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SUNDANCE HOSPITAL 7000 US HIGHWAY 287 ARLINGTON, TX 76001 March 14, 2018
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0168
Based on interview and record review the hospital failed to ensure 1 of 10 patients (Patient #5) who was secluded had a written physician order.

Findings included:

1) Patient #5's High Risk Notification Alert dated 02/07/18 reflected, "Assault/Homicidal..states I want to kill my brother with my fist...hitting and kicking others, destroying property..."

The 02/14/18 Physician Orders and Directions timed at 1140 reflected, "Give Risperdal 1 mg po (by mouth) times one now..."

The Nursing Shift Assessment and Progress Note dated 02/14/18 timed at 1348 reflected, "Patient had a family session...upset started hitting the wall, crying, using profanity and combative with staff...throwing books and papers while in the dayroom...taken to Seclusion at 1126 and released at 1211..."

The Patient Rounding: Hourly, 15 Minute, and 1:1 Precaution Checklist dated 02/14/18 reflected, "1145, 1200, (behavior walking or pacing, irate, yelling, screaming, hitting)...location S/R (seclusion room)...(the back of the checklist) timed at 1125...seclusion ordered by nurse patient was hitting and being destructive...(written in was seclusion ended at 1210)."

On 03/09/18 from 1527 to 1554 Personnel #2 was interviewed. Personnel #2 was asked to review the medical record for Patient #5. Personnel #2 verified and acknowledged she did not see a physician's order for seclusion on 02/14/18 from 1126 and released at 1211. Personnel #2 stated it was unacceptable for not having a physician order for seclusion.
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 the RN (Registered Nurse) evaluated and reassessed 3 of 10 patients (Patient #2, #3 and #4) upon returning to the hospital after eloping from the adolescent unit.

Findings included:

1) Patient #2's Behavioral Health Integrative Psychiatric assessment dated [DATE] timed at 2112 reflected, "Arrived by police...stated she had no reason to live and wanted to kill herself...said they are putting her [AGE] year old boyfriend in jail and she cannot live without him...currently in PHP program...has been sexually abused by mother's boyfriend two years ago..."

The Patient Rounding: Hourly, 15 Minute, and 1:1 Precaution Checklist dated 01/08/18 reflected, "2015 to 2130...patient AWOL (eloped)."

The Nursing Shift Assessment and Progress Note dated 01/08/18 timed at 2100 reflected, "Patient involved in physical altercation with another patient...attempted to take staff badge and escape...escaped...code called...police, Dr, family notified...found by police and returned...stable." No documentation was found when the patient left and when the patient returned and/or Patient #2 was assessed for injuries upon return to the hospital.

On 03/09/18 at approximately 1604 Personnel #2 was interviewed. Personnel #2 was asked to review Patient #2's medical record. Personnel #2 verified the nurse did not document when the patient left and returned and verified the nurse did not complete a nursing assessment on the patient when she returned.

2) Patient #4's 01/01/18 Behavioral Health Integrative Psychiatric Assessment timed at 2340 reflected, "Patient arrived by police...cut on left wrist...history of cutting...gotten upset with her mother...police found a razor blade under her pillow...mother reports it has been a month since (patient) has had an episode of violence and gets upset when she does not get her way..."

The 01/08/18 Nursing Shift Assessment and Progress Note time at 2030 reflected, "Patient physically attacked another patient...attempted to deescalate...hit the room door threatening other patients...attempted to take 3 staff members badge...kicked through door and escaped...code called family notified...patient stable will continue to monitor." No documentation was found which indicated when the patient returned to the unit and whether an assessment was completed.

The Physician Orders and Directions dated 01/08/18 timed at 2125 reflected, "Unit restriction and elopement precautions..."

The 01/08/18 Patient Rounding: Hourly, 15 Minute, and 1:1 Precaution Checklist, reflected, "1945, 2000 (lying, sitting)...2015, 2030, 2045 (AWOL)...2130, 2145 (location bedroom)."

On 03/09/18 at 1617 Personnel #2 was interviewed and asked to review Patient #4's medical record. Personnel #2 verified the nurse did not document the patient was assessed after returning from eloping. Personnel #2 verified the nurse did not document when the patient left and returned.

3) Patient #3's Behavioral Health Integrative Psychiatric assessment dated [DATE] timed at 0105 reflected, "Patient presented to hospital by police department...threw a brick through her father's window...history of destructive behaviors and destruction of property...assaultive, aggressive."

The Nursing Shift Assessment and Progress Note dated 01/08/18 timed at 2100 reflected, "Patient involved in physical altercation...threw a chair and hit another patient...attempted to grab staff's badge and kicked through doors and AWOL code called...police called...patient found and returned upon assessment stable, family notified." The documentation did not indicate when patient eloped and/or when the patient returned. No assessment was found documented upon Patient #3's return.

The Patient Rounding: Hourly, 15 Minute, and 1:1 Precaution Checklist dated 01/08/18 reflected, "2030, 2045, 2100, 2115, 2130, 2145...AWOL..."

On 03/09/18 at 1616 Personnel #2 was interviewed and asked to review Patient #3's medical record. Personnel #2 reviewed the nursing documentation and the fifteen minute rounds record and verified the nurse did not complete a nursing assessment of the patient upon return after eloping. Personnel #2 verified when the patient left and returned was not documented.

The Policy and Procedure entitled, "Assessment and Reassessment of Patients with a revision dated of 09/26/2016 reflected, "An accurate record of the patient's condition, care, and treatment is provided throughout the hospital visit...reassessments are documented when there is a significant change in patient status...RN will reassess the patient based on the patient's needs..."
VIOLATION: ADMINISTRATION OF DRUGS Tag No: A0405
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review the hospital failed to ensure emergent medication administered to 2 of 10 patients (Patient #5 and Patient #1) by RN's (Registered Nurses) for agitation and/or aggressive behavior. The nursing documentation did not match the patient rounding records for patient behavior which warranted the administration of emergent medication.

Findings included:


1) Patient #5'sThe High Risk Notification Alert dated 02/07/18 reflected, "Assaultive/Homicidal..states I want to kill my brother with my fist...hitting and kicking others, destroying property..."

The 02/08/18 Restraint/Seclusion/Emergency/Medication Order timed at 1110 reflected, "Physician ordering Dr...on 02/08/18 at 1100...emergency medication, Benadryl 25 mg (milligrams) IM (intramuscular)...specific behavior fighting..."

The 02/08/18 Patient Rounding: Hourly, 15 minute, and 1:1 Precaution Checklist reflected, "1100, 1115,1130 (Lying and sitting)...1145 (walking, pacing)." The above documentation did not reveal behaviors which warranted emergent medication administration.

The 02/09/18 Restraint/Seclusion/Emergency/Medication Order timed at 1124 reflected, "Dr order...02/09/18 timed at 1124...physical restraint time in 1124 time out 1125...emergency medication Benadryl 50 mg, IM...1125...behavior hitting his hand on the wall, fighting..."

The 02/09/18 Patient Rounding: Hourly, 15 Minute, and 1:1 Precaution Checklist reflected, "1115 (walking or pacing)...1130 (lying or sitting), 1145 (resting, sleeping)..." The above patient behavior documentation did not reveal behaviors which warranted the use of emergent medication administration.

The 02/11/18 Restraint/Seclusion/Emergency Medication Order dated 02/11/18 timed at 0920 reflected, "Dr order...02/11/18 timed at 0920...emergency medication, Benadryl 50 mg IM...time administered 0940...cursing, pushing staff and other patients, throwing things and yelling..."

The 02/11/18 Patient Rounding: Hourly, 15 Minute, and 1:1 Precaution Checklist reflected, "0900, 0915, 0930, 0945, 1000, 1015 (lying, sitting)..." No documentation was found during the above time frame which indicated the patient demonstrated behaviors which warranted emergent medication administration.

The 02/11/8 Restraint/Seclusion/Emergency Medication Order dated timed at 1815 reflected, "Dr order...1815...benadryl 25 mg IM administered at 1825...behaviors...pushing table over, cursing at staff, hitting staff, kicking at staff..."

The 02/11/18 Patient Rounding: Hourly, 15 Minute, and 1:1 Precaution Checklist reflected, "1800, 1815, 1830,1845, 1900 (lying or sitting)." No documentation was found during the above time frame which indicated the patient demonstrated behaviors which warranted emergent medication administration.

The Physician Orders and Directions dated 02/12/18 timed at 1400 reflected, "Benadryl 50 mg IM times on dose, Thorazine 12.5 IM times one dose..."

The Nursing Shift Assessment and Progress Note dated 02/12/18 timed at 1428 reflected, "Patient is alert, oriented times 2...being aggressive, hitting the wall, and his peers...oppositional would not follow staff orders ...received order from Dr...tolerated injection..."

The Patient Rounding: Hourly, 15 Minute, and 1:1 Precaution Checklist dated 02/12/18 reflected, "1400, 1415, 1430 (lying, sitting) , 1500 (Group Therapy)..." No documentation was found during the above time frame which indicated the patient demonstrated behaviors which warranted emergent medication administration.

On 03/09/18 from 1527 to 1554 Personnel #2 was interviewed. Personnel #2 was asked to review the medical record for Patient #5. Personnel #2 verified and acknowledged the above emergent medications administration by the nurse with documented behavior did not match the documentation the Mental Health Technician's documented on the above observation rounds records. Personnel #2 verifed the observation rounds records behavior documentation did not describe the behavior documented by the RN which would warrant the administration of emergent medication.


2) Patient #1's Behavioral Health Integrative Psychiatric assessment dated [DATE] timed at 1607 reflected, "Patient became angry after being told no today...tried to run out of the door...became angry and agitated...started calling brother names...tried to hit, punch and kick mother...mother had to restrain patient to get him to calm down...hit mother in the face...threatened to kill mother, brother and stepfather...tried to hit stepdad...patient kicked mother into the wall...mother called police for help, bit mother 3 days ago..."

The physician's orders dated 02/09/18 timed at 1650 reflected, "Haldol 5 mg (milligrams) stat IM (Intramuscular) for agitation, Benadryl 50 mg stat IM for agitation..."

The Nursing Shift Assessment and Progress Note dated 02/09/18 timed at 1650 reflected, "Patient observed to have sudden burst of anger, trying to hit patient on the unit throwing chair on the floor, banging on the door, verbal de-escalation given with no effects...Dr. order for Haldol 5 mg and Benadryl given with good effect...mother informed on the phone..."

The Patient Rounding: Hourly, 15 Minute, and 1:1 Precaution Checklist dated 02/09/18 reflected, "1515 to 1700 (walking or pacing)." The patient observation rounding documentation did not indicate behaviors that warranted the use of emergent medication that was described in the nursing documentation above dated 02/09/18 timed at 1650.

On 03/09/18 at 1330 Personnel #2 was asked to review Patient #1's medical record. Personnel #2 stated the patient rounding record for 02/09/18 timed from 1515 to 1700 indicated the patient was walking, pacing. Personnel #2 verified the rounds record did not indicate patient behaviors warranting administration of emergent medication as documented by the nurse.

The Policy and Procedure entitled, "Precaution/Patient Monitoring" with a review dated of 09/26/16 reflected, "Staff making rounds shall observe patient's activity, behavior, whereabouts and document observations..."