unit where patients need present.
IT is the policy of Sundance Hospital that clinical decisions be made to address exclusionary criteria that may prevent a patient admission to inpatient services.