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.

DALLAS BEHAVIORAL HEALTHCARE HOSPITAL LLC 800 KIRNWOOD DRIVE DE SOTO, TX 75115 Oct. 13, 2015
VIOLATION: PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION Tag No: A0123
Based on record review and interview, the hospital failed to ensure in its resolution of patient grievances to provide four of four patients (Patients #16, #12, #13, #15) with written notices regarding their complaints.

Findings included:

Patient #16 filed a written complaint with staff on 07/29/15. A letter dated 07/30/15 acknowledged the "receipt of grievance" and noted to "continue to look into this matter." The space provided for the resolution of the patient concern was left blank.

Hospital Personnel #3 reviewed the patient advocacy documentation and denied that there was "anything in writing after 07/07/15."

Patient #12 filed a written complaint dated 03/26/15. A letter dated 03/31/15 noted the patient advocate's intention to "...continue to look into this matter." The space provided for date and time of complaint resolution was left blank.

Patient #13 filed a written complaint dated 02/21/15. The space provided for date and time of complaint resolution was left blank.


Patient #15 filed a written complaint dated 02/21/15. The space provided for date and time of complaint resolution was left blank.


Record review of a patient advocacy log provided to the surveyor on 10/09/15 did not reflect the complaints filed by Patients #16, #12, #13, #15. There was no entry of patient complaints dated after 07/07/15.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview the hospital failed to ensure that a registered nurse evaluated the nursing care for one of one patient (Patient #4) who was admitted with severe panic attacks. The patient's anxiety did not diminish throughout her hospitalization . Although the clinician assessed Patient #4 to have severe anxiety symptoms shortly before discharge, nursing failed to reevaluate the patient's anxiety level.

Findings included:

Patient #4's Intake assessment dated [DATE] at 06:31 (not specified AM or PM) noted the patient arrived as a memorandum of transfer from an acute care hospital with complaints of anxiety and "jerking" like in a "seizure," panic attacks, tremors, crying spells, and nightmares. The patient had a plan to overdose on medication in a suicide attempt.

Psychiatric Progress Notes dated 04/10/15 at 15:00, 04/11/15 at 09:00, 04/12/15 at 10:10 reflected that Patient #4 was physician assessed to be anxious. The patient stated she was anxious. On 04/13/15 at 12:00 the physician noted the patient's mood was anxious.


Patient Data and Assessment documentation dated 04/09/15, 04/10/15, 04/11/15, 04/12/15, and 04/13/15 (the day of discharge) reflected nursing staff assessed Patient #4 to be anxious for at least 16 hours a day. On 04/10/15 at 11:00 the patient complained to nursing staff that she was anxious. One hour later, on 04/10/15 at 12:00 Patient #4 had an anxiety attack and "started twitching." On 04/11/15 at 18:30 nursing received a complaint from the patient that her anxiety level was "9 to 10" on a scale with "10" as the highest score.

On the day of discharge (04/13/15) at 10:40, Patient #4 complained to nursing staff of increased anxiety and lability. Approximately one hour later during a coping skills group, the therapist noted that the patient was "anxious, trembling, reporting panic attacks daily." Nursing documented that Patient #4 was discharged home on 04/13/15 at 17:20. Forty minutes later, nursing noted that the patient was "anxious" during the 15:00 to 23:00 shift.

Hospital Personnel #2 reviewed Patient #4's medical record on 10/13/15 at 14:10 and agreed that Patient #4 was admitted and discharged with severe anxiety.