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 76001 Sept. 19, 2018
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on observation, interview, and review of documentation, the facility failed to provide a safe setting for the psychiatric patients, as ligature risks were observed and identified during the tour of the adolescent and pediatric units. The presence of ligature risks in the physical environment of a psychiatric patient, including any setting where psychiatric patients may be present, even for a short period of time, compromises their right to receive care in a safe setting.


Findings included:


During a tour of the girls and boys adolescent units at approximately 2:45pm on 09/17/18 accompanied by the Chief Nursing Officer (CNO), Staff #1, the exit and entrance door openers were observed to have ligature risks. Door hinges with ligature risks were observed on the Clean Linen and Soiled Linen rooms. These hinges present a ligature risk as the hinges could be used as an anchor point for hanging.


During a tour of the facility at approximately 3:00pm on 09/17/18 accompanied by Staff #1 the door openers in the fish bowl room and the hallway exit doors were observed to have ligature risks. The physical environment for patients at risk for suicide or other forms of self-harm or violent behaviors toward others, should be free of ligature risks.


During a tour of the pediatric units at approximately 3:00pm, on 09/17/18, accompanied by Staff #1 the exit and entrance door openers were observed to have ligature risks. The physical environment for patients at risk for suicide or other forms of self-harm or violent behaviors toward others, should be free of ligature risks.


In an interview during the tour of the adolescent and pediatric units at approximately 3:00pm on 09/17/18 accompanied by Staff #1; Staff 1 acknowledged the door hinges ligature risks.


Review of a work order estimate document by "Michaels Keys Inc" dated 9/18/2018 stated in part "Remove Old Hinges and install new continuous hinges with Anti-ligature tips" The document had not been signed and also stated in part "ESTIMATE GOOD FOR 30 DAYS"


"Many hospital facilities management professionals manage and mitigate ligature risks on a daily basis. It is up to the facilities team-along with other departments and staff-to understand, identify, and correct physical environment fixtures and objects that may pose a ligature, or hanging, risk to behavioral health patients.

A complete risk assessment of the physical environment may be required which can include any area where the patient may be moved and treated...
Some examples of risks include ... door hinges and hardware ...

The smallest risks must be identified and eliminated ..."

Giovinazzo, G. (2018) Healthcare Facilities Today. Compliance 101: Mitigating ligature risks in behavioral health patient care environments. Retrieved 9/1/2018 from https://www.healthcarefacilitiestoday.com/posts/Compliance-101-Mitigating-ligature-risks-in-behavioral-health-patient-care-environments--
VIOLATION: MAINTENANCE OF PHYSICAL PLANT Tag No: A0701
Based on observation, review of documentation, and interview it was determined that the hospital failed to ensure that potential safety issues were addressed in an effort to ensure patient and staff safety.


Findings were:


The hospital failed to secure sharps, specifically needles and diabetic accucheck lancets in a manner that prevented the potential for unauthorized access. During a tour of the adolescent/pediatric female unit on the afternoon of 9/17/2018 it was observed that the wall mounted cabinets located directly behind the desk area in the nurse's station were not able to be locked as they had no locking mechanism. Examination of the interior of one of cabinets located above the handwashing sink revealed that there was a bin with approximately 10 diabetic accucheck lancets used for blood glucose sampling. Also found was an unopened box of 200 lancets. Without the ability to lock the cabinet, there is a likelihood that these sharps could be accessed by unauthorized individuals.


On a tour of the male adolescent/pediatric male unit on the afternoon of 9/17/2018 it was observed that the wall mounted cabinets located directly behind the desk area in the nurse's station were not able to be locked as they had no locking mechanism. Examination of the interior of one of cabinets revealed there was a bin containing diabetic accuchecks lancets used for blood glucose sampling. Additionally there was an opened box of 1ml insulin syringes. Without an ability to lock the cabinet, there is a likelihood that these sharps could be accessed by unauthorized individuals.


Review of hospital policy provided to the survey team entitled: "Policy entitled: "Hospital Wide-General Facility Safety and Patient Management (1204)." (revised date of 7/2018) stated: "The facility environment is maintained in a safe, clean and orderly manner at all times. This facility is routinely checked to protect patients, visitors and personnel from potential safety hazards."


Review of hospital policy provided to the survey team entitled: "Environment of Care EC.01.01.01" (revised/review date of 07/2018) stated: "Sundance Hospital will plan activities and processes - or Management Plans - to minimize inherent risks in the environment of care. Risks are a direct result of the type of care provided and the equipment and materials necessary to provide care. Risks in the environment include, but are not limited to: Safety and security for people entering Hickory Trail Hospital, Safety of equipment, and other material ..." "Sundance Hospital will develop a systemic approach involving proactive evaluation of the risks and accompanying possible harm. These plans should also address the scope and objectives of risk assessment and management, describe the responsibilities of individuals or groups, and give timeframes for specific activities identified in the plan."


In an interview on the afternoon of 9/17/2018 with hospital staff member #6 (who accompanied the surveyors on the above tour) the above findings were confirmed.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
Based on review of documentation and interviews, the facility failed to ensure that an RN conducted and completed an initial comprehensive nursing assessment of a patient within eight hours of the patient's admission, as the nursing assessment of patient # 3 was performed by an LVN.


Findings included:


The facility practice for nursing assessments did not comply with the psychiatric hospital regulations for the state in which the facility is licensed.


Assessment and Reassessment of Patent. Revised 09/26/2016. Policy. An accurate record of the patient's condition, care and treatment is provided throughout the hospital visit. Screening and admission assessments and histories are completed upon arrival to the hospitals and during the admission process on the inpatients units. A Nursing Supervisor or Registered Nurse (RN) is designated as Admitting Nurse and is responsible for ensuring the completion of the comprehensive Nursing Admissions. V/S signs and the completion of other routine tasks and information gathering may be assigned to other nursing staff as allowed and defined by statutory regulations and the Texas Board of Nursing. 1. An RN shall conduct and complete an initial comprehensive nursing assessment of the patient (25 TAC 411.473 e).


Review of patient #3 medical record reveal the nursing assessment was performed by an LVN.


According to the Texas Board of Nursing online reference site https://www.bon.texas.gov/faq_nursing_practice.asp#t25,

"The question of an RN co-signing after an LVN most often arises in situations when an attempt is made to expand the LVN's scope of practice by holding the RN responsible for expanded tasks performed by the LVN. The RN co-signing for something that is beyond the LVN's scope of practice does not legitimize the LVN's actions. A nurse never functions "under the license" of another nurse. For example, if a patient requires a comprehensive assessment performed by an RN, the assignment (or a portion thereof) may not be given to an LVN. If such an assignment is given to an LVN, he/she is responsible for notifying the nurse who made the assignment that it is beyond his/her scope of practice to perform the assigned task [Board Rule 217.11(1)(S) & (T)]. Each nurse has a duty to maintain client safety [Board Rule217.11(1)(B)] that includes communication with appropriate personnel [Board Rule217.11(1)(P)]. Position Statement 15.14, Duty of a Nurse in Any Setting, further explains a nurse's duty to a client."


According to Texas Board of Nursing online reference site https://www.bon.texas.gov/pdfs/practice_dept_pdfs/position_statements_pdfs/positionstatements2014.pdf,
" ...The LVN performs focused assessments and contributes to care planning, interventions, and evaluations. The RN is responsible for the overall coordination of care and performs comprehensive assessments, initiates the nursing care plan, implements and evaluates care of the client or patient."


An interview was conducted with staff #10 LVN in the conference room on the morning of 09/18/2018 at 10:45 am. The surveyor ask staff #10 did she do the assessment for patient #3? Staff #10 reviewed the medical record and said she did perform the nursing assessment. Staff # 10 said she helps the RN out all the time, by doing assessments, sometimes the RN is busy, may have 4 admissions so she has to help her.
VIOLATION: ADMINISTRATION OF DRUGS Tag No: A0405
Based on review of documentation and staff interviews, it was determined that the hospital failed to ensure that ordered medications were transferred to the Medication Administration record (MAR). The facility also failed to ensure nursing staff documented medications on the Medication Administration record (MAR) at the time they were administered to patients. This could result in the likelihood of harm to patients due to missed ordered medications.


Findings were:


Review of the medical record for Patient #1 did not reveal a completed MAR for ordered and admiinistered medications as documented in the following nurse narrative dated 12/15/17 which stated in part "MD notified and ordered Albuterol neb tx (nebulizer treatment) which was given 2x within 90 min. Before MD was called his PRN (as necessary) inhaler had been given. MD called the second time and received order to start prednisone 40 mg PO (by mouth) which was given at 2130."


The review of the physician orders for 12/15/17, at "2120," stated, "Albuterol 0.083 25 mg/3 ml stat (immediate) for wheezing/coughing.) Telephone Orders Read Back (TORB) (Staff #13)\ (Staff #9)"


The review of physician orders for 12/15/17, at "2145," stated, "Start prednisone 40mg PO now for Asthma then prednisone 40mg po dly (daily) x 2 day then prednisone 20 mg PO dly x 2 day then prednisone 10 mg PO dly x 2 day then prednisone 5 mg PO dly X 2 day then D/C (discontinue). Discontinue previous prednisone orders. TORB (Staff #13)/ (Staff #9)"


The review of physician orders for 12/15/17, at "2230," stated "Can administer Albuterol neb tx every hour for 24 hours for asthma. TORB (Staff #13)\(Staff #9)"


The review of the Medication Administration Record (MAR) Scheduled Meds form only had documentation that Augmentin 875 mg was given to Patient #1 on 12/15/17 at 0900 and 2100. There was no documentation on any other reviewed MAR forms that any other medications had been administered to Patient #1 during his hospital stay.


Review of the hospital policy titled: "ORDERS: Medication" with a "Date Revised of 3/2018" stated in part: "Place the original order forms in the patient's medical record; and note off the order when the MAR has been updated and/or received/completed.


An interview was conducted with the facility registered nurse supervisor, Staff #7, on 09/18/18, at approximately 11:15 am, in the facility conference room. When Staff #7 was asked for the Medication Administration Record (MAR) forms to validate the administration of ordered medications for Patient #1, Staff #7 acknowledged the only MAR form with documentation of medication administered was the documentation that Augmentin 875 mg was given to Patient #1 on 12/15/17 at 0900 and 2100. Staff #7 stated, "I don't see the nebulizer treatments on the MARs. I don't see the PRN (As needed) inhaler documented on the MARs. That's all the MARs we have for this patient."


An interview was conducted with a facility Registered Nurse, Staff #9 on 09/18/18, at approximately 12:40 pm, in the facility conference room. Staff #9 reviewed the medical record for Patient #1 at the time of the interview. He acknowledged he did not see the MAR form with the documented medications he documented were given to Patient #1 on 12/15/17. Staff #9 stated "I remember I wrote everything on a fresh sheet for the Prednisone and Albuterol. I wrote all the orders." When Staff #9 was asked for the MAR documentation of the PRN inhaler given to Patient #1 on 12/15/17, he stated "I probably didn't sign it because I gave it to him first. He was wheezing and tight and I was trying to get him relieved or transferred. I started with the inhaler first and he was not improving."
VIOLATION: MEDICAL RECORD SERVICES Tag No: A0450
Based on review of documentation and interview, it was determined that the hospital failed to ensure that medical records were complete.


Findings were:


Review of Interdisciplinary Treatment Plan for patient #2 revealed on the first page that the area in the date resolved column for the problem list was blank. There were three psychiatric problems listed. #1 was risk of violence, #2 was anxiety, and #3 was depression. None of these had a date found for when the problem had been resolved. In an interview on 9/18/2018 with hospital staff #4 it was confirmed that there should have been dates filled in the date resolved column.


Review of Treatment Plan Update for patient #2, dated 3/23/2018 revealed that the area at the top of the form where a check mark can be selected for "Dx changed? Yes, No" had not been checked. At the bottom of the form the area entitled: "Indicate Reason(s) patient continues to need hospitalization : (Please check all of the items that apply)" had not been completed. The "Estimated discharge date :" area was blank with no date. The back of the form contained areas for the patient, physician, nursing, social services and activity therapy to sign and date. Only the physician and activity therapist had signed and dated, no signatures were found from the patient or family, nursing, or social services.


Review of hospital policy entitled: "Documentation Requirements" (revised/reviewed date of 8/21/12) stated: "5. The medical record documentation must be clear, concise and complete and current." "11. The medical record must not contain blank spaces or line where comments could be added at a later date. Any blank line or space on a progress, order etc. should have a line drawn through it."


In an interview with hospital staff member #4 on the morning of 9/18/2018 the above findings were confirmed.
VIOLATION: FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE Tag No: A0724
Based on observation, review of documentation, and interview, it was determined that the hospital failed to ensure that the patient units were maintained in a sanitary manner.


Findings were:


The tour of the female adolescent unit revealed the following observations:


One moveable blue chair with vinyl covering, seating, and back rest area had torn vinyl.


One moveable cloth covered chair with seating area soiled in appearance.


Wall mounted sharps container with visible dust on it, the surveyor ran finger across dusty area and was able to move the dust.


Visible dust on wall above door to medication room and on the top horizontal area of the door frame.


Area around the wall mounted fire alarm by the school liaison office door had a stained appearance.


Ceiling mounted vent directly above the numbered small lockers had visible dust.


Ceiling mounted fluorescent light fixture above clean linen room and the dictation consult room was not working and a small recessed light above the nursing station area was not working.


Carpet in nurse's station area was dirty and stained in appearance.


The tour of the male adolescent unit revealed the following observations:


Two stained ceiling tiles directly above the soiled utility room door and an area of peeling paint on the ceiling approximately 4 to 5 inches in diameter directly adjacent to stained ceiling tiles.


Stained ceiling tile above door to room 306, the stained area was darkish in color. Additionally there were three other stained ceiling tiles noted on the same hallway.


Carpet in nurse's station area was dirty and stained in appearance.


Review of hospital policy provided to the survey team entitled: "Hospital Wide-General Facility Safety and Patient Management (1204)." (revised date of 7/2018) stated: "The facility environment is maintained in a safe, clean and orderly manner at all times. This facility is routinely checked to protect patients, visitors and personnel from potential safety hazards."


Review of hospital policy provided to the survey team entitled: "Housekeeping" (revised date of 2/2018) stated: "Daily Cleaning Procedures for general facility and patient care areas include but are not limited to: 3. Damp dust all ledges, surfaces and fixed equipment." "9. Wipe down walls and remove stubborn spots with cleanser, rinse thoroughly and dry with clean cloth."


In an interview on the afternoon of 9/17/2018 with hospital staff member #6 (who accompanied the surveyors on the above tour) the above findings were confirmed.