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SUNDANCE HOSPITAL 7000 US HIGHWAY 287 ARLINGTON, TX 76001 July 24, 2018
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on record review, observation, and interview, the hospital failed to ensure the right to receive care in a physically and emotionally safe setting for two of two patients (Patient #10, Patient #9).

1) Patient #10, an adolescent, had been admitted with the suicidal plan to hang himself. During his hospitalization Patient #10 was assessed to be irritable, labile, angry, with poor judgment, and in need to be under close staff supervision. Forty-six hours into his hospitalization the patient had access to a razor blade and placed it in his mouth with the threat to swallow it. A day later, Patient #10 made an "escape plan" and eloped from the locked hospital five days later. He did not return.

2) Patient #9, an adolescent, was admitted with suicidal ideation and plans for self-harm. Patient #9's room lacked components of a physically and emotionally safe environment with a broken mattress potentially usable to hide contraband items, and obscene drawings on two of the four walls. Hospital personnel in charge of safety in patient environments was unaware of the broken mattress.



Findings included:

1) Record review of Patient #10's Preadmission Evaluation dated 06/25/18 at 2145 reflected the patient had tied a shirt around his neck "in an attempt to hang himself to get the voices out of his head..."

Physician orders dated 06/26/18 at 0040 reflected Patient #10 was admitted to inpatient psychiatric care. Admission diagnoses included Major Depressive Disorder, Recurrent, Severe, with Psychotic Features.

Physician notes dated 06/30/18 at 0745 and 07/01/18 at 1734 reflected Patient #10 was "irritable, angry, agitated, poor judgement."

Nursing progress notes dated 06/27/18, untimed, reflected Patient #10 had a razor blade of "rectangular shape," sized one-quarter inch by one inch, under his tongue and threatened to swallow it. Nursing noted the physician's concern about a possible elopement in case the patient needed emergency care at an outside medical facility.

Patient #10's observation rounding report dated 06/28/18, untimed, reflected the patient had "a blade and a screw...to be watched very carefully...trying to elope..."

Nursing progress notes dated 07/03/18 at 1310 reflected Patient #10 had "escaped by jumping over the outside fence in the back of the hospital..."

During an interview on 07/24/18 at 1145, Hospital Personnel #6 stated Patient#10 left the court-yard during an outside break and "never came back." Hospital Personnel #10 in charge of the adolescent patients at that time did not count the patients and told Personnel #6 he "may have not locked the door to the court yard." Hospital Personnel #10 had a previous hospital disciplinary action for leaving a patient behind.

Hospital Personnel #3 stated during an interview on 07/24/18 at 1645 that Patient #10 "knew what he wanted to do."

2) Observations in Patient #9's room on 07/24/18 at 1350 reflected the mattress on Bed A had slit of about five centimeters potentially usable to hide small sharp objects. Crayon drawings on two walls included four sets of male genitalia visible to the observer.

Hospital Personnel #4 was asked during an interview on 07/24/18 at 1350 regarding patient access to crayons and stated adolescent patients took them away from pediatric patients.

Hospital Personnel #9 in charge of the patients' care environment denied awareness of the broken mattress during an interview on 07/24/18 at approximately 1415.

Record review of Patient #9's physician preadmission evaluation reflected the patient had been admitted with suicidal plans to hang himself and/or slit his wrists or throat.

Patient #9's observation rounding report dated 07/24/18 noted the patient was on suicide precautions.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
Based on record review, interview, and observation, the hospital registered nurse staff failed to assess behavior and verify location for nine of nine patients (Patient #10, #6, #7, #8, #9, #11, #12, #13, #14) on precautionary staff observation for suicide, assault, elopement, and/or sexual aggressive behavior.


1) Patient #10's had been admitted with suicidal ideation and had plans to elope from the facility. During his approximately 152 hours of inpatient hospitalization , licensed nursing staff failed to supervise and verify the patient's location and behavior for about 50 hours or approximately one-third of the time. The adolescent patient had access to a razor blade and placed it into his mouth with the threat to swallow it. Patient #10 eloped on 07/03/18 after a post-lunch recess in the hospital's court yard. The patient did not return to the facility.

2) Although on precautionary status for suicide, assault behavior, and/or sexual aggression, current Patients #6, #7, #8, #9, #11, #12, #13, #14 did not have any nurse rounding or patient behavior verification for approximately five hours on the day of survey.



Findings included:

1) Record review of Patient #10's Preadmission Evaluation dated 06/25/18 at 2145 reflected the patient had tied a shirt around his neck "in an attempt to hang himself to get the voices out of his head..."

Physician orders dated 06/26/18 at 0040 reflected Patient #10 was admitted to inpatient psychiatric care. Admission diagnoses included Major Depressive Disorder, Recurrent, Severe, with Psychotic Features.

Nursing progress notes dated 06/27/18, untimed, reflected Patient #10 had a razor blade of "rectangular shape," sized one-quarter inch by one inch, under his tongue and threatened to swallow it. Nursing noted the physician's concern about a possible elopement in case the patient needed emergency care at an outside medical facility.


Patient #10's observation rounding report dated 06/28/18, untimed, reflected the patient had "a blade and a screw...to be watched very carefully...trying to elope..." There was no evidence of nursing rounding on Patient #10 at 0000, 0200, 0400, 0600, 0800, 1000, 1200, 1400, 1600, and 1800 (20 hours).

Patient #10's observation rounding report dated 06/26/18 reflected the space for nurse rounding verification was left blank at 1400, 1600, 1800, 2000, and 2200 (10 hours). Rounding Report dated 06/27/17 reflected lack of verification signatures at 1600 and 1800 (4 hours), on 06/30/18 at 1400, 1600, and 1800 (six hours), on 07/01/18 at 2000 and 2200 (4 hours), on 07/02/18 at 0800 (2 hours), and on 07/03/18 at 1000 and 1200 (4 hours).

Nursing progress notes dated 07/03/18 at 1310 reflected Patient #10 had "escaped by jumping over the outside fence in the back of the hospital..."

Hospital Personnel #6 stated during an interview on 07/24/18 at 1145 that Hospital Personnel #3 "did not co-sign [Patient #10's] rounding sheets at noon " on the day of the patient's elopement.

2) Observation on the hospital's pediatric/adolescent male unit on 07/24/18 at 1340 reflected non-licensed Hospital Personnel #2 was in charge of Patients #6, 7, 8, 9, 11, 12, 13, and 14.

Record review of the patients' rounding sheets reflected there was no evidence of nurse rounding verification of the patients' location and behaviors between 0800 and the time of survey at 1340 (5 hours and 40 minutes).

Licensed Hospital Personnel #4 agreed during an interview on 07/24/18 at 1340 that he was assigned to provide nursing care to Patients #6, 7, 8, 9, 11, 12, 13, and 14. Hospital Personnel #4 stated he did not have time that morning and had been "in meetings."

Record review reflected that Patient #6 and Patient #11 were on precautions for assault behavior and sexual aggression, Patient # 7 and Patient #9 were on suicide precautionary status, Patient #8 and Patient #12 were on precautions for suicide and assault behavior, and Patient #13 and Patient #14 were on precautionary status for assault behavior.