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 Nov. 14, 2018
VIOLATION: DISCHARGE PLANNING Tag No: A0799
Based on review and interview the facility failed to:

1.)
a.) ensure a timely discharge assessment was completed to allow for arrangements for post-hospital care to be made in 6 of 6 (#1,3, 4, 18, 19, and 150) charts reviewed.

b.) ensure discharge planning was started at admission and keep the patient, and, when applicable, the patient's representatives informed throughout the development of the discharge plan.

Refer to Tag A0810

2.)
a.) have adequate personnel trained and prepared to counsel, collaborate, or provide care to the patients for discharge.

b.) ensure discharge planning was started at admission and keep the patient, and, when applicable, the patient's representatives informed throughout the development of the discharge plan in 2(#1 and #150) of 2 patient charts reviewed.

Refer to Tag A0818

3.
Based on review and interview the discharge planning in the Garland facility has not been reassessed and reviewed in the Quality Assessment Performance Improvement (QAPI) process.

Refer to Tag A0843
VIOLATION: GOVERNING BODY Tag No: A0043
Based on observation, review of documentation and interview it was determined that the Governing Body failed to ensure that patient safety was maintained at the hospital (both locations: Arlington and Garland, Texas) as the survey team encountered multiple concerns during the November 5-9 and 12-15, 2018 survey. Issues included:

Physical environment- Arlington location: ceiling mounted light fixtures dirty, debris observed on floors in nursing units. Floors tiles discolored stained ceiling tiles. Broken hinges on cabinets in nursing stations. Visible dust found on horizontal surfaces (top of Omincell medication cabinet). Drawers in unit nutrition room, had food residue and snack food (cubed cheese) stored in refrigerator had no date as to when prepared or discard date. Multiple expired supplies found on site during the survey.
Cross refer to:
CFR 482.41(a) - Maintenance of Physical Plant (A0701)
CFR 482.21(a)(c)(2)(e)(3) Patient Safety (A286)
CRR 482.25(b0(2)(i) Secure Storage (A502)
CFR 482.25(b0(3) Unusable Drugs Not Used (A505)

Dietary- Arlington location: kitchen dirty and unsanitary, dietary staff not trained, not wearing hair nets, food temperatures not being taken, no specialized diets (diabetic diets) available. New dietary contract vendor not supervised as contractor started service prior to kitchen being cleaned.
Cross refer to:
CFR 482.28(a)(3) Competent Dietary Staff (A0622)

Patient Rights- Arlington location: Diabetic patient restricted to unit during mealtime without physician order. Patient personal property (eyeglasses) not returned to patient upon discharge. Patient home medications (controlled drug) not returned to family upon discharge of patient. Patient not receiving ordered home medications. Documentation does not indicate that patient/family members were involved in treatment plans. Sharps (disposable plastic razors in unlocked drawer) in nursing station and again found the following day on the same unit. Black electrical cord, approximately 4 feet in length and able to be physically removed from television in dayroom (ligature risk). Expired biomedical inspection stickers found on patient care equipment. Diabetic accuchecks not done as ordered. Pencil found in patient room (staff informed survey team that pencils not allowed in patient rooms). Laminate found with broken edges on wardrobe in patient room and potentially able to be removed and used as weapon or for self-injurious behaviors. Lightweight chairs on patient units (able to be thrown or used as weapon). Expired medical supplies found and available for use to include: medication syringes, suction tubing, and diabetic accucheck test strips.
Cross refer to:
CFR 482.13 Patients Rights (A115)
CFR 482.13(a)(1) Patient Rights: Notice of Rights (A117)
CFR 482.13(b) Patient Rights: Exercise of Rights (A129)
CFR 482.13(b)(1)Patient Rights: Participating In Care Planning (A130)
CFR 482.13(c)(2) Patient Rights: Care in a Safe Setting (A144)
CFR 482.13(c)(3) Patient Rightgs: Free From Abuse/Harrassment (A145)
CFR 482.13(f) Patient Rights: Restraint Or Seclusion (A194)
CFR 482.43 Discharge Planning (A799)
CFR 482.43(b)(5) Timely Discharge Planning Evaluations (A810)
CFR 482.43(b)(6) Documentation Of Evaluation (A812)
CFR 482.43(c)(1) Discharge Planning Personnel (A818)
CFR 482.43(c)(3), (5) Implementation Of A Discharge Plan (A820)
CFR 482.57 Respiratory Care Services (A1151)
CFR 482.57(a) Organization Of Respiratory Care Services (A1152)
CFR 482.57(a)(1) Director Of Respiratory Services (1153)
CFR 482.57(b) Respiratory Care Services Policies (1160)
CFR 482.57(b)(1) Respiratory Care Personnel Policies (A1161)

Nursing services- Arlington location: nursing staff not acknowledging physician orders, not signing patient master treatment plans. Nursing staff not performing ordered accuchecks and patient not receiving (missed dosage) ordered medication (birth control pill), Nursing staff not evaluating patient with scratch on back and another patient with vaginal discharge. Pill cutters (used to cut pills in half) not cleaned, found to contain residue from prior use and one still contained a portion of a previous medication which had been cut.
Cross refer to:
CFR 482.23 Nursing Services (A385)
CFR 482.23(b)(3) RN Supervision of Nursing Care (A395)
CFR 482.23(c)(1)(c)(1)(i) &(c)(2)- Administration of Drugs (A405)

Infection control- Arlington location: The hospital (Arlington location) did not have a functioning infection control program as no documentation of tuberculosis (TB) testing was found for 5 of 8 kitchen staff. There was no documentation found for tuberculosis (TB) testing for mid-level practitioners. Issues found in the Arlington kitchens to include: cleanliness, food temperatures not being taken, staff not wearing hairnets.
Cross refer to:
CFR 482.42 Infection Control (A747)
CFR 482.429(a)(1) Infection Control Program (A749)

Medical records - Arlington location: Physicians not signing medication consents. Delinquent medical records, the survey team found approximately 126 delinquent records (discharge summaries incomplete) and at the Arlington location and 236 discharge summaries incomplete at the Garland location.
Cross refer to:
CFR 482.24(b) Form and Retention of Records (A438)
CFR 482.54 Reassessment Of Discharge Plannning Process (A843)



















PATIENT RIGHTS - Garland Location
Observation, review of documentation and interview revealed that the Governing Body failed to protect, promote and ensure each patients' rights at the Garland facility and failed to implement and enforce adopted Patient Rights policies and procedures.

Cross refer to:
CFR 482.13(a)(1) Patient Rights: Notice of Rights Tag A0117
CFR 482.13(a)(2)(iii) Patient Rights: Notice of Grievance Decision Tag A0123
CFR 482.13(b) Patient Rights: Exercise of Rights Tag A0129
CFR 482.13(b)(1) Patient Rights: Participation in Care Planning Tag A0130
CFR 482.13(b)(2) Patient Rights: Informed Consent A0131
CFR 482.13(c)(2) Patient Rights: Care in a Safe Setting Tag A0144
CFR 482.13(c)(3) Patient Rights: Free from Abuse/Harassment Tag A0145

QUALITY ASSESSMENT AND PERFORMANCE IMPROVEMENT - Garland Location

Record review, observation, and interview revealed that the Governing Body failed to implement and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program reflecting the complexity of the hospital's organization and services, including those services furnished under contract or arrangement. The governing body failed to ensure that the Garland Facility Patient Safety Program was in compliance with the Texas Administrative Code Program Requirements for responsibility and accountability for ensuring that clear expectations for safety are established, implemented, and enforced.

Cross refer to:
CFR 482.21(a), (c)(2), (e)(3) Patient Safety Tag A0286
CFR 482.21 QAPI Governing Body Tag A0308

NURSING SERVICES - Garland Location

Record review, observation, and interview revealed that the Governing Body failed to ensure that the Garland facility Nursing Services provided patient care in accordance with facility policy, state regulation, and standards of nursing practice, which presents a risk to all patients admitted to the Garland facility.
Cross refer to:
CFR 482.23(b)(3) RN Supervision of Nursing Care Tag A0395
CFR 482.23(c)(1), (c)(1)(i) & (c)(2) Administration of Drugs Tag A0405

MEDICAL RECORDS - Garland Location

Observation, review of records, and interview revealed the facility failed to ensure medical records were accurately and promptly completed and properly filed 30 days after discharge, ensure the integrity of the authentication and protect the security of all record entries, and ensure medical records were properly stored in secure locations, protected from fire, water damage and other threats.
Cross refer to CFR 482.24(b) Medical Record Services Tag A0438

INFECTION CONTROL - Garland Location

Based on observation, review of documentation, and interviews, the Governing Body failed to provide a sanitary environment at the Garland facility to avoid sources of infections and communicable diseases, and failed to implement and enforce an effective program for the prevention, identification, control, and investigation of conditions and risks conducive to food-borne illness and cross contamination at the Garland facility.

1) There were unsanitary conditions in the kitchen and patient units. The Garland facility failed to ensure the safe storage of food, that kitchen, equipment, storage facilities and dining room were sanitary, and failed to provide a sanitary environment for the preparation, service and storage of food as the kitchen and dining room were in need of cleaning of dirt, debris, insects, and grease; the kitchen was not maintained in a clean and sanitary manner in accordance with current, accepted food service standards. This presents a risk for a food-borne illness or other cross contamination when preparing and serving food in an unsanitary environment.

These deficient practices were identified under this Condition of Participation and were determined to pose Immediate Jeopardy to patient health and safety, and placed all patients at risk for the likelihood of harm, serious injury, and possibly subsequent death.

The Garland facility did take corrective action while the survey team was on site on 11/7/18 at 1700 to initially abate the unsanitary environment and risk for food-borne illness in the kitchen and dining room which was found by the survey team. The Immediate Jeopardy was removed but the deficient practice is present at the condition level.

2) The Garland facility failed to provide a sanitary environment to avoidsources and transmission of infections and communicablediseases for patients and staff in areas for direct patient care. These findings present a risk of cross contamination to staff and patients of the hospital and these practices were not consistent with current infection control guidelines.
Cross refer to: CFR 482.42(a)(1) Infection Control Program Tag A0749

DISCHARGE PLANNING - Garland Location

Review of records and interview revealed that the Governing Body failed to ensure that the Garland facility had an effective discharge planning process for all patients, involving the patient or their representatives, and failed to
have adequate personnel trained and prepared to counsel, collaborate, or provide care to the patients for discharge. The Garland facility Quality Assessment Performance Improvement (QAPI) process failed to include the
discharge planning process.
Cross refer to:
CFR 482.43(b)(5) Timely Discharge Planning Evaluations Tag A0810
CFR 482.43(c)(1) Discharge Planning Personnel Tag A0818
CFR 482.43(e) Reassessment of Discharge Planning Process Tag A0843
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on observation, review of documentation and interview, it was determined that the Governing Body failed to protect, promote and ensure each patients' rights were maintained at the Garland facility and failed to implement and enforce adopted policies and procedures.

The findings included:

Review of records and interview revealed the facility (Garland location) failed to ensure that individuals who arrived under a Apprehension by a Peace Officer Without Warrant (APOWW) were provided with notice of their rights while under emergency detention. Patients were held in the locked facility, against their will, without due process of an attorney or Order of Protective Custody in 2 (Patient #19 and #4) of 2 patient charts reviewed.
Cross refer: CFR 482.13(a)(1) Patient Rights: Notice of Rights Tag A0117

Review of records and interview revealed that the facility failed to ensure that patient allegations were appropriately processed as grievances, investigated, and/or complainants received the appropriate determination notification within a timely manner in 4 out of 4 complaints/grievances reviewed for the Garland facility.
Cross refer: CFR 482.13(a)(2)(iii) Patient Rights: Notice of Grievance Decision Tag A0123

Observation, record review, and interviews revealed that:
1) the Garland facility failed to ensure patients personal property rights were upheld, as the facility failed to document receipt of and return of personal property, staff and patient signatures were not documented on property forms, and patient's personal medical items, such as a patient's hearing aid and a patient's personal glucometer were found stored in the medication room after the patients were discharged . This was not in compliance with facility policy or patient rights
2) the Arlington facility failed to ensure two of patient's rights (Patient #148 and #144) to have their home-bought medications returned to them prior to leaving the hospital. One of the medication was an amphetamine derivative with the potential to cause addiction and withdrawal symptoms. Other patient items retained at the hospital included a pair of glasses and a medical walker
3) the Arlington facility failed to ensure the rights of Patient #32, a minor, to be treated in an environment restricted as least as possible and failed to receive a physician order for the patient's unit restriction until a day after the patient was noted to remain on the unit during meal times.
Cross refer: CFR 482.13(b) Patient Rights: Exercise of Rights Tag A0129

Review of records and interview revealed that the facility failed to ensure parents/guardians of minors and authorized representatives of adults were invited to treatment team meetings for the purpose of developing a master treatment plan and establishing goals for the patient at the Garland facility.
Cross refer: CFR 482.13(b)(1) Patient Rights: Participation in Care Planning Tag A0130

Review of records and interview revealed the Garland facility failed to ensure consents for psychotropic medications were properly executed, ensuring patients and/or the patient's Legally Appointed Representative (LAR) had all appropriate information to make an informed decision on their treatment in 4 out of 4 (Patient #53, #54, #55, and #56) patient charts reviewed.
Multiple medications were preprinted on a single consent form so that staff could check a box for the medication. Staff were allowed to use one consent form and select multiple medications on the form during the consent process. Multiple medications listed on one consent allows the opportunity for consents to be altered at a later date and medications added to the consent without the patient and/or LAR's knowledge. It also creates confusion as to which medications the consent was still good for if the patient and/or LAR revoked consent for one of the medications listed. This increases the risk that the patient may continue to receive treatment with the unwanted medication or have a needed/consented medications stopped by mistake.
Consents did not contain appropriate signatures.
Appropriate education, including a written summary of the information given during the consent procedure (e.g. risks, benefits, side effects, etc.), was not documented or provided.
Cross refer: CFR 482.13(b)(2) Patient Rights: Informed Consent A0131

Record review, observation and interview revealed the facility failed to:
A.) provide a safe setting for the psychiatric patients in the adult unit of the Garland facility. Ligature risks were observed and identified on the morning of 11/7/18. Administrative personnel and nursing personnel were present. The presence of ligature risks in the physical environment of psychiatric patients, 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 in 1(adult) of 2(child and adolescent) units.
B.) provide safety on the children's unit by allowing the adolescent population to have access to the children. The facility failed to have a working monitoring system and a secured door between the children's unit and adolescent unit. The nursing personnel failed to monitor the adolescent population and allowed the patients to be on the floor unsupervised.
C.) provide timely staff education on ligature risks and patient safety.
D.) provide a quality assurance performance improvement (QAPI) plan for sustainability of staff education, data collection through chart audits, or tracking method to prevent a patient from harm.

Additionally, the Garland facility failed to ensure that patients were provided a safe, humane treatment environment that ensured protection from harm.
1) The Garland facility staff members were routinely allowed to work without the required training to protect patients and staff from harm when dealing with aggressive patients as the Garland facility failed to ensure that staff providing direct patient care maintained current training in non-violent crisis intervention and restraint/seclusion training with skills demonstration and competency. The Garland facility allowed staff members to be on duty with patients without confirmation or documentation that the staff member was compliant in training, which presents a risk that behavioral interventions with aggressive patients may not be conducted in a safe manner. This was not in compliance with facility policy or state regulation.
2) The Garland facility allowed staff members to be on duty with patients without confirmation or documentation that the staff member was current in in American Heart Association or the American Red Cross CPR with skills demonstration and competency, which presents a risk that clinical staff may not be competent to respond in a medical emergency. This was not in accordance with facility policy or state regulation. The Garland facility failed to ensure that staff were trained and competency assessed in the duties of their position as there was no documented evidence provided of job specific orientation or other training. Lack of training presents a risk that staff members will not have the knowledge or skills to perform duties related to patient care in a safe and competent manner. The Garland facility failed to ensure that the staff received an accurate job description, which presents a risk that the staff member will not understand the duties, responsibilities, skills, and knowledge necessary to perform duties related to patient care.
3) The Garland facility failed to verify, prior to allowing agency/contract personnel to work at the facility in patient care, that nursing personnel were currently licensed as nurses in the state of Texas, were current in CPR certification, had been trained in non-violent crisis intervention, had been trained in infection control, fire, safety, and disaster response, and had been oriented to the facility, before working at the facility. This was not in accordance with facility policy which could have potentially resulted in unlicensed, untrained contract staff working at the facility which presents a risk that staff responsible for patient care would not be able to effectively respond in a medical or behavioral emergency situation.
4) The facility failed to ensure that clean and functional emergency equipment and supplies were available to respond to an emergency medical condition.
5) The Garland facility failed to ensure that the patient dining area was safe as there were non-tamper resistant screws used to hang artwork, broken shelving and other safety hazards staff and patients.
6) The Garland facility failed to ensure a safe environment for patients on the unit as there were ligatures and areas for admitting patients to conceal contraband.

Additionally, review of documentation and interviews revealed that the governing body failed to ensure that the Garland Facility Patient Safety Program:
A) included consequences for failing to report events and there was no provision in the policy for intentional errors or acts. The governing body failed to ensure that Garland facility staff had been queried regarding their willingness to report medical or health care errors on at least an annual basis; failed to provide mechanisms for preservation and collection of event data that were relevant; and failed to have a requirement for completing a root cause analysis within 45 days of becoming aware of a reportable event, developing an action plan identifying the strategies that the facility intends to employ to reduce the risk of similar events occurring in the future, designating responsibility for implementation and oversight; specifying time frames for implementation; and including a strategy for measuring the effectiveness of the actions taken.
B) developed and implemented processes to ensure patient safety problems and allegations were identified and investigated.

The lack of a functioning Patient Safety Program promoted a culture where unsafe practices were not identified and corrected, placing all patients at risk of harm or death.
Cross Refer to CFR 482.21(a), (c)(2), (e)(3) Tag A0286 Patient Safety for findings.

These condition and deficient practices were determined to pose Immediate Jeopardy to patient health and safety and placed all patients at risk for the likelihood of harm, serious injury, and possibly subsequent death.
Cross refer: CFR 482.13(c)(2) Patient Rights: Care in a Safe Setting Tag A0144

Review of records, observation, and interviews revealed that the facility failed to protect the patients from neglect and abuse by not allowing the patient to have access to drinking water, without rationing from the staff, or at staff convenience.
Cross refer: CFR 482.13(c)(3) Patient Rights: Free from Abuse/Harassment Tag A0145
VIOLATION: PATIENT RIGHTS: NOTICE OF RIGHTS Tag No: A0117
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of records and interview, the facility (Garland location) failed to ensure that individuals who arrived under a Apprehension by a Peace Officer Without Warrant (APOWW) were provided with notice of their rights while under emergency detention. Patients were held in the locked facility, against their will, without due process of an attorney or Order of Protective Custody in 3 (Patient #2, #4 and #19) of 3 patient charts reviewed.


Findings:

1. Observation in the Garland facility revealed Patient #19 was talking loud and visibly upset. He was requesting to leave on the morning of 11/7/18. The nursing personnel told Patient #19 that he would have to wait and just settle down.

Review of Patient #19's chart revealed he was admitted on [DATE] at 03:41(3:41AM) as an involuntary patient. The patient was brought to the facility on an Apprehension by a Peace Officer Without Warrant (APOWW). This action is taken when officials have reason to think a person's actions or words suggest they pose an imminent threat of harm to themselves or others, and APOWW is used to protect a person while being evaluated by a physician. The APOWW stated, "he attempted to cut himself earlier today. ____ (Pt. #19) appears confused and stated he needs help. I believe _____ (Pt. #19) is a danger to himself based on the above."

According to the "State of Texas Psychiatric Hospital Licensing Rules" 404.158(1)(F),

"Each person apprehended or detained, but not yet admitted , has the following rights.

(F) The right to a preliminary examination by a physician conducted immediately upon arrival at the department facility, community center, or psychiatric hospital following apprehension to determine whether the person meets the criteria for admission for emergency detention. If a physician is not available to conduct the examination, steps shall immediately be taken to arrange for the examination as soon as possible, but in no case more than 24 hours after apprehension."

Review of Patient #19's chart revealed he was seen by a telemedicine physician on 10/21/18 at 3:42AM. The physician order stated the patient would be held as an "involuntary" status. There were no orders found that Patient #19 was changed to a voluntary status.

Review of the chart revealed the APOWW was void after 48 hours on 10/23/18 at 0315 (3:15AM). The physician had signed orders daily for patient #19 to be on elopement precautions from 10/21 to 11/6/2018. There was no Order of Protective Custody (OPC)warrant in the patients chart to keep him against his will in the facility.

Review of Patient #19's chart revealed the patient was forced to take Emergency Behavioral Medications (psychotropic meds) IM by an injection into a muscle, 6 times (in a 12-day period) against his will, with no Order of Protective Custody from a legal magistrate. An Order of Protective Custody is an order issued by a Probate Court after an Application for Court Ordered Mental Health Services has been filed. Once the OPC is issued, an attorney is appointed to the case. The patient will go before the judge to determine if he/ she requires further inpatient psychiatric treatment and medications. The patient may wave their right to appear before the court after the attorney has counseled the patient.

Review of the Patient #19's chart revealed a "Consent Document" that gave consent for treatment, Consent for admission, Understanding your health record, Rights, and disclosure of payments. The consent was signed by staff members on 10/21/18 but no patient signature.

Review of the physician orders dated 10/30/18 at 1630 (4:30PM) stated, "Place pt on 24 hour hold for re-evaluation after he filed for AMA." (Against Medical Advice) Review of the nurses notes for 10/30/18 revealed no documentation of the patient requesting discharge. There was no "four-hour discharge form" on Patient #19's chart.

An interview was conducted on the morning of 11/7/18 with Personnel #160, court liaison. Personnel #160 reported that Patient #19 was a voluntary patient once the APOWW ended. Personnel #160 was shown the chart and physician orders. Personnel #160 confirmed there was no physician orders to change the patient to a voluntary status. Personnel #160 stated, "I didn't know a physician had to write an order to change their status. I have been changing patient's over when the APOWW runs out." Personnel #160 was asked how they were taking care of psychotic patients that needed to be there and forced medications without an OPC warrant from the county judge. Personnel #160 reported that the facility could not get the county judge to sign the OPC's. Personnel #160 reported the county judge was not easy to work with and refuses to assist the facility to hold the patients legally. Personnel #160 stated, "That's why I change their status over to voluntary because the judge will not sign any OPC's."

An interview with Personnel #5 and #25 was conducted on the morning of 11/7/18. Personnel #5 was unaware the patients were in the facility as voluntary patients when the physician had not written orders to change the legal status from involuntary to voluntary. Personnel #25 stated, "We have always done it this way because the county judge will not sign the OPC's." Personnel #25 stated Patient #19 had been too unstable and psychotic to let go. Personnel #5 reported she was unaware of the issue but would contact all the physicians immediately to decide the appropriate status of the patients and inform the patients of their legal status.

Review of Patient #4's chart revealed she was a [AGE]-year-old female admitted to the facility on [DATE] at 01:30 (1:30AM). Patient #4 was admitted as an involuntary patient with a diagnosis of suicidal ideation with a plan.

Review of the telemedicine physician's note dated 7/19/18 at 1:09AM stated, "Legal status: Involuntary. Hold patient for involuntary admission while pending involuntary commitment filing with court. Per Intake staff: Pt arrived via APOWW., pt. is a [AGE]-year-old African American female, presents with SI with a plan. Per police report pt. stated she wanted to hurt herself and that others wanted to hurt her. Per police report pt. wanted to go to the hospital. Pt. reported she has all kinds of thoughts running thoughts. Pt reports thoughts of hurting herself, take some pills, and get out of this place. Pt stated today she wanted to take pills and not have any worry hurt and pain anymore. Pt reports symptoms of depression and feelings of hopelessness."

2.) Review of Patient #4's chart revealed a "Psychiatrist Evaluation" dated 7/19/18 at 8:10PM. The evaluation revealed, "The patient is seen in the consult room. The patient is a poor historian, minimizing her story, consistently changing her story. The patient stated, "I went to my apartment. I see things were displaced, so I called the police, and when police came, I told police that I need to go to the hospital to Medical City to see my medical doctor." Later, the patient reports she has been feeling depressed and she had some cravings of alcohol and she called the police for help. Later, she reports she was in psychiatric hospital and was on medication but she does not remember. The patient is a poor historian. Stories keep changing may be possibly due to her dementia and current mental status, but unable to get any further information because the patient is preoccupied and just labile mood and started saying, "Let me go to jail, I do not want to stay here." Later said, "Okay, let me do some work here to help you out so you can let me go." The patient is having circumstantial thought process and not giving much information.

PLAN OF CARE: I. The patient is not safe to be discharged due to her current mental status. We do not know right now any collateral information, past psychiatric, and medication history. Treatment team will get collateral information and get the list of her medication. 2. Encouraged the patient to attend group and learn coping skills. 3. Estimated length of stay will be 8 to 10 days."

Review of Patient #4's chart revealed there was an Apprehension by Peace Officer Without Warrant (APOWW) on the chart dated 7/18/18 at 9:00PM. The warrant expired in 48 hours on 7/20/18 at 9:00PM or after the patient was evaluated by the physician. There was no physician order to hold the patient and start commitment paperwork. There was no warrant started on the patient to hold and medicate.

Review of the APOWW revealed a note written on the warrant in the left hand corner. The note stated, " Pts. vol. adm. cons. are signed and in chart @ 9:00am 7/24/18 ...."

Review of the chart revealed there was no physician order to change the patient's legal status from involuntary to voluntary. There was no documentation that an Order of Protective Custody was started or filed with the courts to hold and medicate the patient legally within the facility. A consent was signed by the patient for treatment with no date or time on the consent. The consent does not change the patient from an involuntary to voluntary status.

Review of Patient #4's nurse's notes dated 7/23/18 at 2040, "Pt lay down in hallway claiming to have chest pain. Pt crying and moaning about having heart attack. Dr. Hussain examined pt, vs taken and were wnl. Dr. ordered 911 call and 0.1 Clonidine which pt refused to take, insisting we were trying to poison her, and kept crying for paramedics. Paramedics came assessed pt, and refused to take pt to hospital. Pt later began screaming and crying on phone, telling boyfriend we were trying to harm her. Will continue to encourage pt to use coping skills and interact with peers and group sessions. 2103 (9:03PM) Patient refused to take bedtime. (sic) denies SI/HI depression, anxiety, pain, AVH. Fixed on going home, will continue to monitor." There was no documentation of a nursing exam of the patient's complaint of chest pain. There were no documented vital signs or any reassessment documented. There was no paramedic run sheet in the chart to show the paramedics exam or reason for not transporting the patient.

Review of the physician's progress notes revealed a note with no date or time. The note stated, "PT seen and chart review. Pt is minimizing her symptoms, not giving consent to talk to her family and focused for discharge only. Later today she pretended to have chest pain and EMS came to evaluate her, and refused to take her to ER due to possible malingering to go to medical ER. We offer her blood pressure meds that time for higher blood pressure but she refused and later she was calm, cooperative and focused for discharge and minimizing symptoms. Team will get collateral information from her PCP and niece if she agrees to give consent and phone number." There was no documentation found that the physician acknowledged that the patient had no warrant to hold her in the facility nor wrote a physician's order to hold for commitment. There was no evidence that Patient #4 was given an opportunity to request a discharge or given due process of an attorney and Order of Protective Custody.

3.) Review of Patient #2's chart revealed he was a [AGE]-year-old male admitted to the facility on [DATE] at 1110 (11:10AM). Patient #2's was admitted with a diagnosis of psychosis NOS R/O Schizophrenia, Catatonic type.

Review of Patient #2's physician orders dated 9/28/17 at 23:13 (11:13PM) revealed the patient's legal status was incomplete. The order read "Legal Status: Continue legal status per transfer."
It was unclear of the patient's legal status. Patient #2 had come to the facility with an Apprehension by Peace Officer Without Warrant (APOWW).

In the physician's Discharge Summary dated 1/26/18 at 0330 (3:30AM) revealed, "The patient had been identifying increased impairments in mental status, brought on a voluntary basis by police, having been standing in the middle of the street." There were no physician orders found on the patient's legal status of voluntary or involuntary.

Review of Patient #2's chart revealed an Order of Protective Custody (OPC) was found dated 9/29/17. The order had been signed by the judge in Dallas County and to transport Patient #2 to the Garland facility.

A court document was found dated 10/23/17. The order was a "Affidavit in Support and Request for Dismissal of Order of Protective Custody." The request for dismissal was initiated by the CEO of Sundance Hospital during this time frame (The CEO of the Garland facility was no longer an employee of the facility.) The request was from the Garland facility.

The application stated, "_____ (past CEO), a representative for Sundance Hospital requests a dismissal of the Order of Protective Custody for the above listed Proposed Patient because: The proposed Patient no longer meets criteria for protective custody prescribed by Section 574.002 of the Texas Health and Safety Code, in accordance with Section 574.028 of the Texas Health and Safety Code." The application was signed by a county clerk in Tarrant County. The facility was in Dallas County.

An Order for Dismissing Guardianship Investigation was found dated 10/23/17. The order was signed by a judge on 10/23/17. The order stated, "On this date, the court, sua sponte, reviewed its files in above entitled and numbered case and determined that the proposed ward is located in Dallas County, Texas, and a court initiated guardianship investigation, if necessary, should be conducted in Dallas County. Therefore, the court finds that this guardianship investigation should be dismissed. IT IS THEREFORE ORDERED, ADJUDGED and DECREED that cause No. 2017-GD -1 be and hereby dismissed." Signed 10/23/17.

A Petition for Order to Administer Psychoactive Medications was issued on 10/12/17. The physician had filled out the application and it was taken to the court for filing on 10/12/17. There is no further documentation on what happened with the court and no evidence it was heard in a court of law. There was no physician order found to pursue a court order for psychoactive medication administration. There was no documented reason why the facility was going through Tarrant County court systems for a patient in Dallas County. There was no further documented evidence that a physician ordered a dismissal of the OPC.

There was no found documentation that patient #2 was told his legal status, patient rights, given a patient handbook, nor were any consents signed for treatment. The physician documented in the Discharge Summary that the patient was " preoccupied with discharge." There was no evidence that the physician discussed the patients discharge with the patient nor his legal status. Patient #2 was discharged from the Garland facility on 10/23/17.
VIOLATION: INFECTION CONTROL Tag No: A0747
Based on observation, review of documentation, and interviews, the Garland facility failed to provide a sanitary environment to avoid sources and transmission of infections and communicable diseases.

1) There were unsanitary conditions in the kitchen and patient units. The Garland facility failed to ensure the safe storage of food, that kitchen, equipment, storage facilities and dining room were sanitary and failed to provide a sanitary environment for the preparations, service and storage of food as the kitchen and dining room were in need of cleaning of dirt, debris, insects, and grease; the kitchen was not maintained in a clean and sanitary manner in accordance with food service standards. This presents a risk for a food-borne illness or other cross contamination preparing and serving food in an unsanitary environment.

These deficient practices were identified under this Condition of Participation and were determined to pose Immediate Jeopardy to patient health and safety, and placed all patients at risk for the likelihood of harm, serious injury, and possibly subsequent death.

The Garland facility did take corrective action while the survey team was on site on 11/7/18 to initially abate the unsanitary environment and risk for food-borne illness in the kitchen and dining room which was found by the survey team. The Immediate Jeopardy was removed but the deficient practice is present at the condition level.

2) The Garland facility failed to provide a sanitary environment to avoidsources and transmission of infections and communicablediseases for patients and staff in areas for direct patient care. These findings present a risk of cross contamination to staff and patients of the hospital and these practices were not consistent with current infection control guidelines. The Garland facility new employee orientation handouts included the statement that glucometer and lancets are cleaned between patient uses. This training presents a risk that staff will engage in practices resulting in cross-contamination of blood-borne pathogens such as Hepatitis B and HIV. The Garland facility failed to ensure that the facility policy for reportable diseases was current to comply with state statute and failed to ensure that employee infections were monitored to prevent the spread of infection. Cross refer to: CFR 482.42(a)(1) Infection Control Program Tag A0749

Findings included:

1) A tour of the Garland dietary area, the kitchen and dining room was conducted beginning the afternoon of 11/5/18, accompanied by Personnel #18 and Personnel #17, kitchen manager for the contracted food service company.

The dining room was in need of cleaning, as there was black and brown raised dirt, debris and grime on the floors, including food, such as lettuce, strips of carrot, long hairs, especially in the near the walls and in the corners of the room. There were dirty splashes on the walls in the dining room.

Inside the door of the dining room, the 4 ceiling tiles in the corner of the room were damaged, broken, and deteriorated with a hole in the middle of one ceiling tile; the edges of the hole were brownish-black. A brownish-black liquid had drained out of the ceiling tile. There were brownish-black drips and splashes on the wall underneath hole in the ceiling tile.

The plastic condiment bins were dirty as there were food particles, granular substances, and dirty in the bins with the condiments.

The floor underneath the serving line and the ice/drink dispenser was in need of cleaning as there was raised dirt and grime, what appeared to be sticky cola that had spilled, and a dirty styrofoam cup was at the base of the ice/drink dispenser. There was a thick layer of dust on top of the ice/drink dispenser. There were dust and food crumbs in the drink dispenser tray.
There was an electric box with a conduit running from the box to underneath the food serving line which was mounted to the wall next to the ice/drink dispenser, however it had pulled away from the wall, presenting a risk for injury or liquids to enter the electrical box from the nearby drink dispenser. The electric box had drips on the top and the sides.

The plexiglass sneeze guard on the steam tables at the serving line was cracked and dirty and presented a hazard for particles of plexiglass falling into the food and could not be thoroughly cleaned. There was greasy grime around the edges of the sneeze guard. There was a metal bracket along the lower edge of the plexiglass sneeze guard which was in need of cleaning as old dried food and other dirt collected on the metal bracket. There were drips and dried food and debris on all surfaces of the steam tables, which were in use for serving patient meals. There was a thick layer of food particles, grease, and dust on the horizontal surfaces of the steam table, especially around screws and corners.

There was standing water under and around the steam table, which presents a safety and infection control risk.
The knobs on the steam table were covered in raised, black, greasy film.
There was a large, sticky brown spill on the shelf underneath the steam table.

The sign indicating the location of the fire extinguisher extended out from the wall and there was raised dust covering the sign and dust hanging down from the bottom of the sign approximately 1/3 of an inch. The fire extinguisher was covered in dust and a greasy film.
There was a cup of coffee on the steam table in a cardboard cup that belonged to staff.

The metal wire shelving unit behind the serving line was in need of cleaning. There were drips and splatters and dust and grime on the shelving unit. The lower shelf was especially dirty, and there were dirty mop strings around the wheels.

There was a red bucket (used for sanitizing solution) on the shelving unit containing a greyish liquid with foam and floating particles. The handwritten date appeared to be 11/4 on the red bucket label during the tour the afternoon of 11/5/18. The sanitizer solution in red buckets should be changed when dirty or at least every few hours to keep the water clean and the sanitizer effective.
There was a green bucket (used for detergent solution) on the shelving unit containing a dirty, but clearer liquid with particles in the liquid. The handwritten date on the green bucket label stated "9-23-18". There was a towel in the bucket.

There were stacks of styrofoam plates, food trays, and bowls on the metal shelving unit, uncovered and stacked bowl side/face up, which presents a risk for contamination available for use with patient food. There was a pair of dirty gloves wadded up on the shelving unit. There was a dirty, damp towel wadded up on the shelving unit next to and touching an opened box of vinyl food service gloves.
Next to the shelving unit was a plastic trash can which was broken and did not have a lid. The inside and the outside of the plastic trash can was in need of cleaning, as there was dried food and drips on the trash can, which did not have a bag or sack inside the can.

The pass through warmer was in need of cleaning as the area was heavily soiled with grease, dirt, and food particles. The door seals were worn and there was a buildup of food particles and dirt in the door seals.
Underneath the warming unit on the serving line there was a thick layer of grease, dirt, and food particles adhered to the cabinet.
The return vent in the ceiling over the serving line was covered in dust and had strings of dust hanging down from the vent screen.
The syrup dispensing manifold for the drink dispenser had a thick layer of dust and a greasy film adhered to it.

Behind the serving line in a shelving unit, there was a closed, large three compartment styrofoam container. The container was opened and it was full of shredded meat which had a strong smell. There was no label on the container. There was no means to determine how long the meat had been sitting at room temperature.

There were 2 wall electric outlets behind the serving line. One outlet did not have a cover and the other cover with a sticker "K-14" was covered in dust and grease.

In preparation to enter the kitchen during the tour on 11/5/18 at 3:10 pm, the survey team requested hairnets or a hair covering to enter the kitchen area. Kitchen staff stated that the kitchen did not have any hairnets. After a few minutes, the survey team was told by Personnel #18 that hairnets had been requested from a nearby facility and would be delivered to the Garland facility "soon." At approximately 3:28 pm, Personnel #18 went to the patient unit and returned with paper shoe covers which were modified such that the survey team could cover their hair and enter the kitchen area, as the facility still did not have hairnets or hair covers for entering the kitchen. Hair nets are required in the kitchen to keep human hair from contacting exposed food, clean and sanitized equipment and utensils and to maintain a sanitary environment.

Once inside the kitchen, the door frame going into the kitchen was soiled and dirty. The light switch cover inside the kitchen was broken, exposing the electrical inner workings. The light switch cover was dirty, covered with grease and drips and, of the 14 screw holes, only 7 were had screws to hold the cover in place.

The "Ice Machine Cleaning and Sanitizing Log - Daily, Weekly and Monthly Cleaning" was reviewed. The last date on the log to indicate cleaning was "9/23". Staff #17 stated that there was no other log or documentation to indicate that the ice machine had been cleaned or sanitized in 43 days.

The Cleveland electric steamer was in need of cleaning, as there were dried food smears covering the door and the handle, and there was a layer of grease and dust on the surface. There was dried food and grease on the handle of the steamer. There were six baking sheets which were found to have a heavy carbon build up on a shelf near the steamer that was spoiled with food particles, grease, and dust.

The floor in the housekeeping closet was in need of cleaning as there were damp areas and dirt and grime on the floor. The shelving units were dusty, and the spray bottles containing cleaning products had dirty labels. There was a spray bottle with the words handwritten, "Orange Force", yet there was no indication of the date mixed or the date of expiration for the solution.
There was a mop standing in dirty, greyish-black water in the mop bucket.

An interview was conducted with Personnel #125, kitchen aide, at approximately 3:45 pm on 11/5/18. Personnel #125 stated that she and the other kitchen aides were responsible for mixing the sanitizing solution in the red buckets for sanitizing the food prep and serving surfaces. Personnel #125 demonstrated preparing a red bucket of sanitizing solution, as the current bucket in use was contaminated and there was no means to determine when the solution was last mixed. Personnel #125 prepared the solution. When asked how she knew how much water and how much sanitizer to put into the bucket, Personnel #125 did not respond and shrugged her shoulders. The test strip was put into the bucket by Personnel #125 for approximately 35 seconds. It was removed 10 times to check the color of the strip. Personnel #125 stated, "You just keep putting it [the test strip] in until it turns green to be up to 400." The test strip never changed color and remained orange, with a result of 0 parts per million.
Review of the QT-40 test strip used by Personnel #125 read "Immerse for 10 seconds, compare when wet."
Personnel #125 emptied the bucket and attempted to prepare another bucket of sanitizing solution with the same results: 0 parts per million of sanitizer in the solution.
There was no detected sanitizer in the sanitizing solution prepared either time. This presents a risk for cross contamination as food prep and serving surfaces are not sanitized with a solution that does not contain sanitizer.
A second bucket of sanitizing solution was prepared by Personnel #19, kitchen aide. Personnel #19 prepared the solution and when testing the amount of sanitizer in the solution, the test strip was removed after 3 seconds and read 500 ppm, indicating that too much sanitizer was being mixed into the bucket.

There was a greasy substance on the cooking fryer and the cooking fryer contained grease which was dark and had food particles floating in it. There was no means to determine the last time the grease had been changed or when the fryer had been last cleaned. In an interview with Personnel #19, he stated that "It has been like that since I got here and I started the first of November."
There was a metal wire shelving unit in the kitchen.
The shelves were dirty, with dust and grease and there were drips hanging from the individual shelves.
Hanging on the side of the shelving unit were "clean" utensils, including 2 large soup ladles, hanging with the bowl up. There was dried food adhered inside the ladles, and there were crumbs, dust, and what appeared to be salt inside the ladles.
There was a red bucket containing a bubbled liquid and a white cloth and a green bucket containing a bubbled liquid and a white cloth on the bottom shelf of the unit. The cloths in these buckets were used for cleaning and disinfecting food prep areas. Next to and touching the buckets on the shelf were pans which were "clean" and available for use in food prep. Placing "clean" pans next to buckets used in cleaning and disinfecting food prep areas presents a risk for cross contamination. The pans next to the buckets were soiled with carbon build up and grease.
On another shelf there was a bottle labeled, "Antimicrobial Fruit & Vegetable Treatment Test Strip" which was dirty and dusty and labeled with an expiration date of April 2016.

The drawers in the food prep table contained utensils for use in food prep. There were crumbs, debris, and drips inside the drawers along with a greasy film. The ice cream scoops and large serving spoons had dried food adhered to them and 2 large spoons had a greasy film on the handle. A meat cleaver had raised, dried food on all surfaces, including the surface used on food products. All the drawers were soiled with dust, grease and food particles.
Inside one of the drawers was a plastic box containing cooking utensils. The plastic box was dirty, with drips and stains and dried food. The utensils were greasy and had food adhered. The sides and surfaces of the drawers had dirt and grime and drips down the sides. There was dried food inside the cabinet.

There was a wire metal shelving unit used for "clean" food pans and cook ware. The bottom shelf had a plastic shelving liner which had a layer of grease and dried food and dirt. On top of the shelving liner were stored large pans and pots, available for use in food prep. On the other shelves were other pans, pots, and bowls, available for use in food prep. The kitchen ware was observed being placed in stacks on the shelving unit by the kitchen aide after washing without air drying. Observation of a stack of 5 pans revealed food particles on the pans and each of the pans was dripping wet. Observation of a stack of 3 long pans revealed food particles and wet pans.

There was no handwashing soap at the handwashing sink next to the dishwashing sink. The paper towel dispenser was empty. The sink was dirty with dirt and a black substance adhered to the faucets. The faucet handles had a large amount of an unknown raised black substance adhered to the surface of the handles. The first aid kit hanging on the wall had a thick layer of black grease particles and dust on the surface. There was an foaming hand sanitizer dispenser mounted on the wall next to the handwashing sink which was covered in dust, grease, and black particles and was empty. The wall behind the sink and stove area had a greasy film and drips and splashes adhered. There was a dirty, yellow toothbrush with black debris in the brush sitting on the sink. The handwashing sink was very slow to drain.

There were "clean" dishes and pans stored underneath the dishwashing line, including colanders, plastic pans, plastic lids, and muffin tins. This presents a risk of cross contamination.

The walk-in refrigerator door handle was dirty with a black substance on and around the handle. Inside the refrigerator, there was a pitcher containing an orange-ish thick liquid was particles floating in the liquid. There was no label on the pitcher to indicate the contents or the date.

There were 2 trays of sandwiches which were in plastic sandwich bags in the refrigerator. The sandwiches were not labeled as to type of sandwich or date. Approximately 1/3 of the plastic sandwich bags were not closed, leaving the sandwich bread and meat exposed. There was a large tray of lettuce and salad greens in the refrigerator which was unlabeled. The staff stated it had been on the serving line at lunch and had been put in the refrigerator after lunch, but none of the kitchen staff knew when the salad had been made originally.

There were 5 cases of 72 individual serving 4 ounce orange juice containers. The outside of the box was labeled 10/31. The manufacturer label on the box stated, "Storage & Handling Store at 0 [degrees] F. Thaw before serving. Keep refrigerated once thawed. Serve within 10 days of thawing for best flavor. Do not refreeze." The individual orange juice containers were not labeled as to the date placed in the refrigerator to thaw. The individual containers were distributed to the unit refrigerators for patient snacks or meals. There was no label placed on the orange juice to determine the date the orange juice should no longer be served. This was confirmed in an interview with Personnel #17.

There were 6 "clean" frying pans which were found heavily soiled in carbon build up. When the surveyor ran her thumb across the pan, a black, greasy substance came off on the thumb. There was a thick layer of greasy dust on top of the oven.

There were no temperatures being documented for food being served. When asked for temperature logs the morning of 11/6/18, Personnel #21, Dietary Manager stated, "We just started here the first of November and haven't started using logs yet." There were no logs or documentation for Dishwashing/Warewashing Machine, including the washing temperature, the rinse temperature, checking the sanitizer ppm. When asked, Personnel #19, kitchen aide stated, "we don't have any logs."
There was no monitoring of food temperatures. There was no means to determine that food was cooked to the recommended minimum internal temperature, which is a leading cause of food borne illness.

There were 3 trays of lemon custard pastries in the food pass through with no date label and which were uncovered, prepared for patient meals.
There was a food prep table which had cutting boards and wire racks, a large pan, and plastic food wrap on the lower shelf. There was also a dirty apron which had been placed on the shelf and was touching the pan, thereby contaminating the pan and the other contents on the shelf. While observing in the kitchen, a staff member was standing next to the food prep table, leaned against the table and propped her foot on the lower shelf next to the food prep items.

The plastic, maroon colored plates were stacked while still wet. Upon inspection, the plates had food particles adhered and a slight greasy film.

There were gnats flying around in the kitchen. There was open food on the food prep tables where the gnats were flying. When asked about open, uncovered food with gnats flying around, he stated, "It's okay, we're serving it in about 15 minutes."
Later during the tour, the surveyor tapped on a box of styrofoam cups and plastic cups which were on a shelving unit near the floor drain and a large group of gnats swarmed out of the area of the box. The floor drain was full of food and other debris, presenting a likely source for the gnats.

The temperatures on the oven were not calibrated and there was no means to determine what the temperature was. A pan of lasagna had been baked inside the oven and had burned on the outside, however inside the pan, the lasagna was still cold. This presents a risk of a food borne illness from undercooked food.

Log sheets provided to the survey team on 11/8/18 included the following:
- Hot Holding Warmer Cabinet Temperature Log - blank and no documentation between 11/1/18 and 11/6/18
- Dishwashing/warewashing machine temperature Log - blank and no documentation between 11/1/18 and 11/6/18.
Sanitizer Solution Log - blank and no documentation between 11/1/18 and 11/6/18.
Thermometer calibration Log - blank and no documentation between 1/1/18 and 11/6/18.
Freezer Temperature Log - blank and no documentation between 11/1/18 and 11/6/18.
HACCP Refrigerator Temperature Log - blank and no documentation between 11/1/18 and 11/6/18.

The external doors in the hallway next to the kitchen had insufficient door seals or weather stripping, leaving a gap between the doors and the frame with outside light visible seen from inside the building.

In the dry storage area, there was a 4 pound jar of grape jelly which had been opened and was approximately 1/2 full on the shelf.

On 11/6/18 in the kitchen, there were 4 trays of uncooked bacon strips on flat pans in the pass through between the kitchen and the serving line area. The bacon was not covered, nor was it maintained at a proper temperature.

In the walk in refrigerator, there was a box containing hamburger patties which was opened and partially crushed.

There was a tray of chicken in the refrigerator which had been thawing in the refrigerator for 4 days.

There were dead insects on the floor near one of the kitchen doors and the refrigerator. The side by side refrigerator doors would not stay closed to maintain an acceptable temperature range. When one door was closed, the other door would pop open. There was no means to determine whether the food in the refrigerator was maintained at an acceptable temperature due to an inability to keep the doors closed.
All refrigerator and freezer seals in the kitchen were torn and deteriorated and were in need of cleaning or replacing, as there was a thick, black substance that appeared to be mildew and what appeared to be dried food in the seals.

There was a small styrofoam container with a lid containing an unknown food substance and a hand written date "12/27/17".

The metal cart used to take food products to the patient units was dirty and in need of cleaning as there was dried food particles, including grated cheese, dirt, and dust and a layer of a grey substance on the shelves. At one point, someone had placed a pair of worker's heavy duty, black knee cushion pads with straps on top of the metal cart. This presents a risk of contamination of food.

There was a pan of utensils on the shelf which had recently washed items, such as tongs and knives. There was water standing in the bottom of the pan that the utensils were sitting in. There was a stack of 9 pans which were stacked wet, with water dripping off of them when separated and observed.

Review of the Position Profile for the Food Service Manager revealed the duties of "Directs daily operations of food service operations to ensure employees have appropriate equipment, inventory and resources to perform their jobs ...Oversees the preparation ...and safe storage of food. Ensures that kitchen, equipment, storage facilities and dining room are sanitary, neat and organized ...Ensures compliance with all federal, state, and local regulations ...(e.g. quality assurance, safety, operations, personnel). Establishes a safe work environment for employees ..."

Facility policy, "Infection Control" Function: Dietary, stated, in part, "Purpose To prevent the spread of infection in the Food Service area and to patients and/or staff. Policy Food Service employees or persons providing food service to patients are responsible for following infection control procedures to aid in the prevention and control of infections.
Procedure ...a. Food Service Department adheres to the Sundance Hospital Infection Control Policies and Procedures the Centers for Disease Control (CDC's) Standard Precaution Guidelines.
b. Develop and maintain clean and sanitary work areas, storage areas and equipment for the handling of supplies in accordance with local and state Health Department standards.
c ...Procedures for preparation and serving of food will be such as to minimize contamination by microorganisms and chemicals that may result in food poisoning ...
3. Prevention of Contamination
a. Wash hands with soap and water ...
c. All dietary employees or persons entering the kitchen area will wear a hairnet ...
h. Keep pests controlled ...
4. Cleaning of Equipment
a. Clean all equipment ...
b. Wash all dishes and silver after each meal following procedures.
i. Before beginning operation-check temperature procedure.
ii. Wash at 140 degrees to 160 degrees.
iii. Rinse at 180 degrees or above.
5. Clean Equipment ...
b. Stainless Steel
i. Clean stainless steel tables with a cleanser made for stainess (sic) steel to stop growth of bacteria in this area ...
7. Rules for Food Storage
a. Refrigerated Storage
i. Refrigerate all potentially hazardous foods below 41 degrees F. Keep frozen products at -10degrees to 0 degrees F ...
iii. Check temperatures twice daily and report any irregularities.
iv. Clean thoroughly weekly and wipe up spills immediately ...
vi. Cover and date cooked foods to reduce evaporation losses and to limit odor absorption and damage from possible leakage. Use within 24 hours.
b. Dry Storage
i. Sweep storeroom floors regularly. Keep storeroom orderly and shelves labeled ...
v. Store flour, sugar, rice, potatoes and onions in covered bins on rollers that can be moved for cleaning ...
c. Perishable Goods ...
1. if meat is to be used at once, store in refrigerator held to 32 degrees F with relative humidity 75-85 percent. DO NOT keep fresh meat longer than three to four days.
2. Store meats away from other foods ...
3. Use ground meats within 24 hours ...
4. Cook at once frozen meats that have been allowed to thaw ...
iii. Keep poultry packed in ice, ready to cook, for 1-2 days in refrigerator at 36 degrees F or less ...
d. Planned-over Foods
Place leftover food ion (sic) shallow pans, cool, cover with clean wrap, label with contents and date and place in refrigerator at a temperature below 42 degrees F. Utilize planned-overs within 24 hours ...
e. Food Display
i. Keep potentially hazardous foods at 45 degrees F or below, or 150 degrees F or above ..."

The above findings were confirmed at the Garland facility with Staff #1 the afternoon 11/14/18 in the facility conference room.
VIOLATION: PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION Tag No: A0123
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of records and interview, the facility failed to ensure that patient allegations were appropriately processed as grievances, investigated, and/or complainants received the appropriate determination notification within a timely manner in 4 out of 4 complaints/grievances reviewed for the Garland facility.

Findings included:

On 11-13-2018 at 1311, an interview was conducted with Personnel #162. During the interview, the complaint and grievance logs were reviewed.

Findings for Patient #60

A complaint was filed on behalf of Patient #60 by his mother. It was not documented on the form the date/time the complaint was made or the staff member name that took the complaint. The date/time the patient advocate was notified and "notified by" box were also blank. The complaint was as follows:

" A little girl named ______ (patient name redacted for privacy) and another girl drew a penis and a highfive on my sons face on 9/28/18 in the dayroom @ nighttime. My concern is that staff or techs were not around to witness or help or wipe off, let alone know this happened. I wanna make sure that they stay away from him and him away from them and staff do what they told me they were gonna do. Please call me @ ________ (phone number redacted for privacy) Friday night 9 years old House supervisor knows ... 6 year old boy helped him wiped off" (sic)

On 10-4-2018, six days after the alleged event, Personnel #5 documented the Action/Follow-up. An investigation was conducted with patient interviews. All kids "stated this child was making sexually inappropriate comments, had drawn the penis on his own face, rec'd complaints from female peers re this boy's sexually inapprop behaviors & house sup placed him on SAO (sexually acting out) precautions." (sic)

There was an unreadable scribble in the Patient Signature block. The Patient Name (printed) block contained notes from the Action/Follow Up listed above. No Date/Time Complaint was Resolved was filled in.

Personnel #162 stated he did not send a letter because the incident had been resolved by Personnel #5. Personnel #162 did agree that this situation had required an investigation and could not have been resolved immediately.

No information on an investigation into the mother's concern about adequate staffing was made. Her concern had been that all of this had taken place without staff awareness or intervention.

Findings for Patient #63

On 10-10-2018, Patient #63 filed a grievance that the patient's brown bag was missing. The bottom half of the form was blank. This included:

Date/Time Patient Advocate Notified:
Notified By:
Patient Advocate Signature:
Action/Follow Up:

A letter to the patient dated October 22, 2018 was attached to the grievance. This letter was dated 12 days after the grievance was made. The letter stated, "I have attempted to reach out to you at the group home you were discharged to so we can resolve this matter but wasn't able to get in contact with you and was told by the owner that she would have you call me back. If you can please give me a call ... so we can resolve this matter."

There was no documentation of any investigation into the loss of the bag or investigation/evaluation of the process for securing patient belongings.

Personnel #162 stated he had looked for the bag, but was attempting to contact the patient for further description of the bag or to see if the patient had found the bag once the patient had arrived at the group home. Personnel #162 acknowledged that the letter was sent out past the required response time of 7 days. Personnel #162 acknowledged that lost belongings were not uncommon in the Garland facility.

Findings for Patient #61

On 10/12/2018 a grievance was documented on behalf of Patient #61 and her mother. The mother spoke Spanish and required a translator to communicate with staff. The patient's mother alleged that she had been told during the admission intake process that "If I don't' sign my child in, CPS will take my kids away ...I was scared. So I did it." The mother alleges that she was not provided a translator during the intake process to help her understand the hospital procedure. She also alleged that the patient, a female minor, "had contact with an adult male patient in intake and that patient was fearful at hospital because of that interaction."

The bottom half of the grievance form was blank. This included:

Date/Time Patient Advocate Notified:
Notified By:
Patient Advocate Signature:
Action/Follow Up:

A letter dated October 22, 2018 (10 days after the grievance was made) was attached to the grievance form. The letter was in English and was addressed to the patient's mother who only speaks Spanish. The letter stated:

"This is in response to the complaint you filed on October 12th, 2018. In your complaint you mentioned upon admission in intake you mentioned (sic) that CPS said if you didn't sign your child in, they would take your kids away. You also mentioned that your daughter had an interaction with an adult patient in intake and upon the interaction your daughter became very fearful to be admitted .

I have attempted to reach out to you to resolve this matter and have left voicemails."

The complaint did not state that CPS had told the patient's mother her children would be taken away. The complaint stated that she had been told in intake that if she didn't sign her daughter in that CPS would take her kids away.

Personnel#162 confirmed the voicemails left were in English. Personel#162 confirmed that the allegations were not investigated.

Findings for Patient #62

On 10-18-2018, Patient #62 filed a grievance as follows:

"Pt was ignored for 30 min when requesting a glass of water. Pt stated his requests have been ignored regularly and he observes staff member no (sic) working and sitting around gossiping when he was told they were busy.

Also Tuesday 10/16, Pt was given a physical by a female nurse. Pt requested multiple times for a male staffer or nurse to perform physical but pt reported he was refused. Pt also reported he was not provided his medication in a timely manner."


The following sections were blank:
Date/Time Patient Advocate Notified
Notified By
Patient Advocate Signature

The Action/Follow Up sections contained the following:

"Spoke with _______(Patient #62) on Tuesday [DATE]rd @ 2:34p and apologized for the way he was ignored and staff not meeting his requests. After explaining to him that patient care comes first and no one should ever make them feel like they are not human, I told him I would talk to nursing staff and make sure this doesn't happen again. I also informed _______(Patient #62) if he ever needs our services we are available for him 24hrs 7days a week for him. ______(Patient #62) was very thankful for my call and showing that their (sic) is still good people out there that care and wanna (sic) help."

This entry was not dated, timed, or signed. The Date/Time Complaint was Resolved was dated 10/23/18, not timed.

No letter to complainant was attached.

When asked, Personnel #162 stated Personnel #5 had made the entry. Personnel #162 stated he did not send a letter because Personnel #5 had resolved the situation with a phone call. When asked if this was permissible by regulatory requirements, Personnel #162 confirmed that he did not have a copy of the regulatory requirements and was going off how he had been trained to do the job. In an interview with Personnel #5, Personnel #5 confirmed she had made the entry and phone call to the patient. When asked if she had investigated the patient's accusation that he was not receiving medication on time and the he had been denied a staff member of the same sex be present for a physical examination, Personnel #5 stated she had not investigated those allegations.

Review of the Policy and Procedure titled Grievance Procedure, Date Issued 08/11/2014 was as follows:

"Definitions
A "patient grievance" is a written or verbal complaint (when the verbal complaint bout care is not resolved at the time of the complaint by staff present) ...

If a verbal patient care complaint cannot be resolved at the time of the complaint by staff present, is postponed for later resolution, is referred to other staff for later resolution, requires investigation, and/or requires further actions for resolution, then the complaint is a grievance for the purposes of these requirements.

...

Notice of Resolution to the Person Reporting the Concern. The hospital shall review, investigate and resolve each patient's grievance within a reasonable time frame. If the grievance will not be resolved, or if the investigation is not or will not be completed within 7 days, the hospital should inform the patient or the patient's representative that the hospital is still working to resolve the grievance and that the hospital will follow-up with a written response within a stated number of days. The hospital must attempt to resolve all grievances as soon as possible.

Once contact with complainant has been made, efforts should be made to resolve the problem within seven days. If that timeframe cannot be met, follow-up contact with the complainant should occur every seven days until the problem has been addressed."

Review of the "Patient Advocacy Plan Sundance Hospital - Garland", item 9). was as follows:

"If a Grievance is made, then a follow up letter is sent within 7 days of the patient advocate receiving the grievance. If the grievance has not been resolved within 7 days and is still going through investigation, then a letter is sent every 7 days until the grievance is resolved or investigation is completed."
VIOLATION: PATIENT RIGHTS: EXERCISE OF RIGHTS Tag No: A0129
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, record review, and interviews it was determined that
1) the Garland facility failed to ensure patients personal property rights were upheld, as the facility failed to document receipt of and return of personal property, staff and patient signatures were not documented on property forms, and patient's personal medical items, such as a patient's hearing aid and a patient's personal glucometer were found stored in the medication room after the patients were discharged . This was not in compliance with facility policy or patient rights
2) the Arlington facility failed to ensure two of patient's rights (Patient #148 and #144) to have their home-bought medications returned to them prior to leaving the hospital. One of the medication was an amphetamine derivative with the potential to cause addiction and withdrawal symptoms. Other patient items retained at the hospital included a pair of glasses and a medical walker
3) the Arlington facility failed to ensure the rights of Patient #32, a minor, to be treated in an environment restricted as least as possible and failed to receive a physician order for the patient's unit restriction until a day after the patient was noted to remain on the unit during meal times.

Findings included:

1) Facility policy, "Patient Belongings" provided to the survey team stated, in part, "Personal belongings will be searched and inventoried to provide for safe storage and accounting of patient belongings, and to identify and secure items that may be unsafe on an inpatient unit ...
PROCEDURE
1. Patient belongings will be searched and inventoried on admission, and as items are brought into the unit for the patient..
2. The inventory will be maintained in the discharge section of the patient's medical record ...
7. At discharge, the patient shall gather all personal items from their room, the secured areas, and any storage areas utilized by staff. Patients shall review their personal items prior to leaving the unit to be sure that they have all of their belongings."
The policy failed to include instructions for staff the document that patients received their personal property at discharge and to have the patient sign the form acknowledging their personal property intake or release.

Review of the Patient Property Inventory form revealed instructions to "Indicate all patient property received by Nursing/MHT staff" with a column for the item, the quantity, and the date released. The form provided spaces with dates and times to be entered for the following:
Patient Signature (logged in)
Staff Signature (logged in)
Patient property released to
Staff Signature (logged out)."

Facility policy, "Patient Rights" provided to the survey team stated, in part, "All patients receiving mental health services at Sundance Hospital will be granted the following rights ...
25. The right to reasonable protection of personal property from theft or loss. The Chief Executive Officer (CEO) shall institute and monitor procedures to protect and adequately secure the personal property of persons served, including clothing. Sundance Hospital will develop, maintain and post procedures regarding protection and security of personal property of persons served."

In an interview conducted the afternoon of 11/13/18 in the Garland admissions area, Personnel #25, House Supervisor, stated that the Patient Property Inventory Sheet should be completed on all patients when they are admitted . Personnel #25 stated that all items that belong to a patient are inventoried, including the clothes that the patient is wearing. Personnel #25 confirmed that when a patient is discharged and the personal property is released, that the patient and the staff member sign the Patient Property Inventory form to indicate that all the patient property has been returned to the patient.

Garland patient medical records were reviewed the morning of 11/13/18.
Review of the patient records for Patient #9 and Patient #58 and Patient #71 revealed no Patient Property Inventory form in the medical record. There was no documented evidence in the medical record that these patient's personal property was inventoried.

Review of the patient records for Patient #52 and Patient #54 revealed a blank Patient Property Inventory form in the medical record, with no documentation or signatures on the form. There was no documented evidence in the medical record that these patient's personal property was inventoried.

Review of the patient records for Patient #56 and Patient #59 revealed that the Patient Property Inventory form had been completed when the patient's personal property was received; however there was no documented signature or other evidence that the patient's personal property was returned to the patient or LAR. There was no means to determine if the patients received their personal property when they were discharged .

During a tour of the Garland facility the morning of 11/6/18, accompanied by Personnel #18, there were patient's personal medical items observed which were stored in a cabinet in the medication room of Unit 3, as follows:
Patient #67, admitted [DATE], hearing aid.
Patient #68, admitted [DATE], contact lens case and contact lens disinfecting solution
Patient #69, admitted [DATE], eye glass case
Patient #70, admitted [DATE]. personal glucometer with a prescription label adhered from an external clinic pharmacy dated 5/26/17.
In an interview with Staff #52, RN, she confirmed that Patient's #67, 68, 69, and 70 had been discharged , yet the patient's medical care items were stored in a cabinet in the medication room. Staff #52 stated that she was not aware of any attempts made by hospital staff to contact the former patients to retrieve their personal medical items.

During a tour of the Garland facility the morning of 11/6/18, in the Unit 3 Patient Belongings room, the floor was observed in need of cleaning as there was dust, debris, stains, and drips on the floor. A shoe was on the floor and there was no means to determine who the shoe belonged to. There was a pair of vision glasses on a shelf with no means to determine who the glasses belonged to. The shelving unit the patient belongings were stored on was in need of cleaning, as there was dust and drips on the shelving with patient belongings. This was confirmed during the tour with Personnel #5.

Patient Rights set forth in the Texas Administrative Code were as follows:
"404.154 Persons receiving mental health services from department facilities, community centers, and psychiatric hospitals have the following rights ...
(25) The right to reasonable protection of personal property from theft or loss. At department facilities, the head of the facility must institute procedures to protect and adequately secure the personal property of persons served, including clothing. Community centers and psychiatric hospitals should develop and post procedures regarding protection and security of personal property of persons served."

The above findings were confirmed in an interview with the Chief Nursing Officer the afternoon of 11/13/18 in the Garland facility conference room.

2.) During a tour of the Arlington location girls unit on 11/05/2018 the following observations were made: in a locked cabinet in the medication room there was a bottle of Vyvanse 40mg capsules (approximately 31 in the bottle).The medication was labeled as belonging to Patient #148. Also found was a bottle of Kirkland Sleep Aid (doxylamine succinate) tablets, there were approximatlety 8 tablets in the bottle and a label indicated that they were for patient # 144. Personnel # 28 accompanied the surveyor on the tour and confirmed that Patient #148 and Patient #144 had been discharged .

In an additional interview with Personnel # 31, on the afternoon of 11/05/2018 it was confirmed that was a controlled medication. It was additionally confirmed that Patient #148 had been discharged from the hospital and that this medication should have been returned to the patient upon discharge.

Also found in the same cabinet was a clear plastic bag containing a broken pair of blue framed glasses. The patient name on the label was for Patient # 147 and the admitted was 2/13/2018. In an interview with Personnel # 28 on the afternoon of 11/05/2018 it was confirmed that this patient had been discharged .


Observations in the Arlington facility's PICU patient laundry room on 11/06/18 at approximately 1330 reflected three medical walkers halfway covered with a plastic sheet. Personnel #37 stated at that time that the walkers were not in use and one of the walkers belonged to Patient #113 who "had been discharged ."


3).
Record review of Patient #32's Physician Admission Orders dated 11/02/18 at 0813 reflected the patient had previously attempted suicide and "just wanted to die." The patient's admission diagnoses included Major Depression and Diabetis Mellitus.

Patient #32 was interviewed on 11/05/18 at 1630 and stated staff did not do "anything for my blood sugar. I had pancakes this morning, and my blood sugar is getting worse."

Observations in the Arlington facility patient dining area on 11/05/18 at 1705 reflected the adolescent patients including Patient #32 had access to a carbonated beverage dispenser.

Nursing notes dated 11/06/18 at 0550 reflected the Patient #32's constant increasing ...[blood sugar] levels."

Nutrition assessment dated ,d+[DATE]/[2018] reflected Patient #32 "is now eating on unit to ensure diabetic diet and limiting CHO (carbohydrates) and sugars ..."

Record review of Patient #32's physician order dated 11/07/18 at 1000 reflected an order for unit restriction "for meals only."

During an interview on 11/07/18 at approximately 1300 Personnel #163 stated the Patient #32 was unit restricted because her diabetic medical condition and to "restrict the easy access to the soda fountain."




Based on observation, record review, and interview, the hospital failed to ensure patients' rights requirements were met for one of one patient (Patient #32) who was noted to be unit restricted during meals to prevent unrestricted access to carbonated sweet beverages. An order was not written by the physician until a day later.

Findings included:


Record review of Patient #32's Physician Admission Orders dated 11/02/18 at 0813 reflected the patient had previously attempted suicide and "just wanted to die."

Patient #32 was interviewed on 11/05/18 at 1630 and stated staff did not do "anything for my blood sugar. I had pancakes this morning, and my blood sugar is getting worse."

Observations in the Arlington facility patient dining area on 11/05/18 at 1705 reflected the adolescent patients including Patient #32 had access to a carbonated beverage dispenser.

Nursing notes dated 11/06/18 at 0550 reflected the Patient #32's " constant increasing ...[blood sugar] levels."

Nutrition assessment dated ,d+[DATE]/[2018], untimed, reflected Patient #32 "is now eating on unit to ensure diabetic diet and limiting CHO (carbohydrates) and sugars ..."

Record review of Patient #32's physician order dated 11/07/18 at 1000 reflected an order for unit restriction "for meals only."

During an interview on 11/07/18 at approximately 1300 Personnel #163 stated the Patient #32 was unit restricted because her diabetic medical condition and to "restrict the easy access to the soda fountain."
VIOLATION: PATIENT RIGHTS: PARTICIPATION IN CARE PLANNING Tag No: A0130
Based on observation, record review, and interview, the hospital failed to ensure that one of one patient (Patient #26) participated in the development and implementation of his care plan and received information of treatment of his dangerously high fluctuating blood sugars.


Findings included:



Patient #26 was observed in bed on the Arlington facility's PICU (Psychiatric Intensive Care Unit) on 11/06/18 at 0950 and granted an interview to the surveyor. Patient #26 stated she had a leg amputation and an "artificial leg" since 2010 and has Diabetes Mellitus. The patient stated, "I eat regular meals." Patient #26 denied having received information regarding a diabetic diet at the hospital and stated, "I had chocolate cake last night." The patient denied knowledge about the physician who treated him at the hospital.

Patient #26's Master Treatment Plan dated 11/02/18 reflected Patient #26's physician had participated by phone. The document did not reflect evidence of Patient #26's participation in the treatment plan conference. Record review reflected that Personnel #151, a social worker, signed the document two days and 95 minutes later on 11/04/10 at 1200
.
Patient #26's blood sugar results dated 11/01/18, 11/02/18, 11/03/18, and 11/04/18 reflected the patient had blood sugar readings fluctuated between 284 mg/dL (milligram per deciliter) on 11/04/18 at 0735 and 579 mg/dL on 11/03/18 at 2100.

The American Diabetics Association noted that a core aspect to diabetics management was blood glucose control and support (http://www.diabetes.org/living-with-diabetes/recently-diagnosed /living-with-type-1-diabetes.html?loc=lwd-slabnav).




Based on review of records and interview, the facility failed to ensure parents/guardians of minors and authorized representatives of adults were invited to treatment team meetings for the purpose of developing a master treatment plan and establishing goals for the patient at the Garland facility.

Findings included:

Review of Patient #6's chart revealed he was a 6-year-old who had been voluntarily admitted to the Garland facility on 10-5-2018 by his mother. No documentation was found in his chart where his mother was advised of treatment team date and times so that she could participate in the development of his Master Treatment Plan and goals.

An interview was conducted with the Interim Clinical Director, Personnel #4 on 11-9-2018. Personnel #4 stated that parents and guardians are not invited to treatment teams. Personnel #4 stated they are contacted for discharge planning and for family therapy sessions with the clinical therapist, but are not invited to attend treatment team. When asked if adult patients are advised they can have a designated representative such as a spouse or family member be present to assist them with development of a master treatment plan and goals, Personnel #4 stated they are not.

On 11-12-2018 an interview was conducted with Personnel #74, RN, on the Adult unit. Personnel #74 was asked when treatment teams meet. Personnel #74 stated she wasn't sure, "I think it may be on Tuesday and Thursday." When asked who attends, Personnel #74 stated she did not know. She explained that everyone just puts down information on the Treatment Plan forms when they had time. When asked if the patients are ever allowed to have a family member with them in treatment team, Personnel #74 replied that she had never seen it done.

Review of Policy titled Patient Rights, Date Issued 8/11/2014, page 1, item 7 was as follows:
Patients have "The right to participate in the development and periodic review of an individualized treatment plan (extending to the parent or conservator of a minor, and the legal guardian of the person, when applicable); and the right to a timely consideration of any request for the participation of any other person in this process, with the right to be informed of the reasons for any denial of such request. (Staff must document in the medical record that the parent, guardian, conservator, or other person was notified of the date, time, and location of each meeting so that he or she could participate.)"
VIOLATION: PATIENT RIGHTS: INFORMED CONSENT Tag No: A0131
Based on review of records and interview, the Garland facility failed to ensure consents for psychotropic medications were properly executed, ensuring patients and/or the patient's Legally Appointed Representative (LAR) had all appropriate information to make an informed decision on their treatment in 4 out of 4 (Patient #53, #54, #55, and #56) patient charts reviewed.

Multiple medications were preprinted on a single consent form so that staff could check a box for the medication. Staff were allowed to use one consent form and select multiple medications on the form during the consent process. Multiple medications listed on one consent allows the opportunity for consents to be altered at a later date and medications added to the consent without the patient and/or LAR's knowledge. It also creates confusion as to which medications the consent was still good for if the patient and/or LAR revoked consent for one of the medications listed. This increases the risk that the patient may continue to receive treatment with the unwanted medication or have a needed/consented medications stopped by mistake.

Consents did not contain appropriate signatures.

Appropriate education, including a written summary of the information given during the consent procedure (e.g. risks, benefits, side effects, etc.), was not documented or provided.


Findings included:

Patient #53
Review of physician orders showed that an order was written on 10/20/2018 at 10:15 for the following psychotropic medications:

Lexapro 10 mg (milligram) po (by mouth) qam (every morning)
Seroquel 50 mg po ______ (unclear if written as "bid", which means twice a day, or if it was written as "bed", which could mean at bedtime).

On 10/20/2018 at 11:00 AM, a telephone consent was obtained. In the patient signature it was written Patient 53's name,then "(father)". It was signed by two nurses, one acting as a witness to the telephone consent. The physician signature was blank. The section for "Consent for Treatment Involving a Minor, If this consent is for the treating of a minor, under Section 35.04, Texas Family Code, the following information must be provided:" was also left blank. The information required in this section included:
Name of one or both parents, if known
Name of legally authorized representative of person, if appointed
Date on which treatment began.

The consent listed both Lexapro and Seroquel at the top, instead of initiating a separate consent for each individual medication as required.

A statement was checked indicating that the father had received an Oral Explanation of the medication. No documentation of printed material given or mailed to the parent was found.

On 10-20-2018 at 1730, an order clarification was written for the Seroquel confirming that the medication was to be given twice a day (BID). No information was documented that the parent received the appropriate information about the frequency Patient #53 would be receiving this information.


Patient #54

Review of Patient #54's chart was made. A lined form that did not have a title was in the chart. The form had a section for the Patient Name and Date. The rest of the form was a series of blank lines similar to notebook paper. The form was dated 10-24-2018. The form was noted, "There are not consents frm pts. mtr. ________ (name redacted for privacy) in chart on 10/24/18 @ 7:30 a.m." A second note on the form read, "I rechecked chart after verifying w/________(name redacted for privacy) pts mtr had signed all consents. No originals in chrt just copies @ 7:58 AM on 10/24/18."

Review of the chart did not contain original or copies of consents. The patient had physician orders written on 10/24/2018 at 1817, over 10 hours after the note about consents being written. The order was for Zyprexa and Clonidine and to please obtain consent prior to administration. Medication administration records show the medication was administered routinely as ordered between 10-25-2018 and 10-31-2018. No record of consent was found in chart.

No documentation of printed material given or mailed to the parent was found.

Patient #55

Review of Patient #55's chart was made. A physician order was written on 10-27-2018 at 1100 for the psychotropic medications, Cymbalta, Seroquel, Trileptal, and Topamax.

A consent form was found and listed medications Cymbalta, Seroquel, Trileptal, and Topamax on a single consent form. The section titled "Patient Education" was blank. There was no Patient/Guardian Signature. Two nurses signed the consent and dated 10-27-18 at 1155. No physician signature was present.

Medication administration records show the medication was administered routinely as ordered between 10-27-2018 and 11-1-2018.

No documentation of printed material given or mailed to the parent was found.

Patient #56

Review of Patient #56's chart was made. Upon admission, the patient and family member provided a list of home medications to the nurse. These medications were documented on "Universal Medication List" form on 10/22/18 at 1620 and listed as the psychotropic medications, Fluoxetine (Prozac), Hydroxyzine (Vistaril), and Quetiapine (Seroquel). A physician signed the order to continue the medications on 10-23-2018 at 1100. Another order for the same medications was written on 10-23-18 at 1630 that changed the dosages and time of medication administration.

One consent form with the three medications was found on the chart. The section titled "Patient Education" was blank. There was a name printed in the Patient/Guardian Signature block that did not indicate the relationship to the patient. Two nurses signed the consent and dated 10-27-18 at 1155. No physician signature was present.

The section for "Consent for Treatment Involving a Minor, If this consent is for the treating of a minor, under Section 35.04, Texas Family Code, the following information must be provided:" was also left blank. The information required in this section included"
Name of one or both parents, if known
Name of legally authorized representative of person, if appointed
Date on which treatment began.

A second consent form with the three medications was found on the chart. The section titled "Patient Education" was blank. There was a name printed in the Patient/Guardian Signature block that indicated the relationship to the patient was father. Two nurses signed the consent and dated 10-23-18 at 1504. No physician signature was present.

No documentation of printed material given or mailed to the parent was found.

Medication administration records show the medication was administered routinely as ordered between 10-23-2018 and 10-29-2018.

An interview was conducted with Personnel #5. Personnel #5 stated that she had never heard that the hospital was required to provide the parent/LAR with a printed summary of information provided by telephone consent. Personnel #5 stated the staff provide an oral explanation but do not give the patients handouts or printed information about the medication they have consented to take.


Review of hospital policy entitled: "Informed Consent for Psychoactive Medications" with a review date of 9/26/2016 stated: "The prescribing physician is ultimately responsible for ensuring informed consent; however, this function may be delegated to the licensed nurse responsible for implementing the physician's written orders for psychoactive medications." "Preprinted information/consent for medication forms that have been approved by Sundance Hospital may be utilized. Informed medication consent must be obtained for each individual medication, not by medication class. Medication consents shall identify the specific medication for which consent is being given."

Page three of the policy stated: "A. The treating physician, registered nurse (RN), licensed vocational nurse (LVN), physician's assistant (PA), or registered pharmacist (RPh) will explain to the patient and to the patient's legally authorized representative, the psychoactive medication in simple, nontechnical language in the person's primary language, if possible. If the explanation is not provided by the treating physician, he/she must confirm the explanation with the patient's legally authorized representative, within two working days, not including weekends or legal holidays."

Review of hospital policy entitled: "Documentation Requirements" stated under the procedure section: "5. The medical record documentation must be clear, concise, complete and current." "11. The medical record must not contain blank, spaces or lines 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." "17. The attending practitioner shall be responsible for the preparation of a complete and legible record for each patient. Its content shall be pertinent and current."
Review of hospital policy entitled: "Patient Records" stated: "The facility shall establish and maintain a single record for every patient beginning at the time of admission. The content of the record shall be complete, current and well organized."



Review of Texas Administrative Code, 414.404 (b), was as follows:

"The patient and his or her LAR must also be provided a summary of this information in writing, along with an offer to answer any questions concerning treatment. If the LAR is not present, the information must be mailed to the representative (via certified letter) within 24 hours, except on weekdays and legal holidays when the information will be mailed the next business day."

This exact language was also found in Sundance Hospital Policy and Procedure, Title: Informed Consent for Psychoactive Medications, Date Issued: 08/11/2014.
VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES Tag No: A0749
Based on review of documentation, observation, and interview, the Garland facility failed to develop, implement, and enforce a system for preventing, identifying, reporting, investigating, and controlling infections and communicable disease, including food-borne illness to provide a sanitary environment at the facility.

1) The Garland facility failed to provide a sanitary environment as the laundry room for washing patient clothing was in need of cleaning of lint, dust, dirt, grime, trash, and soap film on the floor, the machines, hoses, cords, and walls. The wash temperature for washing patient clothing was set on "Cold" which could have resulted in inadequate cleaning. The facility laundry procedure did not specify what wash temperature was to be used. The facility policy did not reflect the current practices.

2) The Garland facility failed to provide a sanitary environment as there was torn vinyl, water damaged ceiling tiles, floors in need of cleaning, and contaminants in the patient care areas.

3) The Garland facility new employee orientation handouts included the statement that glucometer and lancets are cleaned between patient uses. This training presents a risk that staff will engage in practices resulting in cross-contamination of blood-borne pathogens such as Hepatitis B and HIV.

4) The Garland facility failed to ensure that the facility policy for reportable diseases was current to comply with state statute.

5) The Garland facility failed to ensure that employee infections were identified and monitored to control infections and communicable diseases between patients and personnel.

These findings present a risk of cross contamination to staff and patients of the hospital and these practices were not consistent with current infection control guidelines.

Findings included:

1) A tour of the Garland facility Unit 3 patient laundry room was conducted the morning of 11/6/18. In the washing machine and the dryer were what appeared to be patient clothes. The washing machine dial was set for a cycle for a cold water wash. The washing machine was in need of cleaning as there was dust, lint, and grime adhered to the knobs and the outer surfaces of the machine. There was a thick layer of dirt, grime, and sticky soap film inside the washer lid and above and on the tub. There was dust, dirt, and grime covering the dryer, and there was lint in the lint filter of the dryer. The water hoses from the wall to the machine, the detergent and bleach dispenser hoses, and the electrical cords had lint, grime, and a soap film adhered to them. The was lint and dust adhered to the walls. On the floor of the laundry room under and around the washing machine and dryer, the tile was water damaged, warped, cracked, raised, and covered with a thick layer of lint, dust, dirt, grime, bottles, bottle caps, and soap film. This allowed conditions for potential mold, mildew, and bacterial growth to grow as a potential source of infections.

A sign posted in the laundry room stated, "Bleach needs to be ran through the machine after every wash." Review of the "Washer and Dryer Cleaning Log" in the Unit 3 Laundry room on 11/6/18 revealed no documentation of cleaning after 11/4/18. There was no documented evidence that the washer and dryer had been cleaned between patient loads, even though there were patient clothes in the washer and in the dryer. There was no documented evidence that the washer was being disinfected with an "empty load of wash with 1 ounce of bleach during the 11PM - 7AM shift".

In an interview with Personnel #25 during the Garland tour the morning of 11/6/18, Personnel #25 acknowledged that the washing machine was set for a cold water wash and rinse cycle. Review of the facility laundry policy revealed that the water temperature for washing patient laundry was not specified. In an interview with Personnel #25, he stated that patients do not come into the laundry room and stated that only the staff come into the room and do the patient laundry, contrary to facility policy. Review of the facility policy revealed that patients are able to use the washer and dryers. Staff #25 confirmed the need for a thorough and deep cleaning of the patient laundry facilities. The inspection chart did not contain a place to document inspection of "general cleanliness including behind the machines and in corners of the floor". There was also no documentation on the chart that the housekeeping department had been notified of the need for additional cleaning.

A tour of the Garland facility Unit 2 Laundry room was conducted the afternoon of 11/8/18 accompanied by Personnel #23. A sign was posted on the wall which read, "Please Sanitize after every wash and log in binder ...Thanks Management" and another sign which stated, "Only employees should be in the laundry room. No Patients!!! Thanks." There was no documentation on the "Washer and Dryer Cleaning Log" that the washer had been sanitized on the night shift or that housekeeping had been notified of the need for additional cleaning. On top of the dryer, there was a styrofoam cup lying on its side with a blue substance which had spilled onto the top of the dryer and dried and had not been cleaned up. The washing machine was in need of cleaning, as there was dust, lint, soap film, and grime adhered to the knobs and the outer surfaces of the machine. There was a thick layer of dirt, grime, and sticky soap film inside the washer lid and above and on the tub. On the floor of the laundry room under and around the washing machine and dryer, the tile was water damaged, warped, cracked, raised, and covered with a thick layer of lint, dust, dirt, grime, bottles, bottle caps, and gooey soap. Staff #23 demonstrated by pushing with his foot that the flooring was damaged in the laundry room between the washer and dryer and stated, "All this flooring needs to be replaced." Personnel #23 then moved the washing machine away from the wall to reveal spills, dried soap, trash, dirt, grime, soap residue, and water damaged tile also underneath the machine. Staff #23 confirmed the need for a thorough and deep cleaning of the patient laundry facilities, and replacement of the broken and dirty floor on Unit 2.

A tour of the Garland Facility Unit 2 Soiled Linen room the afternoon of 11/8/18, accompanied by Personnel #23. There were 2 bags of dirty linen, which appeared to be sheets and towels, in the large soiled laundry bin/cart, which were overfull and had dirty linen falling out of the bags. The bags were too full to be transported from the patient care area to the Soiled Linen room and this presents a risk of cross-contamination.

Facility policy, "Proper Handling of Soiled Linen" provided to the survey team stated, in part, "It is the policy of Sundance Hospital to properly handle soiled linen. PROCEDURE: Soiled linen is to be placed in receptacle. When receptacle is no more than 2/3 full, it is to be tied and placed in the soiled laundry bin. Do not overfill receptacle."

Facility policy, "Washing Patient Clothing" provided to the survey team, stated, in part, "It is the policy of Sundance Hospital that the patient or a staff member may launder soiled clothing. They may use the hospital's washer/dryer services ...
PROCEDURE ...
2. Take clothes to the washer and put into washer.
3. Set water temperature.
4. Use detergent ...
7. Clean lint trap after you remove the clothes. Wipe dryer out with germicidal cleaner.
8. Have patient get their clothes after they are dry. Do not leave the clothes in the laundry room or mix patient clothes ...
A. Laundry Room ...
2. The following rules apply for patient use of the washer and dryer:
a. Patient must be supervised by nursing staff ...
c. A single wash quantity of laundry soap is provided to the patient for each load of laundry - an automated dispense may be used to dispense soap.
d. After the wash cycle is complete, the patient removes the clothing and places the load in the dryer.
e. Washing machines are disinfected between patient laundry loads to decrease the risk of nosocomial infection.
3. Daily cleaning of the laundry room ...
The table below describes daily duties for Housekeeping personnel and Nursing staff for daily upkeep of the laundry room:
Staff: Housekeeping
Duties: Wipe off the machines to assure the outside is clean. Lift the lid of the washer and wipe off excess soap. Dust laundry room walls. Dust behind and on top of the machines ...Clean underneath machines and the remainder of the floor.
Staff: Nursing
Duties: Run an empty load of wash with 1 ounce of bleach during the 11PM - 7AM shift. Inspect machines and laundry room for cleanliness. Maintain an inspection chart in the laundry room and document inspection and disinfecting on the chart. Inspect the room for general cleanliness including behind the machines and in corners of the floor and record on the chart. Page Housekeeping if additional cleaning is needed and document on the comments section of the chart as follows, 'called Housekeeping.'"

The Centers for Disease Control "Guidelines for Environmental Infection Control in Health-Care Facilities" dated 2003 reflected in part "The antimicrobial action of the laundering process results from a combination of mechanical, thermal, and chemical factors. Dilution and agitation in water remove substantial quantities of microorganisms. Soaps and detergents function to suspend soils and also exhibit some microbiocidal properties. Hot water provides an effective means of destroying microorganisms. A temperature of at least 160F (71C) for a minimum of 25 minutes is commonly recommended for hot-water washing."

The uncovered linen on the unit had been an ongoing issue. Environment of Care rounds on a form entitled "INFECTION CONTROL MONITORING", from 8/1/18 to 11/5/18 revealed that linen issues had been documented by Staff #6, Infection Control Nurse,
Item 14 on the form stated, "Linen carts are clean and covered. Linen closet contains no other items." Item 14 had been checked "N" with comments for the following dates:
8/4/18 Unit 2 "[Not] covered"
8/14/18 Unit 3 "Uncovered"
8/20/18 Unit 2 "[Not] covered"
8/28/18 Unit 3 "[Not] covered"
8/30/18 Unit 3 "[Not] covered"
9/4/18 Unit 3 "Uncovered"
9/26/18 Unit 3 "Uncovered"
10/3/18 Unit 3 "Uncovered (1)"
11/5/18 Unit 3 "Uncovered"
The Environment of Care rounds results were confirmed in an interview the afternoon of 11/8/18 with Staff #6 in the Garland facility conference room.

The Centers for Disease Control "Guidelines for Environmental Infection Control in Health-Care Facilities" dated 2003 reflected in part "After washing, cleaned and dried textiles, fabrics, and clothing are pressed, folded, and packaged for transport, distribution, and storage by methods that ensure their cleanliness until use."

2) A tour of the Garland facility was conducted the afternoon of 11/5/18, accompanied by Personnel #1.
In the hospital lobby, there were 3 seats and backs with torn vinyl. One seat had a tear approximately 10 inches, the back of the second chair had a hole approximately the size of a quarter, and the third chair had 5 small holes. The tears on the upholstery exposed the porous material beneath the vinyl covering. This porous material cannot be adequately cleaned between patients, and could harbor pathogens.

There were two water damaged ceiling tiles in the lobby; the presence of water damaged tiles indicated a potential for contamination from the moisture and airborne bacterial particles.

During the tour of the Admissions unit, the intake room 7, the furniture was in need of cleaning, the light switch plate was dirty, and the floor threshold of the door was dirty with dirt and grime.

In the intake hallway, there was a purple chair with tears in the surface of the chair, stained areas, and dirty tape on the chair. There was dirt and debris on the floor of the intake hallway, especially near the wall baseboards.

In the room called the "Extra Waiting Area" in the intake area, there were 3 water damaged ceiling tiles. There was a risk for patients to conceal contraband in the pockets of the blue geri chairs, available for use in patient care. There was trash and food wrappers found in the pockets of the geri chairs in the room. The chairs were in need of cleaning, as there were drips and crumbs and stains on the chairs.

During a tour of Unit 3 the morning of 11/6/18, in patient room 363, "cleaned" and available for patient use per Personnel #18, the two patient mattresses in the room had writing on them with a thick silver substance. Some of the words, such as "boyfriend ...calling me up ...I ' m ready to go home ...dead ...[name] is dead ...so we can have a baby" were legible and had not been cleaned off the mattress. This is an infection control risk. There was debris in the window sill and the paint had bubbled up in the window sill due to what appeared to be water damage. The moisture presents a risk for mold or mildew. There were 2 used EKG electrode tabs stuck to the wall in the room and dirt and debris on the floor of the room, especially near the wall baseboard.

In the Unit 3 Patient Supply room, the blue bins containing patient personal care items such as toothbrushes and toothpaste were in need of cleaning as there was dust and trash in the bottom of the bins.

In the Unit 3 Patient Examination room, there was an old examination table, which had multiple tears and holes in the vinyl covering. There were strips of dirty, sticky tape adhered to the table and sticky tape residue on the exam table. There was loose paper and trash in between the exam table and the wall. The table was covered with raised dust and grime. There was a red biohazard bag loose on the floor in the room with unknown contents.

The above findings were confirmed with Personnel #5 and Personnel #18 during the tour.

3) An interview was conducted the morning of 11/8/18 in the Garland facility conference room with the Garland Infection Control Director, Personnel #6, who stated that she was responsible for Infection Control training for new employees in orientation at the Garland facility. When asked which guidelines the facility follows for infection control standards, Personnel #6 stated that the facility follows CDC guidelines, stating that, "it's probably not documented anywhere."

The Garland facility new employee orientation Infection Control packet was provided to the survey team by Personnel #6, Infection Control Director the afternoon of 11/8/18. On review, the orientation packet stated, in part,
"Disinfection of Nursing Equipment
Nursing staff is responsible for disinfecting equipment after and between uses on patients ...Glucometer and lancets should be cleaned between patient uses."

Facility policy, "Limiting Transmission of Infections on Medical Equipment and Devices" provided to the survey team stated, in part, "It is the policy of Sundance Hospital that the staff member prevents the spread of infection when utilizing medical equipment and devices. PROCEDURE ...9 Glucometer must be disinfected between patients as manufacturer directed. A different lancet will be used for every patient and the machine will be cleansed after every patient use."

"Fingerstick devices, also called lancing devices, are devices that are used to prick the skin and obtain drops of blood for testing. There are two main types of fingerstick devices: those that are designed for reuse on a single person and those that are disposable and for single-use ...
Reusable Devices: These devices often resemble a pen and have the means to remove and replace the lancet after each use, allowing the device to be used more than once. Some of these devices have been previously approved and marketed for multi-patient use, and require the lancet and disposable components (platforms or endcaps) to be changed between each patient. However, due to failures to change the disposable components, difficulties with cleaning and disinfection after use, and their link to multiple HBV infection outbreaks, CDC recommends that these devices never be used for more than one person." Retrieved from https://www.cdc.gov/injectionsafety/blood-glucose-monitoring.html

An interview was conducted with Personnel #5, CNO the morning of 11/9/18 in the facility conference room. The above new employee orientation Infection Control packet was reviewed with Personnel #5 who stated that the facility did not clean lancets between patient uses and that lancets were single use only. Personnel #5 left the conference room, then returned and stated she went to the orientation currently in session with 19 new employees and collected the Infection Control packets from the employees. Personnel #5 provided the survey team with the packets collected from the new employees and stated that she informed the new employees that the facility uses single-use lancets for glucometer testing.

4) Review of the Garland policy for reporting all reportable diseases to the local health authority revealed that the policy had not been updated since at least 2016. Facility policy, Reports to the Public Health Department stated, "It is the policy of Sundance that all reportable diseases shall be reports (sic) to the Public Health Department.

The list of Texas Notifiable Conditions for the state of Texas from the Texas Department of State Health Services was last revised January 2018, expiration date of 1/31/19 found at http://www.dshs.state.tx.us/idcu/investigation/conditions/ Health care providers, hospitals, laboratories, schools, and others are required to report patients who are confirmed or suspected of having a notifiable condition in the time frame required for reporting (Chapter 97, Title 25, Texas Administrative Code).

The lack of an updated policy presents a risk that confirmed and suspected cases of infectious or notifiable conditions may not be reported as mandated by statute. The above findings were confirmed in an interview with the Infection Control Nurse in the Garland facility conference room the morning of 11/8/18.

5) Facility policy, "Employee Infections", last revised 8/28/18, provided to the survey team, stated, in part, "I. Any employee having an infection is responsible for reporting it to their supervisor, who will report it to the Infection Preventionist/Occupational Health Nurse. II. The Infection Preventionist is responsible for completing and maintaining the employee infection record whenever an infection is reported ...V. The employee will be asked to report to the Infection Control Nurse when returning to work."

Facility policy, "Reporting Employee Infections" last revised 1/30/2018, provided to the survey team, stated, in part, "It is the policy of Sundance Hospital to monitor sick call-ins or self-reports for evidence of infections. I. any employee having an infection is responsible for reporting it to their supervisor, who will report it to the Infection Control Nurse. II. The Infection Control Nurse is responsible for completing and maintaining the employee infection record whenever an infection is reported ..."

Facility policy, "Hospital Wide Departmental Procedures", developed by Infection Control, stated, in part, "B. Personnel ...2. When calling the department to report a sickness, identify symptoms and illness as accurately as possible. This information is submitted to the Infection Control Nurse as call-ins occur to identify and report possible epidemics."

The form entitled, "SUNDANCE HOSPITAL EMPLOYEE CALL-IN" was provided to the survey team in the Garland facility conference room the morning of 11/8/18 by the Infection Control Nurse. The form listed the name, job title, department, date of illness, chief complaint or suspected problem and a list of possible symptoms, including fever, sore throat with ever, "flu-like" symptoms, productive cough, diarrhea, sores boils, burns that are draining, mucus membrane infection, significant rash, and other. There were options for action taken and treatment received, with a space for the supervisor to sign and for Infection Control to sign.

An interview was conducted the morning of 11/8/18 with the Infection Control nurse who stated that the policy was not being followed and the form was not being used and the facility was not monitoring employee sick call-ins or monitoring for evidence of staff infections.













Findings in the Garland Facility on:

11-05-2018

Main Lobby Waiting Area-
Black metal and vinyl chairs were found with the vinyl torn on three chairs. The chairs were not able to be cleaned properly.
The main desk had chips and missing Formica on the sides and facing of the desk. Sheet rock was exposed.


Intake Area-
A cloth and vinyl chair, in the main waiting area, was found to have tears. The chairs were dirty with food particles and paper found down the sides.

The floors were heavily soiled with dirt, hair, and dust.

Purple plastic psychiatric approved chairs, in the intake hallway, was found to be covered in old tape, dirt, hair, and a white residue.

In intake room #7 the walls and light switch plate were covered in a dirty dried substance. The door frame was caked in dirt and a greasy substance.

The intake hallway had sheetrock residue and chunks on the floor. There was no evidence of maintenance work or repair. The walls were stained with dried spills and the floor was heavily soiled with dust and dirt.

The Dynamap machine (blood pressure machine and thermometer on wheels) was found to be heavily soiled with dried food particles, dust, dirt, and hair.

The red crash cart had missing paint and was heavily soiled with dust and hair.

The Formica countertops, in the nursing work area, was found to be chipped and missing in multiple areas. The wooden particle board was exposed and unable to be properly cleaned.

Inside the above cabinets was one blood pressure cuff. The cuff was lying on top of salt packages, ranch dressing, medical tape, an opened package of Halls cough drops, and staples. The patient medical tape was heavily soiled with dust and hair.

A gray bucket was found holding soiled surgical masks, markers, highlighters, pens, a pill crusher and invisible tape.

A large yellow and red Igloo cooler was found sitting on the desk. The cooler was described as the "water" cooler that was for patients to drink in the intake area. Upon inspection of the cooler it was heavily soiled with a black, moldy spout. On the inside, the cooler had a mildew substance on the side of the cooler walls.

A paper sack with a patient's name on it was found on the nursing work desk. The sack had clothing items inside. In the patient's dirty shoe was the patient's medication bottle from home.



Patient Nourishment Room-
In the intake nourishment room, a wooden side table was found with a glass top. On the glass was a microwave. The microwave was heavily coated in burn areas and food particles on the inside. The inside walls were rusted on the bottom and top. The facing was peeling paint and rust particles were on the inside of the microwave. The microwave had a strong smell.

A Keurig tea maker was found sitting under the class table uncovered on the heavily soiled floor. The tea maker was heavily soiled in dust.

A cardboard box was found sitting on the table with packages of cookies inside. Several of the packages had opened and cookies were spilt all in the box. The box was uncovered and was dusty inside.

On top of the refrigerator was wheel chair parts and paper plates. Inside the refrigerator was milk, sack lunches, and yogurt for the patients. The inside of the refrigerator was soiled with mildew, dust, hair, dried food particles, and dried spilt liquids. The floor under the refrigerator was black with dirt and mildew.

The freezer above the refrigerator was found to have a frozen Dr. Pepper bottle, and opened ice cream. The refrigerator ice maker pan was heavily coated in mildew, hair and dirt. The metal shelf was found to be rusted.
Review of the temperature log posted on the outside of the refrigerator showed the last time it was checked was 10/31/18.



Second Floor Child and Adolescent Unit-
The seclusion room was found to be empty. The floor was heavily soiled with dust, dirt, and hair. Holes were noted on the walls exposing the sheetrock. There were some Styrofoam pieces on the floor. The Plexiglas in the wall of the seclusion room was heavily soiled with dust, dirt, and unidentifiable substances. The Plexiglas was scratched with a sharp object on the inside of the seclusion room. Personnel #169 confirmed no one had been in this room today as a patient.

The bathroom in the seclusion area was soiled. The walls and floors were soiled with dried liquids, and dust. The toilet was soiled with dust and fecal matter. The toilet seat was broken and metal was exposed for a patient to retrieve. The sink was stained with a rust colored substance and water stains.



Children's Group Room-
In the children's group room, the TV was covered by a piece of Plexiglas. The Plexiglas was soiled with dust. The TV was not working. Paint was missing around the windows exposing sheetrock. The sheetrock was mildewed.
Electrical plugs were found opened and exposed to the children. There were no protective covers. The electrical plates were found to have crayon colors drawn on the plates. The surveyor had devices plugged in to the socket to show the plugs were active and carried a current.

Profanity was carved into the dry erase boards.

The door frames and floors were heavily soiled with dust and dirt. Children were found barefooted in the room and hallways. The bottom of the children's feet was found to be black from the soiled floors.



Patient Room 268-
The patient room was locked and reported to be "Terminally Cleaned." Terminal cleaning is a cleaning method used in healthcare environments to control the spread of infections. The purpose of this cleaning and disinfection process is to remove bacterial contamination from environmental surfaces and equipment surfaces where patients receive care in order to prevent the transmission of the microorganism from patient to patient, from patients to healthcare workers, and from patients to visitors.

The door frame and threshold was soiled with dust and dirt. The door frames were missing paint.
The floor of the room was soiled with dust, dirt, hair, plastic candy wrappers, and paper. Trash was still in the trash can.

The wooden bed frames that hold the mattress were heavily soiled with dust, dirt, hair and paper.

The window frame was soiled with dirt and hair. The paint was cracked and peeling.

The two mattress were torn and soiled.

The patient room had uncovered working electrical plugs.

The bathroom door had a four-inch piece of rubber all around the door. This allowed the door to close but not latch. Large pieces for the rubber were torn away from the door. The door was soiled with dried liquids and a sticky substance.

Pieces of toilet paper were found lying on the heavily soiled floor. The toilet was soiled with urine, toilet paper, hair and dirt.

The shower floor was mildewed and covered in hard water stains. A white dried substance was splattered all over the walls.



Physician/Patient Exam Room-
The exam room floor was soiled with dust, dirt and hair. The door was covered in a dried liquid stain. The door frame was missing paint and was soiled with dust.

A small refrigerator was found sitting on the soiled floor. The inside of the refrigerator was heavily soiled with dust and long strands of black hair.

In a shelf above the sink a box of tongue depressors, toilet paper, paper rolls for the exam table and multiple papers with patient names was found unsecured.

The exam table was soiled with dust and hair. A red dried substance was on the top of the exam table. There was no soap at the sink to wash your hands.



Patient Room 265-
Was designated as a "Terminally Cleaned" room. The door frame and threshold was soiled with dust and dirt. The door frames were missing paint.

The floor of the room was soiled with dust, dirt, hair, and paper. Trash was still in the trash can. A patient identifier sticker was on the floor in the room.

The window frame was soiled with dirt and hair. The patient was cracked and peeling.

The wooden bed frames that hold the mattress were heavily soiled with dust, dirt, hair and paper.
The two mattress were soiled.

In the bathroom pieces of toilet paper were found lying on the heavily soiled floor. The toilet was soiled with urine, toilet paper, hair and dirt. The shower floor was mildewed and covered in hard water stains. Long black hairs were lying in the shower and on the floor.



Soiled Utility Room-
In the soiled utility room, a broom was found heavily soiled and worn. The broom was ready for use.
Soiled linen was found uncovered in the linen bin.



Patient Linen Wash Room-
This room contained a washing machine and dryer. The washing machine and dryer are used by the staff to wash the patient's clothes. The floor of the room was heavily soiled with a buildup of soap that had dripped on the floor and hardened. The buildup had mildewed and was covered in lint and hair.

The washer was soiled with dust and hair.

The dryer was soiled with dust and hair. The lint trap was removed and a thick roll of lint was on the vent cover.
According to "Washer and Dryer Cleaning Log" the last time they were cleaned and checked was 10-22-18. On top of the log it states, "Every time the washer and dryer is used." The washer had wet clothes inside on 11-5-18.

A switch gear panel (computer and telephone lines) was found behind the door with no cover. The inside was heavily soiled with dust and an empty plastic water bottle.



2nd Floor Nurses Station-
The second floor nurses station was a locked area with Plexiglas windows down both sides. There were doors on both sides. The windows were heavily soiled with dried liquid substances, finger prints, and tape residue.
The counters in the nurse's station were missing Formica and wood was exposed. Multiple patient identifier stickers were found on the edges of the desk. They were worn and had stuck to the surface. One of the patient stickers was from 10-22-18.

Patient belongings were found in paper sacks sitting on the floor of the nurse's station. The floor was heavily soiled with dust, dirt, and hair. The tiles were cracked and worn. Large pieces of tile were missing dirt and grime had built up in those areas.



Medication Room-
In the medication room the floor was heavily soiled with dust, dirt and hair. The floor tiles were cracked and worn. On the floor behind the door was a long piece of cardboard tape that had stuck to the floor. The sticky side was face up. A plastic baggie, hair, and dirt was attached.

Cardboard boxes were sitting on the floor holding patient Styrofoam cups.

An E-cylinder Oxygen tank was found behind the door with nasal cannula tubing attached. The tubing was dragging the floor and was uncovered.

A medication refrigerator was found sitting on the floor. The inside of the refrigerator was soiled with dust and hair.

The Formica around the sink in the medication room was pulled apart from the wall. The wood was exposed to water and germs. The particle board was starting to mildew around the sink.

The pill crusher was heavily soiled with dirt and medication residue.

There was employee drinking cups, shampoos, card board boxes, toothbrush holders, and trash sitting on the nursing medication preparation area.

The medication cart was found to have a copious amount of dirt, hair, and dust on the bottom of the cart. Patient medications were stored in the cart.

The drawer holding lab supplies was found to be soiled with dust and hair.

The cabinets in the medication room were found to be holding patient supplies and employee's personal belongings from home. Those items were in contact with clean and sterile medical supplies.



Patient Nourishment Room-
The floors were soiled with dirt, dust, and hair.

The plastic trash can was heavily soiled on the outside with dried liquids and dust.

The sink was soiled with hard water stains and a black substance in the bottom.

Empty plastic bins were found on the counter heavily soiled with a sticky substance and dust.

Under the sink, the shelves were heavily soiled with dust and long hairs wrapped around the hinges. Two Styrofoam containers were found. Inside the containers was a cooked pot pie and vegetables. The second container had cherry pie. Both items looked dried out and old.

Inside the refrigerator was snacks of fruit and drinks. The refrigerator wa
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review and interview the facility failed to:

A.) provide a safe setting for the psychiatric patients in the adult unit of the Garland facility. Ligature risks were observed and identified on the morning of 11/7/18. Administrative personnel and nursing personnel were present. The presence of ligature risks in the physical environment of psychiatric patients, 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 in 1(adult) of 2(child and adolescent) units.

B.) provide safety on the children's unit by allowing the adolescent population to have access to the children. The facility failed to have a working monitoring system and a secured door between the children's unit and adolescent unit. The nursing personnel failed to monitor the adolescent population and allowed the patients to be on the floor unsupervised.

C.) provide timely staff education on ligature risks and patient safety.

D.) provide a quality assurance performance improvement (QAPI) plan for sustainability of staff education, data collection through chart audits, or tracking method to prevent a patient from harm.


1.) On the morning of 11/7/18 an observation was made on the adult unit in the Garland facility. An elderly female was wearing a cloth head cover called a hijab. The hijab was noted to be covering her head and wrapped around her neck. It was long enough to hang down to her waist. The surveyor asked the nursing personnel why the patient was allowed to wear the garment on the unit with suicidal and homicidal patients. Personnel#25 reported that the physician stated she could keep on her hijab due to religious reasons.

Review of patient #149's chart revealed she was suicidal and delusional. The patient has a diagnosis of bipolar disorder and schizophrenia. The patient was admitted on [DATE]. The patient was seen by the psychiatrist and a psychiatric evaluation was done on 11/6/18. There were no admission orders found on the chart. The patient refused her History and Physical. The psychiatrist wrote in the psychiatric evaluation dated 11/6/18, "The patient is very preoccupied and delusional. The patient is religiously preoccupied. As per report, the patient was psychotic, erratic behavior, and having suicidal thoughts." There were no written orders found to allow the patient to wear the hijab. The patient was on 15 minute checks only according to staff #25. The patient was not on a 1:1(one personnel to one patient within arm's length) to prevent the patient from using her hijab to harm someone or herself. The nursing personnel did not realize the potential for harm until the surveyor pointed out the risk.

The condition and deficient practices were identified under the following Conditions of Participation and were determined to pose Immediate Jeopardy to patient health and safety and placed all patients at risk for the likelihood of harm, serious injury, and possibly subsequent death.

The Garland hospital administrator presented the facility with an "Immediate Action Plan" for the immediate jeopardy.
a.) The patient was placed on a 1:1. The 1:1 was modified to allow the personnel to be close but allow the patient some space when she had high levels of psychosis and negative response to close boundaries.

b.) The policy was revised to include cultural, religious, and medical considerations. The personnel were to be in- serviced immediately on the policy change, but the policy changes had not been approved through medical staff or governing body. The administration had presented no personnel training on patient safety and contraband as of 11/9/18.

c.) There was no plan on how the actions would be monitored, maintained, or followed in QAPI.


2.) A tour of the Garland facility was conducted on 11/05/18, with Personnel #18, in the afternoon. On the 2nd floor of the hospital was the children and adolescent unit. The children rooms and adolescent rooms were separated by a double wooden doors that had magnetic locks. The door between the adolescent boy's side and children's side was not locked. The door was easily opened. Personnel and patients were walking back and forth through the door. Personnel #18 was asked why the door was not locked. Personnel #18 reported she was not sure. Personnel #18 reached up to the magnetic lock and it was turned sideways to prevent it from locking.

The door was broken and personnel#18 was not able to state how long the door had been open. The children were now easily exposed to the adolescent group and at risk for harm. The nursing personnel, CNO, and the CEO were made aware.

The unit had cameras on the hallway and group rooms. In the nurse's station was a TV monitor for the camera system. The TV monitor was not working. The nursing personnel reported that the monitor had not been working for "some time." Personnel #5 reported that she was not sure why the monitors were not working and would let IT know.

A tour of the second floor child and adolescent unit was taken on 11/9/18 in the morning hours. The girls side was found to have an unlocked door between the children's side and adolescent. The surveyor watched as the personnel and patients walked through the unsecured door multiple times. The surveyor observed the Mental Health Technician (MHT) in the group/activities room with the adolescent children. The MHT walked into the hallway and was asked who was monitoring the child on the other side of the door. The MHT walked through the closed double doors and left the 10 adolescents unsupervised. The surveyor waited 3 minutes for the MHT to return to the unsupervised children. The MHT was asked why the door was unsecured. The MHT walked to the door and stated she used her key and didn't realize the doors were not locked. Upon observation these doors were also broken and the magnetic lock was turned sideways to prevent it from locking. Review of the boy's doors on the other side, revealed they were also still broken and had not been secured for 4 days. By having unsecured doors, the children were venerable to sexual predators and potential harm.




Based on observation, review of documentation and interview it was determined that the hospital failed to ensure a safe care setting for .... of .....patients (Patients #44, #90, #43).

1).
2)
3)

Findings were:

1) During a tour of the Arlington Pedi/adolescent unit on 11/7/18 at 1000 Patient # 44 and #90 were cursing shouting at the nursing personnel. Patient #44 picked up a chair walk to the end of the hall hitting the exit light with the chair.

Pt#44 then emptied trash cans on the floor, threw trash across the room. At the same time Patient #90 was arguing with Personnel #38. Personnel #38 called a code 10 for assistance. Personnel arrived to help Personnel #38.

Personnel was in the process of deescalating Patient # 90, when an elopement code was called. The extra personnel left for the elopement code, leaving personnel #38 with 2 MHT's. Patient #90's behavior deteriorated, she jumped over the nurse station, threw medical records on the floor, threw paper work off of the desk on to the floor, pull forms off of the wall, cursing, threatening personnel #38.

While this was happening Patient #44 picks up a chair hitting the clock on the wall, then returned to the exit light at the end of the hall hitting the doors and exit lights.

Surveyors were reviewing medical records at the nurse station on pedi/adolescent unit at 1040 11/7/18 when one of the patients reach over the gate, ran to the back of nurses station hiding behind the recycle bin. Surveyors asked Personnel #38 and #45, how often it happened. Personnel #38 and #45 said it happened frequently and had been reported to administrative personnel more than once.

During a tour of the Arlington location boys unit on the morning of 11/06/2018 the following observations were made:

A loose television style cable/electrical cable on the left side of the television in the day room area, this cable was able to be physically removed from the television and potentially used for self injurious behaviors.

Chipped laminate on the side of a wardrobe in room 316 which could further broken off and potentially used for self injurious behaviors, a small wooden pencil was found in room 309. In interview with personnel # 28 the above findings were confirmed and the surveyors were additionally told that patients are not allowed to have pencils in their rooms.

2) During a tour of the Arlington location girls unit on the morning of 11/06/2018 at approximately 1130 hours the following observations were made:

A small, rectangular Plexiglas style door located underneath the television was found unsecured and the edges of the Plexiglas door were sharp thus potentially posing a risk for self injurious behavior. Inside of the securable (Plexiglas door) area were TV cables which could potentially be pulled out and used for self injurious behaviors).

During a tour of the Arlington location adult unit on the morning of 11/06/2018 at approximately 1145 it was observed that there were 25 double bladed blue plastic razors in an unsecured drawer in the nursing station. Hospital personnel #28 accompanied the surveyors on the tour and confirmed the above observations that were made on the morning of 11/06/2018.

Review of hospital policy entitled: "Patient Rights and Responsibilities" with a revised date of 09/26/16 stated on page two: "I. Personal safety: The patient has the right to expect reasonable safety insofar as the hospital practices and environment are concerned."

Review of hospital policy entitled: "Hospital Wide - Housekeeping (1207)" with a revised date of 07/2018 stated: "Sundance Hospital is committed to ensuring the health, safety and welfare of all individuals. An important component of protecting the health, safety and welfare of all individuals includes actively encouraging good housekeeping services." "The facility environment is always maintained in a safe, clean and orderly manner. Sundance Hospital's physical environments are routinely checked for cleanliness and disinfection." Also found in the policy was: "It is everyone's responsibility to pick up and clean up." "Work areas, storage areas and amenities will be kept and maintained in a clean and hygienic manner."

Review of hospital policy entitled: "Hospital Wide - General Facility Safety and Patient Management (1204)" with a revised date of 07/2018 stated under the purpose section: "To ensure a safe and secure environment of care." "To report unsafe conditions to appropriate level of management and/or primary physician." "To maintain an appropriate therapeutic milieu for treatment services." The policy section stated: The facility is maintained in a safe, clean and orderly manner at all times. The facility is routinely checked to protect patients, visitors and personnel from potential safety hazards." "All patients admitted to the facility are considered at risk for potential injury due to acuity of illness, medication and unfamiliar environment. Therefore, the patient will be assessed each shift and the care plans will incorporate goals and interventions to provide the optimal safe environment for the patient." The procedure portion stated: "Personnel are to report all potential safety hazards to their supervisor immediately."

Review of hospital policy entitled: "Patient Belongings" with a revised date of 9/26/2016 stated: "Contraband items" may include: drugs/medication, unidentified substance or powder, alcohol-containing liquid, or object that could be used to hurt either oneself or someone else. Additional items that may be harmful to a patient and that are considered as contraband include, but are not limited to: knives, aerosol spray, glass items, metal items, sharp items such as razors, scissors, etc. Identified items and/or contraband will be locked in a secure area with controlled and/or limited access by patients, or will not be allowed on the unit."

3) Patient #43 who had been identified as new admission by Personnel #154 was observed without staff supervision in company of a second, unidentified patient on 11/06/18 at 1325 in the Arlington facility's PICU.

Record review of Patient #43's Intake assessment dated [DATE] at 0948 reflected the patient was admitted with suicidal ideation of hanging herself, and was assessed to require inpatient care due to behavior that was "imminent threatening, destructive, or dangerous to self ..." The patient's history of traumatic events included her mother's suicide on Thanksgiving 2017 and her younger brother's suicide of hanging.

A metal domino box and a book ("Brain games") with metal spirals were observed at the nurses' station of the Arlington facility's PICU unlocked nurses' station on 11/06/18 at 1330. A 13-ounce box of disinfectant wipes and a bottle of hand sanitizer were observed visible and accessible to patients by reaching over the counter. Personnel #37 acknowledged the findings at that time and stated the items were "not supposed to be there."

Observation in the Arlington facility's patient accessible dining area on 11/06/18 at 1830 reflected an unlocked cabinet housing the carbonated beverage dispenser equipment. A fist-sized metal clamp and a metal-spring napkin dispenser potentially usable in a patient self-harm attempts were observed in the cabinet accessible to patients.

Record review of the Arlington facility's 2018 incidents reflected self-injurious patient behavior had increased from August 2018 (6.21 percent of all incidents) to September 2018 (6.54 percent of all incidents) and again in October 2018 (6.7 percent of all incidents).

Observations on the "girls overflow unit" on 11/07/18 at 1629 and 1651 reflected the pendulum swing door at the nurses' station was left open with potentially easy access for patients.

Observation on the hospital's Arlington location "Tween Unit" on 11/14/18 at 1115 reflected triangular-shaped metal hinge at the door that connected the unit to the PICU hallway and had the potential for ligature.

Observations on 11/15/18 at 1016 on the adolescent girls' unit reflected Patient #82 opened the latch of the waist-high swing door that separated the nurses' station and the patient day area and and ran into the nurses' station.




Based on review of documentation, observation, and interview, the Garland facility failed to ensure that patients were provided a safe, humane treatment environment that ensured protection from harm.
1) The Garland facility staff members were routinely allowed to work without the required training to protect patients and staff from harm when dealing with aggressive patients as the Garland facility failed to ensure that staff providing direct patient care maintained current training in non-violent crisis intervention and restraint/seclusion training with skills demonstration and competency. The Garland facility allowed staff members to be on duty with patients without confirmation or documentation that the staff member was compliant in training, which presents a risk that behavioral interventions with aggressive patients may not be conducted in a safe manner. This was not in compliance with facility policy or state regulation.

2) The Garland facility allowed staff members to be on duty with patients without confirmation or documentation that the staff member was current in in American Heart Association or the American Red Cross CPR with skills demonstration and competency, which presents a risk that clinical staff may not be competent to respond in a medical emergency. This was not in accordance with facility policy or state regulation. The Garland facility failed to ensure that staff were trained and competency assessed in the duties of their position as there was no documented evidence provided of job specific orientation or other training. Lack of training presents a risk that staff members will not have the knowledge or skills to perform duties related to patient care in a safe and competent manner. The Garland facility failed to ensure that the staff received an accurate job description, which presents a risk that the staff member will not understand the duties, responsibilities, skills, and knowledge necessary to perform duties related to patient care.

3) The Garland facility failed to verify, prior to allowing agency/contract personnel to work at the facility in patient care, that nursing personnel were currently licensed as nurses in the state of Texas, were current in CPR certification, had been trained in non-violent crisis intervention, had been trained in infection control, fire, safety, and disaster response, and had been oriented to the facility, before working at the facility. This was not in accordance with facility policy which could have potentially resulted in unlicensed, untrained contract staff working at the facility which presents a risk that staff responsible for patient care would not be able to effectively respond in a medical or behavioral emergency situation.

4) The facility failed to ensure that clean and functional emergency equipment and supplies were available to respond to an emergency medical condition.

5) The Garland facility failed to ensure that the patient dining area was safe as there were non-tamper resistant screws used to hang artwork, broken shelving and other safety hazards staff and patients.

6) The Garland facility failed to ensure a safe environment for patients on the unit as there were ligatures and areas for admitting patients to conceal contraband.


Findings included:

1) Staff members at the Garland facility were routinely allowed to work without the required training to protect patients and staff from harm when dealing with aggressive patients.

Review of the facility required training showed that the Garland facility used training developed by the Crisis Prevention Institute (CPI). CPI is an international training organization that specializes in the safe management of disruptive and assaultive behavior. The training was required prior to working around patients and annually.

Review of Personnel #62 ' s personnel file showed that her CPI training had expired on [DATE]. Interview with Personnel #62 showed that she was currently at work and fulfilling her duties as a van driver. She was the only adult in the van while transporting mental health patients.

Personnel #112 was interviewed about the missing CPI training. Personnel #112 provided a list of Garland staff that were delinquent in CPI. When asked, Personnel #112 confirmed that staff were still scheduled and allowed to work when required training was expired.

Personnel # 5 stated that the list provided for delinquent CPI training was not current and that they were updating it. On 11-14-2018, a current roster was provided. Time cards were reviewed for the Garland personnel who were delinquent in CPI training. Results were as follows:

Personnel #113 had an expired CPI training as of 11-1-2018. Time card showed that Personnel #113 had worked on 5 days between 11-2-2018 and 11-9-2018.

Personnel #114 had an expired CPI training as of 8/11/2018. Time cards from 9-29-2018 through 11-9-2018 showed that Personnel #114 had worked 27 days during that period with expired training.

Personnel #63 had an expired CPI training as of 10-19-2018. Time card showed that Personnel #63 had worked on 14 days between 10-20-2018 and 11-9-2018.

Personnel #115 had an expired CPI training as of 11-1-2017. Time cards from 9-29-2018 through 11-9-2018 showed that Personnel #115 had worked 3 days during that period with expired training.

Personnel #116 had expired CPI training as of 1-16-2018. Time cards from 9-29-2018 through 11-9-2018 showed that Personnel #116 had worked 8 days during that period with expired training.

Personnel #117 had expired CPI training as of 10-01-2018. Time cards from 9-29-2018 through 11-9-2018 showed that Personnel #117 had worked 10 days during that period with expired training.

Personnel #118 had expired CPI training as of 8-30-2018. Time cards from 9-29-2018 through 11-9-2018 showed that Personnel #118 had worked 17 days during that period with expired training.

Personnel #119 had expired CPI training as of 7-1-2018. Time cards from 9-29-2018 through 11-9-2018 showed that Personnel #119 had worked 19 days during that period with expired training.

Personnel #121 had expired CPI training as of 6-29-2018. Time cards from 9-29-2018 through 11-9-2018 showed that Personnel #121 had worked 7 days during that period with expired training.

Personnel #122 had expired CPI training as of 7-20-2018. Time cards from 9-29-2018 through 11-9-2018 showed that Personnel #122 had worked 26 days during that period with expired training.

Personnel #123 had expired CPI training as of 12-9-2017. Time cards from 9-29-2018 through 11-9-2018 showed that Personnel #123 had worked 11 days during that period with expired training.

Personnel #112 stated that the CPI course is offered every week at the Garland facility.

2) Additionally, 1 RN was not current in BLS CPR, but only Heartsaver, a course designed for anyone with little or no medical training. This presents a risk that clinical staff may not be competent to respond in a medical emergency.

Review of the Garland facility personnel record for Personnel #4, RN revealed he did not have current certification in Basic Life Support CPR; there was only a card in the personnel folder for Personnel #4 for Heartsaver First Aid CPR AED which expired on ,d+[DATE]. This was confirmed in an interview with Personnel #112 on 11/14/2018.

Review of the American Heart Association website revealed, "Heartsaver courses are designed for anyone with little or no medical training who needs a course completion card for job, regulatory (for example, OSHA), or other requirements ...
Healthcare Professional: Basic Life Support training reinforces healthcare professionals' understanding of the importance of early CPR and defibrillation, basic steps of performing CPR, relieving choking, and using an AED; and the role of each link in the Chain of Survival."
Retrieved on 11/14/18 from https://cpr.heart.org/AHAECC/CPRAndECC/Training/HeartsaverCourses/UCM_ 4_Heartsaver-Courses.jsp

Facility policy, "Staff Development/Training" provided to the survey team stated, in part, "PROCEDURE:
1. Sundance Hospital shall provide training to staff members in accordance with the following:
A. All staff members shall receive training in each of the following:
(1) Identifying, preventing, and reporting abuse and neglect of patients and unprofessional or unethical conduct in the hospital related to Training Requirements Relating to Abuse, Neglect and Unprofessional or Unethical Conduct;
(2) Dignity and rights of a patient in accordance with relating to Rights of Persons Receiving Mental Health Services;
(3) Confidentiality of a patient's information in accordance with Texas Health and Safety Code,
B. An RN, LVN, and Mental Health Tech shall receive training in:
(1) Monitoring for patient safety relating to the Protection of a Patient;
(2) Infection control; and
(3) The hospital's mandatory overtime policy as it relates to Nursing Services.
C. A registered nurse (RN) and a licensed vocational nurse (LVN) shall receive training in the process for reporting concerns regarding the adequacy of the staffing plan to the Nurse Advisory Committee (NAC).
D. Any staff member routinely providing treatment to, working with, or providing consultation about a patient who is younger than 18 years of age shall receive training in the aspects of growth and development (including physical, emotional, cognitive, educational and social) and the treatment needs of patients in the following age groups:
(1) Early childhood (approximately 1-5 years of age);
(2) Late childhood (approximately 6-13 years of age); and
(3) Adolescent (approximately 14-17 years of age).
E. A staff member routinely providing treatment to, working with, or providing consultation about a patient diagnosed with COPSD shall receive training in substance use disorders.
F. A staff member routinely providing treatment to, working with, or providing consultation about a geriatric patient shall receive training in the social, psychological and physiological changes associated with aging.
G. In accordance with Texas Health and Safety Code, any staff that function directly or in a delegated roles as a pre-screening assessment professional (PASP) or performing Intake Services shall receive at least eight hours of pre-admission screening and intake training as described in this section. Pre-admission screening and intake training shall provide Instruction to staff members regarding:
(1) Assessing, interviewing, and diagnosing an individual with a mental Illness and an individual diagnosed with Co-Occurring Psychiatric and Substance use Disorders (COPSD);
(2) Obtaining relevant Information about the patient, including information about finances, insurance benefits and advance directives;
(3) Explaining, orally and in writing, the patient's rights relating to Rights of Persons Receiving Mental Health Services;
(4) Explaining, orally and in writing, the hospital's services and treatment as they relate to the patient;
(5) Informing the patient in writing of the existence, telephone number and
address of the protection and advocacy system established in Texas, which is Advocacy, Inc.; and
(6) Determining whether the patient comprehends the information provided in accordance with items (3)-(5) of this section; and documenting the patient's comprehension; and performing the necessary follow up until comprehension is determined ...
H. Any staff member who may initiate an involuntary intervention (i.e., seclusion) shall receive training in and demonstrate competency in performing such interventions, to include, but not be limited to the following:
(1) All staff members are informed of their roles and responsibilities in participating in any involuntary behavior health intervention ...
(8) The facility shall maintain documentation of training for each staff member. Documentation shall include the date of training, the name of the instructor, a list of successfully demonstrated competencies, the date competencies were assessed, and the name of the person who assessed competence ...
4. Documentation of training ...
B. The hospital shall maintain certification or other evidence issued by the American Heart Association or the American Red Cross that a staff member has successfully completed the training in CPR ...
C. Records of required training will be maintained in each staff members employee file In Human Resources."

Facility policy, "Clinical Competency: Staff" provided to the survey team stated, in part, "2. Staff with patient monitoring, supervision and/or treatment responsibilities shall also complete:Non-violent crisis interventions ...
CPR ...
Seclusion and Restraint.."

Review of the Sundance Nursing Job Descriptions provided to the survey team the morning of 11/7/18 revealed that CPR and CPI are requirements in the Job Description for Registered Nurse, Licensed Vocational Nurse, and Mental Health Tech.

"Standards of Care and Treatment in Psychiatric Hospitals" as set forth in 25 Texas Administrative Code 411.490 Staff Member Training, stated, in part,
"(b) A staff member providing direct patient care shall maintain certification in a course, developed by the American Heart Association or the American Red Cross, in recognizing and caring for breathing and cardiac emergencies. The course shall teach the following skills appropriate to the age of the hospital's patients:
(1) rescue breathing with and without devices;
(2) airway obstruction;
(3) cardiopulmonary resuscitation; and
(4) use of an automated external defibrillator."

3) Facility policy, "Agency: Supplemental Nursing Staff" provided to the survey team, stated, in part,
"Supplemental Nursing Staff may be provided through a contract with one or more supplemental staffing agencies. Supplemental Nursing Staff is provided the same orientation as employed nursing staff. Supplemental nursing staff competency is validated and performance evaluated using the hospital's established format.
PROCEDURE A. Supplemental Staffing Agencies: The agency provides:
1. Primary Source Verification of current licensure in the State of Texas or compact licensure
2. Documentation of one year of current experience
3. Documentation of CPR certification ...
4. Documentation of clinical skills
5.Documentation of current training including, but not limited to, infection control, fire and safety and disaster.
6. Criminal background check
7. Verification of negative drug screen.
8. Nurses assigned to specialty areas are to also have documentation of special training and skills provided by the agency.
9. Evidence of current training in nonviolent behavioral crisis intervention is required.
B. Sundance Hospital provides:
1. Assessment, competency evaluation and orientation relevant to the clinical area
2. Validation of Medication administration skills will be documented by successful completion of the medication examination.
3. Facility and unit orientation. Orientation is validated by the agency nurse through the completion of the nurse orientation record ...
C. Completed orientation records are retained by Human Resources.
D. initial orientation and unit schedule is coordinated with the assigned unit through the Nursing Supervisor and/or Chief Nursing Officer or designee ..."

Agency staff personnel documents for staff working at the Garland facility were provided to the survey team and reviewed the morning of 11/9/18 in the facility conference room. Review of the time sheets revealed:
Personnel #64 (RN) worked on 10/5/18.
Personnel #65 (RN) worked on 10/26/18.
Personnel #66 (RN) worked on 9/28/18 and 10/27/18.
Personnel #67 (CNA) worked on 10/6/18.
Personnel #68 (LVN) worked on 9/28/18 and 10/11/18.
Personnel #69 (RN) worked on 9/28/18, 9/30/18, and 10/3/18.

Review of the agency staff personnel folders revealed 2 out of 6 staff had no primary source verification of a nursing license.
-Personnel #69 had no documented evidence of primary source verification of current Registered Nurse licensure in the State of Texas.
-Personnel #68 had no documented evidence of primary source verification of current Licensed Vocational Nurse licensure in the State of Texas.

The facility failed to verify that Personnel #68 and #69 were currently licensed as nurses in the state of Texas before working at the Garland facility providing direct patient care.

In an interview with Personnel #5 on 11/9/18, she confirmed that there was no documentation of a current nursing license for Personnel #69, who worked at the facility on 10/15/18. A current nursing license was confirmed on 11/9/18 after the interview with Personnel #5, 25 days after Personnel #69 worked at the hospital in patient care. A current nursing license was confirmed on 11/9/18 at 1036 in the morning after the interview with Personnel #5, 42 days after Personnel #68 worked at the hospital in patient care. Not verifying current licensure of agency nurses presents a risk that unlicensed staff may provide nursing care and treatment for patients at the facility and was not in compliance with facility policy.

Personnel #67 had no documented evidence of current CPR certification in her personnel documents. Personnel #67 worked at the facility on 10/6/18. The facility failed to verify that Personnel was current in CPR skills prior to working at the facility. In an interview with the Chief Nursing Officer on 11/9/18, she confirmed that there was no documentation of current CPR certification for Personnel #67. The CNO contacted the agency and obtained a current CPR card on 11/9/18 at 1036 (in the morning), 34 days after Personnel #67 worked at the hospital. This presents a risk that agency staff will not be able to effectively respond in a medical emergency situation and is not in accordance with facility policy and state regulation..

There was no documented evidence provided to the survey team of nonviolent crisis intervention training (CPI or other training) for 6 out of 6 agency nursing staff (Personnel #64, 65, 66, 67, 68, and 69) working at the facility during the months of September and October, 2018. This presents a risk that agency staff, RNs, LVNs, and CNAs will not be able to adequately respond in a behavioral
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
Based on review of records, observation, and interviews, the facility failed to protect the patients from neglect and abuse by not allowing the patient to have access to drinking water, without rationing from the staff, or at staff convenience.

During a tour of the Garland children and adolescent unit, on 11/5/18, Patient #150 approached the surveyor and reported that the adolescents and children are not allowed to have water on the unit. The patients have to ask for water from the nursing personnel and sometimes they are busy and are unable to provide water to the patients.

Observation of the nurse's station revealed there was a pitcher of water and cups inside the nurse's station to provide water to the patients. Personnel #6 stated the children and adolescents were not allowed to have water on the units. Personnel #6 stated, "they just throw water on one another and make a mess. It has to be controlled." The surveyor asked Personnel #6 why the nursing personnel were not monitoring the patients to prevent that behavior. Personnel #6 stated, "No, they will just do it anyway."




Review of the Garland complaint log revealed on 10-18-2018 that an adult, Patient #62, had submitted a complaint that he was ignored for 30 minutes when requesting a drink of water. "Pt stated his requests have been ignored regularly and he observes staff member no (sic) working and sitting around gossiping when he was told they were busy." The Action/Follow Up documented by Personnel #5 stated she had called and apologized for the staff not meeting his needs and requests. No investigation into patients not having access to basic needs (water) was documented.

An interview was conducted with Personnel #5. Personnel #5 confirmed that there was no formal investigation of the allegations, only a phone call with an apology. Personnel #5 stated if they put out containers of water, the adult patients could throw them when they became violent. No alternative solutions to securing patient accessible water dispensers was developed, other than restricting patient access.
VIOLATION: QAPI Tag No: A0263
Record review and interview revealed that the governing body failed to ensure an effective process was developed and enforced for internal reporting of patient safety incidents for investigation in 3 out of 3 patients (Patient #5, #6, and #62) patients reviewed.
Review of documentation and interviews revealed that the governing body failed to ensure that the Garland Facility Patient Safety Program was in compliance with the Texas Administrative Code Program Requirements for responsibility and accountability for ensuring that clear expectations for safety are established.

1) The Garland facility Patient Safety Program failed to included consequences for failing to report events and there was no provision in the policy for intentional errors or acts.

2) The governing body failed to ensure that Garland facility staff had been queried regarding their willingness to report medical or health care errors on at least an annual basis; failed to provide mechanisms for preservation and collection of event data that were relevant or realistic examples for hospital staff as the hospital does not administer blood or administer medications intravenously;

3) The governing body failed to have a requirement for completing a root cause analysis within 45 days of becoming aware of a reportable event, developing an action plan identifying the strategies that the facility intends to employ to reduce the risk of similar events occurring in the future, designating responsibility for implementation and oversight; specifying time frames for implementation; and including a strategy for measuring the effectiveness of the actions taken.
Cross refer: CFR 482.21(a), (c)(2), (e)(3) Patient Safety Tag A0286


Review of documents and interviews revealed that the governing body failed to ensure that the Garland facility Patient Safety Program was in compliance with the Texas Administrative Code Program Requirements.

1) The Garland facility failed to reflect the complexity of the hospital's organization and services including those services furnished under contract or arrangement.

2) The Garland facility failed to ensure that a high-risk safety process assessment was conducted.

3) The Garland facility failed to ensure that a quarterly safety survey of patients, families and staff was conducted

4) The Garland facility failed to monitor patient and family education for safe delivery of care and safety communication with caregivers in accordance with the Patient Safety Program.
Cross refer: CFR 482.21 QAPI Governing Body Tag A0308
VIOLATION: PROGRAM DATA, PROGRAM ACTIVITIES Tag No: A0283
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review the hospital quality program failed to ensure a allegation of abuse for 1 of 1 patient (Patient #28) which was identified, was not investigated.

Findings include:

Patient #28's Behavioral Health Integrative Psychiatric assessment dated [DATE] reflected, "Patient ranaway...punched therapist in parking lot at...partial hospitalization ...ran to a neighborhood ringing door bells ...aggressive towards staff, reached for scissors, tried to grab gun from security guard...plan to take spoon and fork to school to hurt some kids...fights with brother yelling."

The 06/02/18 Daily Nursing Assessment timed at 1745 reflected, "Informed by therapist and patient that a tech grabbed him yesterday by his shirt causing him to fall and a bruise to his chest...assessed and visualized two spots of bruising to right upper chest and one spot to left upper chest...Dr called, mother called and informed of incident states patient has a history of lying...will continue to monitor..."

On 11/09/18 Staff #28 was interviewed at 0920. Staff #28 was asked by the surveyor for a facility investigation for the above event Patient #28 reported to the therapist on 06/02/18. Staff #28 stated an event report was completed but she could not find any investigation which had been completed. Staff #28 verified and investigation should have been completed.

On 11/13/18 at 1147 Staff #157 was interviewed. Staff #157 stated the patient reported he was grabbed by his shirt by a tech (unknown name) the previous day. Staff #157 she reported it to the nurse and she assessed the patient and documented it. Staff #157 was asked if anyone from Quality and/or administration contacted her about the event. Staff #157 stated no one did.
VIOLATION: PATIENT SAFETY Tag No: A0286
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview, the governing body failed to ensure an effective process was developed and enforced for internal reporting of patient safety incidents for investigation in 3 out of 3 patients (Patient #5, #6, and #62) patients reviewed.

Findings included:

Review of Patient #5's chart revealed the patient was a [AGE]-year-old male admitted voluntarily on 9-19-2018. The intake assessment stated, "PT was brought in by his Mom because he is suicidal with a plan to jump off a building. PT has been more suicidal recently and today at school. Pt drew a picture of two stick figures and 1 figure was jumping off a building and crying ..." The nursing admission assessment stated, "9/20/18 0207. PT is a very polite 14 y/o African American male. Per PT he has been having difficulty with bullies at school. They make fun of his shoes and his height ..."

On 9-21-2018, per nursing notes, the patient was hit in the eye by another patient. The patient's "eye/cheek bone red & swollen. C/O pain 10/10." The physician was contacted and ibuprofen was ordered for pain. The parent was notified.

On 9-22-2018 the patient's mother signed a request to have her son discharged . The Demand for Release form reason was documented, "Hit in the eye".

Review of incident reports showed that an incident report was filed on 9-22-2018 at 1400. The Summary of Incident in detail: was documented "Requesting AMA & 24 hour hold for _____ (illegible word) evaluation". Under the section for Supervisor Review, Supervisor Action, the following was documented, "Requesty (sic) AMA & 24 hour hold". The Summary of Investigation block was blank. No information was attached for an investigation. No mention was made that a child who was admitted for suicidal ideation and was being bullied at school had been physically attacked in the facility with injury by another patient. No report of the attack or investigation of the attack was made.

Review of Patient #6's chart revealed he was a 6-year-old boy who was admitted after holding scissors to his wrist in a suicidal gesture at school.

Review of the Comprehensive Psychiatric Evaluation conducted on 10-6-2018 at 1300 showed a documented diagnosis of unspecified depressive disorder and rule out disruptive mood dysregulation disorder (DMDD). The initial plan of care included medication adjustment. However, no medications were ordered until 10-10-2018 at 1120.

The nurse charted on "10-7-2018 2200 ... He became upset and anxious after witnessing altercation between two other boys ..."

Mental Health Technician charted on 10-8-2018 for the 7A-7P section of Patient Observation Report, "Client argumentative undecided to go down for or not fought a peer for spitting on him his peers said. Staff down for dinner return giving clients trays in nurse station when happen."(sic)

The nurse charted on 10-11-2018 (no time indicated), "MHT reported that this patient was push out of a chair by another patient. This nurse asses pt and no injury or bruises noted. This nurse notified _______(physician Personnel #8). Pt mom notified as while. (sic) Pt mom upset and stated this is not the first time this is happening."

A Demand for Release form was initiated on 10-10-2018 at 1500 and signed by the patient's mother at 1455. The section that contained the reason for wanting the patient released was left blank. No notes were found indicating why the patient's mother wanted his released. An incident report was filed by staff on 10-10-2018 at 1330. The section for Supervisor Action Taken was blank. The summary of investigation was blank. No records of any investigation of the mother's concerns for her child's safety as indicated by the notes of her son being spit on, her son fighting with other patients, her son being pushed out of his chair, and witnessing other patients fighting were ever provided.

Review of the complaint log revealed on 10-18-2018 that Patient #62 had submitted a complaint that he was ignored for 30 minutes when requesting a drink of water, he was given a physical by a female nurse after requesting a male perform his examination, and that he was not being provided his medication in a timely manner. The Action/Follow Up documented by Staff #5 stated she had called an apologized for the staff not meeting his needs and requests. No investigation into medications not being delivered in a timely manner was documented. No investigation into patients not having access to basic needs (water) was documented. No investigation into patients right to have a same-sex person present during an examination was documented.

An interview was conducted with Staff #5. Staff #5 confirmed that there was no formal investigation of the allegations, only a phone call with an apology.

An interview was conducted with the Patient Advocate (Personnel #162) and the Risk Manager (Personnel #3) on the afternoon of 11-13-2018 at 1411. Personnel #162 explained that he collected complaints and grievances from 4 boxes throughout the hospital. He also collected patient satisfaction surveys that were completed at discharge and incident reports to be given to Personnel #3. However, there was not process defined on how to ensure that specific allegations made that affect patient safety, whether through complaint and grievance forms, patient satisfaction surveys, or incident reports were identified and investigated. Personnel #3 stated they were still working on the process but don't have a process that is "solidified".













Based on review of documentation and interviews, the governing body failed to ensure that the Garland Facility Patient Safety Program was in compliance with the Texas Administrative Code Program Requirements for responsibility and accountability for ensuring that clear expectations for safety are established.

1) The Garland facility Patient Safety Program failed to included consequences for failing to report events and there was no provision in the policy for intentional errors or acts.

2) The governing body failed to ensure that Garland facility staff had been queried regarding their willingness to report medical or health care errors on at least an annual basis; failed to provide mechanisms for preservation and collection of event data that were relevant or realistic examples for hospital staff as the hospital does not administer blood or administer medications intravenously;

3) The governing body failed to have a requirement for completing a root cause analysis within 45 days of becoming aware of a reportable event, developing an action plan identifying the strategies that the facility intends to employ to reduce the risk of similar events occurring in the future, designating responsibility for implementation and oversight; specifying time frames for implementation; and including a strategy for measuring the effectiveness of the actions taken.

Findings included:

Patient Safety Program, Program Requirements, as set forth in 25 Texas Administrative Code (TAC), 134.47(a)(1)(B), stated, in part, "(1) The facility must develop, implement, maintain and enforce an effective, ongoing, organization-wide, data driven Patient Safety Program (PSP).
(B) The PSP must be in writing, approved by the governing body and made available for review by the department. It must include the following components:
(v) consequences for failing to report events in accordance with facility policy;"

1) The Patient Safety Plan, Date Issued 9/15/17, provided to the survey team in the Garland facility conference room stated, in part, "The purpose of the Organizational Patient Safety Plan at Sundance Hospital is to improve patient safety and reduce risk to patients through an environment that encourages ...Minimization of individual blame or retribution for involvement in a medical/health care error ...An effective Patient Safety Program cannot exist without optimal reporting of medical/health care errors and occurrences. Therefore, it is the intent of this institution to adopt a non-punitive approach in its management of errors and occurrences. All personnel are required to report suspected and identified medical/health care errors, and should do so without the fear of reprisal in relationship to their employment. This organization supports the concept that errors occur due to a breakdown in systems and processes, and will focus on improving systems and processes, rather than disciplining those responsible for errors and occurrences. A focus will be placed on remedial actions to assist rather than punish staff members, with the Safety Committee and the individual staff member's department supervisor determining the appropriate course of action to prevent error recurrence ...On at least an annual basis, staff will be queried regarding their willingness to report medical/health care errors."

The Patient Safety Plan Date Revised 10/11/2016 Leadership Function stated, in part, "Types of patient safety or medical/health care errors included in data analysis may include, but are not limited to:
No Harm Errors - those unintended acts, either of omission or commission, or acts that do not achieve their intend outcome (sic) ...
Mid-Moderate Adverse Outcome Errors - those unintended acts, either of omission or commission, or acts that do not achieve their intend outcome (sic), that result in an identified mild to moderate physical or psychological adverse outcome for the patient."

There was no provision in the policy for intentional errors or acts. As stated in the policy, this presents a risk that intended or intentional errors or acts, whether of omission or commission, whether resulting in no harm or with an adverse outcome, if occurred, would not be identified, analyzed, or addressed.

In an interview the morning of 11/14/18 in the Garland conference room, Personnel #3 confirmed that the facility Patient Safety Program did not include consequences for failing to report events in accordance with facility policy, to include any mandatory reporting of health care professionals as required by state law. Personnel #3 stated that the staff had not be queried regarding their willingness to report medical or health care errors on at least an annual basis.

2) Review of 25 TAC Y134.47(a)(1)(B)(vi), Patient Safety Program, stated, in part, "(1) The facility must develop, implement, maintain and enforce an effective, ongoing, organization-wide, data driven Patient Safety Program (PSP).
(B) The PSP must be in writing, approved by the governing body and made available for review by the department. It must include the following components:
(vi) mechanisms for preservation and collection of event data;"

The Patient Safety Plan, Date Issued 9/15/17, provided to the survey team in the Garland facility conference room, stated, in part, "Preserve any information related to the error (including physical information). Examples of preservation of physical information are: Removal and preservation of blood unit for a suspected transfusion reaction; preservation of IV tubing, fluids bags and/or pumps for a patient with a severe drug reaction from IV medication; preservation of medication label for medications administered to the incorrect patient."

In an interview the morning of 11/14/18 in the Garland conference room, Personnel #3 confirmed that the Garland facility did not administer blood or blood products and a patient experiencing a transfusion reaction was not a realistic example for the facility for preservation of physical information. In addition, Personnel #3 confirmed that "preservation of IV tubing, fluids bags and/or pumps for a patient with a severe drug reaction from IV medication" was not a realistic or relevant example for a psychiatric hospital that did not administer medications intravenously with the use of pumps.

3) Review of 25 TAC 134.47(a)(1)(B)(vii) Patient Safety Program, Program Requirements, stated, in part, "(1) The facility must develop, implement, maintain and enforce an effective, ongoing, organization-wide, data driven Patient Safety Program (PSP).
(B) The PSP must be in writing, approved by the governing body and made available for review by the department. It must include the following components:
(vii) the process for conducting root cause analysis;"

Review of 25 TAC 134.47(a)(3), Patient Safety Program, Program Requirements, stated, in part, "(3) Within 45 days of becoming aware of a reportable event ...the facility must:
(A) complete a root cause analysis to examine the cause and effect of the event through an impartial process; and
(B) develop an action plan identifying the strategies that the facility intends to employ to reduce the risk of similar events occurring in the future. The action plan must:
(i) designate responsibility for implementation and oversight;
(ii) specify time frames for implementation; and
(iii) include a strategy for measuring the effectiveness of the actions taken.
(C) must make the root cause analysis and action plan available for on-site review by department representatives."

The Patient Safety Plan, Date Issued 9/15/17, provided to the survey team in the Garland facility conference room stated, in part, "For the most critical effects, conduct a root cause analysis to determine why the undesirable variation leading to that effect may occur ...All sentinel events and near miss occurrences will have a root cause analysis conducted." There was no process for conducting root cause analysis in the Patient Safety Plan. The Patient Safety Program did not have a requirement in compliance with 25 TAC 134.47(a)(3) for completing a root cause analysis within 45 days of becoming aware of a reportable event, developing an action plan identifying the strategies that the facility intends to employ to reduce the risk of similar events occurring in the future, designating responsibility for implementation and oversight; specifying time frames for implementation; and including a strategy for measuring the effectiveness of the actions taken.

In an interview the morning of 11/14/18 in the Garland conference room, Personnel #3 confirmed that the Patient Safety Program did not include the process for conducting root cause analysis or the requirements of 25 TAC 134.47(a)(3). Personnel #3 provided the survey team with the policy entitled, "Risk Management Plan" however there was no process for conducting root cause analysis in the policy entitled "Risk Management Plan."




The medical record of Patient #99 was faxed from the Garland facility to the Arlington facility for review. Review of the medical record revealed Patient #99 was a [AGE]-year-old male that was admitted voluntarily on 10/09/18 to the adolescent unit at the Garland location. The intake assessment stated in part, "This morning pt (patient) got up and told caseworker he wanted to kill himself. Pt denies SI, HI, AVH. Pt was aggravated that he couldn't take his phone or P3 player to school. Pt has a caseworker because he assaulted a teacher a year ago and has a case against him ..." The psychiatric assessment stated the patient had "High Risk Psychosocial Issues" which included "hx (history) suicidality & aggression ..." The master treatment plan included psychiatric problems of suicidal ideations and violence risk.

A nursing note dated 10/15/2018, documented in part "Pt. got involved in a physical altercation with peers. Pt reports pain on the left forearm. Notified on call physician, received order for STAT(immediate) x-ray and Motrin for pain ..." The note documented parents were notified via voice mail message and that patient was medicated for complaints of pain.

Review of a radiology report with a date of service of 10/15/2018 documented "No fracture or dislocation is seen. The elbow and wrist joints are grossly intact. Conclusion: Normal left forearm."

Review of an incident report dated 10/15/18 at 1940 documented that a MHT (Mental Health Technician) observed another male patient started a fight with Patient #99 and that the MHT separated the patients and reported the incident to the nurse. The incident report documented staff reeducation by the Garland Director of Risk Management, Personnel #3 as documented in part "staff being reeducated on verbal de-escalation & ensuring MHTs are with patients at all times ..."

A phone interview was conducted with the Risk Manager (Personnel #3) on the morning of 11-13-2018 at 1155. Personnel #3 confirmed there was no grievance submitted about the incident.

A phone interview was conducted with a Licensed Vocational Nurse (LVN), Personnel #106 on the morning of 11-14-18 at 1000. Personnel #106 was asked if she remembered the above documented incident for Patient #99. Personnel #106 stated "I do remember (Patient #99) coming down holding his arm and stating his arm hurt and he said he got into an altercation with other peers. I went ahead and called his doctor for a stat x-ray and Ibuprofen." Personnel #106 was asked if she assessed Patient #99 for injuries. Personnel #106 stated Patient #99's nurse was (Personnel #168) and she assessed the patient for injuries.
VIOLATION: QUALITY ASSESSMENT AND PERFORMANCE IMPROVEMENT Tag No: A0308
Based on review of documents and interviews, the governing body failed to ensure that the Garland facility Patient Safety Program was in compliance with the Texas Administrative Code Program Requirements.

1) The Garland facility failed to reflect the complexity of the hospital's organization and services including those services furnished under contract or arrangement.

2) The Garland facility failed to ensure that a high-risk safety process assessment was conducted.

3) The Garland facility failed to ensure that a quarterly safety survey of patients, families and staff was conducted

4) The Garland facility failed to monitor patient and family education for safe delivery of care and safety communication with caregivers in accordance with the Patient Safety Program.

Findings included:

Patient Safety Program, as set forth in 25 Texas Administrative Code, 134.47(a)(1)(A), stated, in part,
"(1) The facility must develop, implement, maintain and enforce an effective, ongoing, organization-wide, data driven Patient Safety Program (PSP).
(A) The governing body must ensure that the PSP reflects the complexity of the facility's organization and services, including those services furnished under contract or arrangement, and focuses on the prevention and reduction of medical errors and adverse events."

The Patient Safety Program was reviewed the morning of 11/14/18 with Personnel #3 in the Garland facility conference room. There were two versions of the Patient Safety Plan in use at the facility which were provided to the survey team the morning of 11/14/18. One version had a Date Issued of 11/15/2010 with a Date Revised of 10/11/2016 with Leadership Function. Another version had a Date Issued of 9/15/2017 with an Environment of Care Function issued by Administration.

1) The Patient Safety Plan, Date Issued 9/15/17, provided to the survey team in the Garland facility conference room, stated, in part, "The scope of the Patient Safety Program encompasses the patient population, visitors, volunteers and staff (including medical staff). The program addresses maintenance and improvement in patient safety issues in every department throughout the facility." The Patient Safety Plan, Revised 10/11/2016 Leadership Function, stated, in part, "The purpose of the organizational Patient Safety Plan at Sundance Hospital is to improve patient safety and reduce risk to patients through an environment that encourages: Integration of safety priorities into all relevant organization processes, functions, services, departments and programs."

There was no documented statement that the Patient Safety Program included services furnished under contract or arrangement.

2) The Patient Safety Plan Date Issued 9/15/17, stated, in part, "Through review of internal data reports and reports from external sources ...and through the performance improvement priority criteria grid, the Safety Committee will select at least one high-risk safety process for proactive risk assessment annually. The proactive risk assessment will include:
Assessment of the intended and actual implementation of the process to identify the steps in the process where there is, or may be, undesirable variation ...For the most critical effects, conduct a root cause analysis ...Redesign the process and/or underlying systems ...Test and implement the redesigned process; Identify and implement measures ...Implement a strategy for maintaining the effectiveness of the redesigned process over time."

In an interview the morning of 11/14/18 in the Garland conference room, Personnel #3 confirmed that there was no documentation in the Patient Safety Program to include services furnished under contract or arrangement. Personnel #3 stated that the Garland facility had conducted a high-risk safety process for assessment; however she was unable to provide documentation and the afternoon of 11/14/18 in the Garland facility conference room, Personnel #3 stated that there was no documentation of an assessment of a high-risk safety process conducted by the facility and none was provided to the survey team.

3) The Patient Safety Plan Date Issued 9/15/17, stated, in part, "The Patient Safety Program includes a quarterly survey of patients, their families, volunteers and staff (including medical staff) opinions, needs and perceptions of risks to patients and requests suggestions for improving patient safety."

The Patient Safety Plan Date Issued 9/15/17, also stated, in part, "Staff will educate patients and their families about their role in helping to facilitate the safe delivery of care. The Safety Committee will request a report from the Information Management Committee on a quarterly basis consisting of random record review verifying compliance with this educational process ...The Safety Committee will also request on a quarterly basis, a report from the Information Management Committee identifying the effectiveness of the organization to provide accurate, timely, and complete verbal and written communication among care givers ..."

4) In an interview the morning of 11/14/18 in the Garland conference room, Personnel #3 stated that the Garland facility had not conducted a quarterly safety survey of patients, families and staff. Personnel #3 stated that she was unaware of an Information Management Committee and there was no monitoring available on patient and family education for safe delivery of care or communication with caregivers.
VIOLATION: NURSING SERVICES Tag No: A0385
1) Review of records and interview revealed the Garland facility failed to ensure that a comprehensive nursing assessment was conducted by a Registered nurse every 12 hours for 9 out of 9 patients. This was not in accordance with facility policy, state regulation, and standards of nursing practice and presents a risk to all patients admitted to the hospital.
Cross refer to: CFR 482.23(b)(3) RN Supervision of Nursing Care Tag A0395

2) Review of records, observation, and interview revealed the Garland facility failed to ensure that medications were administered within 45 minutes before or after the scheduled time. Nursing staff were not aware of the time frame for administering medications per facility policy. The facility failed to ensure that medications, including controlled substances, were secured and not available for misuse. These findings were not in compliance with facility policy and presents a risk that patients may not receive medications as ordered or in a timely manner and presents a risk for a medication error.
Cross refer to: CFR 482.23(c)(1), (c)(1)(i) & (c)(2) Administration of Drugs Tag A0405
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of records and interview, the Garland facility failed to ensure that a comprehensive nursing assessment was conducted by a Registered nurse every 12 hours for 9 out of 9 patients. This was not in accordance with facility policy, state regulation, and standards of nursing practice and presents a risk to all patients admitted to the hospital.

Findings included:

Review of the patient records the morning of 11/14/18 in the facility conference room revealed that Licensed Vocational Nurses (LVN) were documenting the comprehensive nursing assessments instead of a Registered Nurse, which is not in compliance with facility policy or state board of nursing scope of practice.

Patient #51 was admitted on [DATE]. The 12 hour shift assessment was performed by a Licensed Vocational Nurse on the following dates:
10/20/18: 7 pm - 7 am shift.
10/22/18: 7 pm - 7 am shift.

Patient #52 was admitted on [DATE]. The 12 hour shift assessment was performed by a Licensed Vocational Nurse on the following dates:
10/24/18: 7 pm - 7 am shift.
10/25/18: 7 pm - 7 am shift.
10/26/18: 7 pm - 7 am shift.
10/27/18: 7 pm - 7 am shift.
10/28/18: 7 pm - 7 am shift.
10/29/18: 7 pm - 7 am shift.
10/30/18: 7 pm - 7 am shift.

Patient #53 was admitted on [DATE]. The 12 hour shift assessment was performed by a Licensed Vocational Nurse on the following dates:
10/20/18: 7 pm - 7 am shift.
10/22/18: 7 pm - 7 am shift.
10/23/18: 7 am - 7 pm shift.
10/24/18: 7 am - 7 pm shift.
10/25/18: 7 pm - 7 am shift.
10/26/18: 7 pm - 7 am shift.

Patient #54 was admitted on [DATE]. The 12 hour shift assessment was performed by a Licensed Vocational Nurse on the following dates:
10/23/18: 7 am - 7 pm shift.
10/24/18: 7 am - 7 pm shift.
10/25/18: 7 pm - 7 am shift.
10/26/18: 7 pm - 7 am shift.
10/29/18: 7 pm - 7 am shift.
10/30/18: 7 am - 7 pm shift.

Patient #55 was admitted on [DATE]. The 12 hour shift assessment was performed by a Licensed Vocational Nurse on the following dates:
10/30/18: 7 pm - 7 am shift.
10/31/18: 7 pm - 7 am shift.

Patient #56 was admitted on [DATE]. The 12 hour shift assessment was performed by a Licensed Vocational Nurse on the following dates:
10/22/18: 7 pm - 7 am shift.
10/25/18: 7 pm - 7 am shift.

Patient #57 was admitted on [DATE]. The 12 hour shift assessment was performed by a Licensed Vocational Nurse on the following dates:
10/20/18: 7 pm - 7 am shift.
10/22/18: 7 pm - 7 am shift.
10/25/18: 7 pm - 7 am shift.

Patient #58 was admitted on [DATE]. The 12 hour shift assessment was performed by a Licensed Vocational Nurse on the following dates:
10/20/18: 7 pm - 7 am shift.

Patient #59 was admitted on [DATE]. The 12 hour shift assessment was performed by a Licensed Vocational Nurse on the following dates:
10/16/18: 7 pm - 7 am shift.
10/17/18: 7 pm - 7 am shift.
10/18/18: 7 pm - 7 am shift.
10/20/18: 7 pm - 7 am shift.

There were 2 patients with 12 hour shift assessments that were unsigned by the nurse with no means to determine who conducted the assessment for the following:
Patient #59, 10/15/18: 7 pm - 7 am shift and 10/18/18: 7 am - 7 pm shift.
Patient #57, 10/25/18: 7 am - 7 pm shift.

Facility policy, "Assessments: Integrated and Specialized" provided to the survey team, stated, in part, "All patients admitted for inpatient services to Sundance Hospital inpatient units have assessments completed ...Assessment and reassessment patient information are documented in the patient's medical record and are permanent parts of the patient's medical record ...2. Nursing Admission Assessment ...
D. Nursing-Reassessments - An RN will reassess the patient based on the patient's needs, but at least every 12 hours after the initial comprehensive nursing assessment has been completed. (25 TAC 411.473 f.)"

Standards of Care and Treatment in Psychiatric Hospitals, as set forth in 25 Texas Administrative Code, 411.473(e-f), stated, in part,
"(e) Assessment. An RN shall conduct and complete an initial comprehensive nursing assessment of a patient within eight hours of the patient's admission.
(f) Reassessment. An RN shall reassess a patient, based on the patient's needs, but at least every 12 hours after the initial comprehensive nursing assessment, required by subsection (e) of this section, is conducted."

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."

"217.11. Standards of Nursing Practice.
The Texas Board of Nursing is responsible for regulating the practice of nursing within the State of Texas for Vocational Nurses, Registered Nurses, and Registered Nurses with advanced practice authorization. The standards of practice establish a minimum acceptable level of nursing practice in any setting for each level of nursing licensure or advanced practice authorization. Failure to meet these standards may result in action against the nurse ' s license even if no actual patient injury resulted ...
(2) Standards Specific to Vocational Nurses. The licensed vocational nurse practice is a directed scope of nursing practice under the supervision of a registered nurse, advanced practice registered nurse, physician ' s assistant, physician, podiatrist, or dentist. Supervision is the process of directing, guiding, and influencing the outcome of an individual ' s performance of an activity. The licensed vocational nurse shall assist in the determination of predictable healthcare needs of clients within healthcare settings and:
(A) Shall utilize a systematic approach to provide individualized, goal-directed nursing care by:
(i) collecting data and performing focused nursing assessments;
(ii) participating in the planning of nursing care needs for clients;
(iii) participating in the development and modification of the comprehensive nursing care plan for
assigned clients;
(iv) implementing appropriate aspects of care within the LVN ' s scope of practice; and
(v) assisting in the evaluation of the client ' s responses to nursing interventions and the identification of
client needs; ...
(3) Standards Specific to Registered Nurses. The registered nurse shall assist in the determination of healthcare needs of clients and shall:
(A) Utilize a systematic approach to provide individualized, goal-directed, nursing care by:
(i) performing comprehensive nursing assessments regarding the health status of the client;"

The above findings were confirmed in an interview with Personnel #5 the morning of 11/14/18 in the Garland facility conference room.





Based on observation, record review, and interview, the hospital's registered nursing staff failed to evaluate the care according to accepted standards of nursing practice for one of one patient (Patient #116) whose order to be closely nurse supervised for suicide precautions was not acknowledged ("noted") by a registered nurse. Patient #116 was in a room farthest away from and not directly visible to the nurses' station at the time of survey.

Findings included:


Record review of Patient #116's Comprehensive Psychiatric Evaluation dated 11/03/18 at 1300 reflected that the patient had been admitted on [DATE] with diagnoses that included Post Traumatic Stress Syndrome (PTSD), Major Depression, and Psychosis. The patient heard voices.

Record review of Patient #116's physician orders dated 11/03/18 at 1250 reflected the patient was supposed to be placed on suicide precautions and moved "to a room to [the] front of the unit." The document reflected lack of evidence that a professional nurse had taken responsibility for the order.

During an interview on 11/08/18 at 1120, Personnel #165 stated Patient #116 was moved to the "overflow girls' unit" the previous night. Personnel #165 was surveyor asked about the physician order to have the patient at "the front of the unit" and stated the patient was "not as close as I liked to."

Personnel #164 showed the surveyor Patient #116's room which was at the end of a hallway that branched off the day room, the farthest away and not directly visible from the nurses' station. Personnel #26 acknowledged the findings during an interview on 11/08/18 at 1130.

The Texas Nurse Practice Act reflected that "part of the practice of nursing ...[was] the administration of medications or treatments ordered by a physician, podiatrist or dentist" (http://www.bon.texas.gov/pdfs/practice_dept_pdfs/position_statements_pdfs/positionstatements2014.pdf)




Based on record review, nursing failed to

A.) evaluate a patient for signs and symptoms of chest pain, reassess, and monitor the patient for signs and symptoms of discomfort or reoccurring chest pain in 1 (#4) of 1 patient charts.

B.) assess, monitor, and seek immediate emergent care for a kidney transplant patient for potential poisoning, Failed to assess the patient for home medication and anti-rejection medications, perform ordered lab work, and failed to document any patient care or assessment for a 10 hour and 20 minute span until patient was found deceased in 1(#21) of 1 patient charts reviewed.


Findings:

A.) Review of Patient #4's chart revealed she was a [AGE]-year-old female admitted to the facility on [DATE] at 01:30 (1:30AM). Patient #4 was admitted as an involuntary patient with a diagnosis of suicidal ideation with a plan.

Review of Patient #4's nurse's notes dated 7/23/18 at 2040, "Pt lay down in hallway claiming to have chest pain. Pt crying and moaning about having heart attack. Dr. Hussain examined pt, vs taken and were wnl. Dr. ordered 911 call and 0.1 Clonidine which pt refused to take, insisting we were trying to poison her, and kept crying for paramedics. Paramedics came assessed pt, and refused to take pt to hospital. Pt later began screaming and crying on phone, telling boyfriend we were trying to harm her. Will continue to encourage pt to use coping skills and interact with peers and group sessions. 2103 (9:03PM) Patient refused to take bedtime. (sic) denies SI/HI depression, anxiety, pain, AVH. Fixed on going home, will continue to monitor." There was no paramedic run sheet in the chart to show the paramedics exam or reason for not transporting the patient. There was no documentation of a nursing exam of the patient's complaint of chest pain. There were no documented vital signs or any nursing reassessment documented concerning the patients complaint of chest pains or discomfort.



B.) Review of patient #21's chart revealed an Apprehension by a Peace Officer Without Warrant (APOWW) form on the chart. The APOWW was dated 3/28/18 at 1834 (6:34PM). The police officer named Patient #21 as the subject and documented, "___ (Patient #21) put rat poison in his food last night.) ___ (Patient #21) advised he doesn't have long to live and he ate poison because his kidneys aren't working." The officer also reported that the patient's wife stated, "___ (Patient#21) also put a small amount of poison in her food."

Review of the physician "Preadmission Evaluation/Management form" revealed that Patient #21 was seen via telemedicine physician for admitted d 3/28/18 at 20:53 (8:53PM) Patient #21 was described as a [AGE]-year-old Asian man on a "involuntary" status pending involuntary commitment filing with court.

Under "Vital Signs" the physician documented, Vitals: Deferred
Blood Pressure : NA / NA
Pulse : NA Resp : NA
Temp : NA
Ht : Deferred
Wt : Deferred

"HPI
Per intake staff : PT PRESENT TO SUNDANCE A APOWW. PER REPORT HONG PUT RAT POISON IN FOOD LAST NIGHT. HONG ADVISED HE DOESN'T HAVE LONG TO LIVE AND HE ATE POISON BECAUSE HIS KIDNEYS ARE NOT WORKING. PT ALSO PUT SMALL AMOUNT PF POISON IN HIS WIFE FOOD. PT STATED PEOPLE ARE WATCHING IN HIS HOME AND IS TRYING TO KILL HIM. Per MD : 56 yo pt presents with depression, mood swings, anger, suicidal thought with plan and Hi. Hopeless. Poor sleeping. paranoid. Denies AVh.

PAST MEDICAL HISTORY-KIDNEY TRANSPLANT

MEDICATIONS -Deferred med reconciliation to attending MD

PAST PSYCHIATRIC HISTORY- UNKNOWN."

There was no physician documentation on why the patient who had recently eaten rat poison had no vital signs documented. The physician documented he was aware of the Kidney Transplant. The physician failed to address any type of prior medical clearance to determine the patient's kidney function. The physician documented, "deferred med reconciliation to attending MD."

Review of Patient #21's physician admission orders dated 3/28/18 at 2053 (8:53PM) revealed the following:

"ADMIT RECOMMENDATION: Inpatient psychiatric unit, notify attending physician for admission
LEGAL STATUS: Involuntary. Hold patient for involuntary admission while pending involuntarily commitment filing with court.
DIAGNOSIS: Bipolar disorder, current episode mixed, severe with psychotic features; Unspecified anxiety disorder
ACTIVE MEDICAL DIAGNOSIS OR ISSUES: KIDNEY TRANSPLANT
CONSULT: For medical H&P and medical management within 24 hours
VITAL SIGNS: Routine Notify MD if Systolic BP > 190 or < 90, FIR > 100 or < 60, T > 100.3
DIET: Regular or per patient preference.
ALLERGY: No Known Drug or Food Allergies
PROFILE: Ht : Deferred Wt. : Deferred
HOME MEDICATION RECONCILIATION: Deferred med reconciliation to attending MD
MEDICATION INSTRUCTION: None
LABS: CBC w/diff, Complete Metabolic Panel, In-House Urine Drug Screen, Lipid Panel
VACCINE: Flu vaccination 0.5m1 IM x 1 on admission if needed and available in the hospital. Applied October through March during influenza vaccination period.
PRECAUTIONS: Assaultive, Suicide
LEVEL OF OBSERVATION: Q15 mins."

Review of the Initial Nursing assessment dated [DATE] at 2040 (8:40PM) was found to be filled out 13 minutes before the patient saw the telemedicine physician. The Initial Nursing Assessment had vital signs, weight, and height recorded. The vital signs were blood pressure 141/73, pulse 94, respiration 20 Temperature 97.3.

In the section marked "Review of Systems" the Registered Nurse (RN) documented, "Kidney Transplant 2013 and patient had problems with nausea and vomiting "but not at this time."

Review of the Initial Nursing Assessment RN Admission Summary revealed the following, "3/28/18 @2030 ___ (Patient #21) is a [AGE] year old Asian male admitted to the unit at this time under the care of Dr.___ (Personnel #8). He is alert and oriented x3 with medical history of Kidney transplant. Pt is currently on antirejection medication r/t the kidney transplant status. He stated he is here because "attempted killing himself and his wife with rat poison". His stressor is tired of life is -people think "he is bad and he is tired of life because Dr said he will not live long d/t his kidney transplant status." He was encouraged to verbalize concern to staff. He endorsed SI/HI with plans before coming to Sundance but said no to both at this time. He also denies AVH, ETOH consumption and illicit drug use. Anxiety 3/10, depression 3/10. Skin is intact with dialysis shunt to left anterior hand. Oriented to unit and Q15 min. check started home meds transcribed and admission in order accordingly." (SIC)

Review of the chart revealed there was no physician orders for any home medications. There was no Medication Administration Record found in the chart. There was no documentation of what medications he was ordered, brought from home (anti-rejection medications), or given. There was no nursing documentation of when the patient ate the rat poisoning, if he had been seen by a physician, or medically cleared from eating the rat poison. There was no documentation of why the patient thought his kidney transplant was failing. There was no documentation that Patient #21 had any lab work or follow up by a Nephrologist to confirm his kidney was not failing. There was no further nursing documentation that the patient was ever assessed, monitored, or treated from 2040 (8:40PM) until the next morning at 0700 (7:00AM) a 10-hour and 20-minute span.

Review of Patient #21's chart revealed the "Patient Rounding Sheets." The rounding sheets are filled out by a staff member who is observing the patient every 15 minutes. Review of the sheets dated 3/29/18 revealed Patient #21 was in his bed "Resting or Sleeping/Rise and Fall of Chest Noted" from 0130 (1:30AM) until 0700 (7:00AM).

Review of the chart revealed Personnel #10, Nurse Practitioner, performed a History and Physical Exam (H&P). The H&P was dated 3/29/18 at 6:00AM. Personnel#10 documented the following:

History of Present Illness: Paranoia, SI

Reason for Consultation: Consultation for general History and Physical

Past Medical History: under this section was check box questions. The questions asked if the past medical history was "none, Unknown, and Unable to obtain history due to mental illness or age. History by chart review and /or nurse's notes was left blank. Personnel #10 documented, "poor sleep, pt has medical history of Kidney transplant currently on multiple meds. Constipation. Sore throat. Dr. ___ (Personnel #8)."

Past Family History was marked "unknown."

Review of Symptoms was marked "not present" on all systems. The vital signs were the same vital signs documented by the RN on 3/28/18 at 2040 (8:40PM). There were no other vital signs documented.

Medications stated, "none" will verify. Allergic to Tetracycline.

Under Physical Exam Personnel #10 documented breath sounds were normal, regular heart rhythm, and normal pulse. Under Genitourinary Personnel #10 had checked the "not indicated box." There was no found documentation that Personnel #10 asked the patient about his consumption of rat poison, when did he eat the poison, if he was seen by a physician or gone to an emergency room , why he thought his kidneys were failing, when he last saw a Nephrologist, what medications he was taken and if he had taken any anti-rejection medications.

Review of the Medical Staff Bylaws, updated March 26, 2018, page 8, item (2) stated: "A non-physician practitioner shall not have the privilege of admitting patients to the hospital nor of performing and recording complete histories and physical examinations ..."

A nurse's note was found dated 3/29/18 at 0700. The note stated, "Late entry for 3/29/18 at 0600. Pt is a new admit under the care of ____ (Personnel #8). He has a hx of kidney transplant status. He is here with his home medications. Which has been transcribed ____ (Personnel #10) is aware. Pt is adjusting well, he slept most time during the shift and visible s/s of respirations distress noted. ____ Personnel #10 saw him this am. Will continue to monitor." (sic)

There was no documentation about the Patient #21's respiratory distress, nursing assessments during the night or vital signs taken.

Review of Patient #21's physician admission orders dated 3/28/18 at 2053 (8:53PM) revealed an order for labs. "CBC w/diff, Complete Metabolic Panel, In-House Urine Drug Screen, Lipid Panel." There was no nursing documentation that Patient #21 had any labs drawn in the facility.

Review of Patient #21's chart revealed a "Code Blue Sheet" The code blue sheet was dated 3/29/18 at 0703 and Code Blue called at 0704. A description was documented leading to Code Blue, "When the techs make rounds in 703, she found patient is no response, suddenly techs repest (sic) the nurse, nurse is assesses (sic) the patient, (illegible word) patient has no pulse and no response the patient." (SIC) The AED was applied at 0705 (7:05AM). Emergency Medical Services (EMS) arrived at 0718 (7:18AM).

The outcome shows the time the patients care was transferred to EMS but no documentation of outcome. There was no EMS run sheet in the chart to reveal the care and outcome of the patient.

Review of a nurses note dated 3/29/18 stated, "at 0705 stat- Receiving report at nurse's station from out going night shift nurse when a shout from the hallway saying "pt, pt, pt". Nurse ____ Personnel #52 and ____ Personnel #25 and other team members ran to the bedside of pt while I initiated a code blue on instruction from nurse. 0715- Called 911 at approximately 0715 when nurse announced pt was not responding. I was on telephone with 911 until paramedics arrived unit at approximately 0717 and took over. All appropriate documents on them. Prepared in anticipation of patients transfer." (sic)

Review of patient #21's nurse's notes dated 3/29/18. Personnel #25 documented, "0703 Reported per tech 'did not see rise and fall of chest on patient. Reported put hands upper arms and touched shoulders and shook patient. Patient did not answer, called patient by name x 3 with no answer by patient.' Nurses went to patient room for further assessment, patient skin warm to touch, coffee ground colored secretions noted on the right cheek carotid pulse is not palpable, absence of rise and fall of chest, instructed another nurse to call code blue. CPR is initiated by nurse ____Personnel #52." (sic)

The Code Blue Sheet revealed the patient was found pulseless and unresponsive at 0704. The nurse documented that 911 was not called until 0715. There is no documentation on why the nurse waited 11 minutes before calling 911.

A physician telephone order was found dated 3/27/18 at 0747(7:47PM). The order was written by Personnel #25. The order stated, "Order obtained from to pronounce patient deceased at 0747AM." (SIC) There was no documentation on who was to pronounce and release of the body.

Review of Patient #21's chart revealed a nurse note dated 3/29/18 at 0830. The note stated, "Summary of events. Pt was found without respirations at 0703. CPR was initiated while 911 was alerted while CPR was going on. Coffee ground emesis was coming out his mouth 911 team arrived at 0718 and continued with the CPR (illegible word) 0748. Pt was pronounced dead by Dr. Taylor. Administrative staff on the unit." (sic)

Review of Patient #21's chart revealed there was no physician progress notes. No documentation that any physician saw the patient besides on telemedicine. There was no Physician Discharge Summary. There is no confirmation on who pronounced the patient, who removed the patient from the premises without a physician order, was the family notified, and who notified the family.

An interview was conducted with Personnel #3 on 11/8/18. Personnel #3 Risk Manager reported that she was not involved in all aspects of the investigation. Personnel #3 stated that the CEO (who is no longer employed in the facility) wanted to conduct the investigation on her own. The CEO worked only with the Pharmacist and Director of Nursing. None of those individuals are employed to at this facility. Personnel #3 reported that she had some of the investigation but was not sure if that was all of the information. Review of the materials revealed there was no formal Root Cause Analysis (RCA) done. There was only a one-page action plan. Personnel #3 confirmed that was all she could locate.

There was no process for conducting root cause analysis in the Patient Safety Plan. There was no written evidence that the Risk Manager was fully involved nor reported to the governing body internal reporting of patient safety incidents under investigation.

Review of the Action Plan under Action Item #1 revealed, "All intake and nursing staff will be educated on notifying poison control immediately if suspected ingestion occurs. All intake and nursing staff will be educated on notifying the physician immediately and sending the patient who is suspected of ingesting any type of poison out for medical clearance. All Nursing staff will be educated in identifying the signs and symptoms of renal failure."

Review of the personnel education records provided there was only one meeting held. The meeting was conducted on 4/12/18. The meeting roster revealed only nursing house supervisors and intake nurses were educated. There was no evidence that any other nursing personnel was educated.

Review of the Quality Assessment Performance Improvement (QAPI) meeting minutes and reports for 2018 revealed there was no monitoring, assessments, or projects that show any measurable progress of the nursing issues identified in the Action Plan.
VIOLATION: ADMINISTRATION OF DRUGS Tag No: A0405
Based on observation, review of records and interview, the Garland facility failed to ensure that medications were administered in accordance with the approved medical staff policies and procedures. Medications were not administered within 45 minutes before or after the scheduled time for 7 out of 10 patient records reviewed. Nursing staff were not aware of the time frame for administering medications per facility policy. These findings were not in compliance with facility policy and presents a risk that patients may not receive medications as ordered or in a timely manner and presents a risk for a medication error.

Findings included:

Facility policy, "Medication Administration: Schedules/Times" provided to the survey team stated, in part, "Sundance Hospital has identified standard times for medication administration ...Nursing staff may administer medication 45 minutes before or after the scheduled time. If the nurse is unable to administer the medication 45 minutes prior or after the scheduled administration time, a comment regarding reason and action is required on the MAR or in the patient medical record ...Changes to regularly scheduled medication times require a physician's order."

Garland patient medical records were reviewed the afternoon of 1/13/18 in the Garland facility conference room and revealed that medications were being administered late, or after the 45 minutes allowed per facility policy.

Patient #12:
-Bactrim DS ordered at 0900. Medication administered at 1000 on 7/19/18 and at 1000 on 7/20/18.

Patient #53:
-Escitalopram ordered at 0900. Medication administered at 1000 on 10/27/18.
-Quetiapine ordered for 0800. Medication administered at 0915 on 10/23/18 and at 0930 on 10/22/18.

Patient #55:
-Topiramate ordered for 0800. Medication administered at 0925 on 10/31/18 and at 0904 on 11/1/18.
-Duloxetine ordered for 0800. Medication administered at 0925 on 10/31/18 and at 0904 on 11/1/18.

Patient #56:
-Hydroxyzine ordered for 0800. Medication administered at 0855 on 10/24/18 and at 0905 on 10/28/18 and 0925 on 10/29/18.
-Fluoxetine ordered for 0800. Medication administered at 0855 on 10/24/18 and at 0905 on 10/28/18 and at 0925 on 10/29/18.
-Fluticasone Spray ordered for 0800. Medication administered at 0905 on 10/28/18 and at 0925 on 10/29/18.
-Quetiapine ordered for 2000. Medication administered at 1900 on 10/28/18.

Patient #57:
-Trazodone ordered at 2000. Medication administered at 2100 on 10/24/18.

Patient #59:
-Fluoxetine ordered for 0800. Medication administered at 0940 on 10/16/18 and at 0940 on 10/17/18.

Patient #66:
-Escitalopram ordered at 0800. Medication administered at 0911 on 11/14/18.
-Hydroxyzine ordered at 0800. Medication administered at 0911 on 11/14/18.

An interview was conducted on Unit 2 the afternoon of 11/19/18 with Staff #106, unit nurse. When asked how long before or after the ordered time a medication may be given, Staff 106 stated, "One hour before or after." Staff #106 stated that this was the hospital policy.

An interview was conducted on Unit 2 the afternoon of 11/19/18 with Staff #107, unit nurse, who stated that, per policy, a medication may be given up to one hour before or after the ordered administration time.

An interview was conducted on Unit 2 the afternoon of 11/19/18 with Staff #25 who stated that the facility policy allowed medications to be given one hour before or after medications. When shown that the facility policy stated, "Nursing staff may administer medication 45 minutes before or after the scheduled time," Staff #25 stated that many nurses work at different facilities and "they all have different policies so it is hard to know what it is at each place."

The above findings, that medications were not administered within the time frame specified in policy, and that nursing personnel were unaware of the facility policy, were confirmed in an interview the afternoon of 11/19/18 with the CNO in the facility conference room.
VIOLATION: FORM AND RETENTION OF RECORDS Tag No: A0438
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of documentation and interview it was determined that the hospital failed to ensure that medical records at the Arlington location were complete.

Findings were:
Medical records were not complete as patient observation records,treatment plans, restraint/seclusion/emergency medication orders and treatment plan modification forms were not completed or signed and patients had not participated in their treatment plans.

Review of the medical record for Patient #77 revealed that it was not complete. Review of the "Patient Observation Record" sheet for 02/19/2018 revealed that the area where staff was to document if the patient had attended the community groups by checking: "yes" or "no" had not been checked. The area where the patient's "Goal for the day" was to be documented was also blank.

The "Patient Observation Record" sheet for 02/20/2018 revealed that the area where staff was to document any unit restrictions (ie: safety q15 min., etc.) had not been checked.

The "Patient Observation Record" sheet for 02/21/2018 revealed area where staff was to document if the patient had attended the community groups by checking: "yes" or "no" had not been checked. The area where staff was to check "yes" or "no" to document whether the patient "Attended Wrap-up Goal" was blank as was the area where staff was to document if the patient had "Achieved goals for the day." Additionally the area where staff is to document any unit restrictions (ie: safety q15 min., etc.) had not been checked.

The "Patient Observation Record" sheet for 02/22/2018 revealed area where staff was to document if the patient had "Attended Wrap-up Goal" was blank. Additionally the area where staff is to document any unit restrictions (ie: safety q15 min, etc.) had not been checked.

The "Patient Observation Record" sheet for 02/23/2018 revealed area where staff was to document if the patient had attended the community groups by checking: "yes" or "no" had not been checked. The area where staff was to check "yes" or "no" to document whether the patient "Attended Wrap-up Goal" was blank as was the area where staff was to document if the patient had "Achieved goals for the day." The area where staff documents the physical location as well as the behaviors of the patient was found to be blank from 1045am until 1145. Additionally the area where staff is to document any unit restrictions (ie: safety q15 min., etc.) had not been checked.

The "Patient Observation Record" sheet for 02/24/2018 revealed area where staff was to document if the patient had attended the community groups by checking: "yes" or "no" had not been checked. The area where staff was to check "yes" or "no" to document whether the patient "Attended Wrap-up Goal" was blank as was the area where staff was to document if the patient had "Achieved goals for the day."

In an interview with Personnel #28 on 11/09/2018 the above findings were confirmed.

The hospital failed to ensure that treatment plans were complete and Restraint/Seclusion/Emergency medication orders and treatment plan modification forms related to restraint or seclusion episodes were not completed. Additionally patients had not participated in the development of their treatment plan.

A review of the medical record for Patient #77 revealed that the treatment plans was not complete.

Based on review of documentation and interview it was determined that the hospital failed to ensure that the treatment plan for patient #77 was complete. Patient #77 was admitted on [DATE] and discharged on [DATE]. During the hospitalization , Patient #77 was placed on assaultive and suicide precautions as documented by physician preliminary orders on 2/17/2018. On 2/18/2018, 2/19/2018, 2/21/2018, 2/22/2018, 2/23/2018 and 2/24/2018 the orders for assaultive and suicide precautions were renewed.

Review of the Interdisciplinary Treatment Plan for patient # 77 revealed no documentation as to the continued need for assaultive and suicide precautions. Page two the treatment plan contained an area where the level of monitoring was to be documented. This area was found to be blank.

Patient #77 received emergency medications (Thorazine 25mg and Benadryl 50mg IM) on 2/20/2018 and 2/23/2018 per physician orders. Review of the Interdisciplinary Treatment Plan revealed an area on page two where Emergency Behavior Management issues could be documented, this included the date and type (IM, Restrain, Seclusion). This area was blank with no dates or documentation concerning the two episodes where patient #77 had received emergency medications.

Review of hospital policy entitled: "Treatment Plan: Interdisciplinary Treatment Planning/Master Treatment Plan" stated on page 2: "7. The treatment plan shall be reviewed and its effectiveness evaluated: A. When there is a significant change in the patient's condition or diagnosis or as otherwise clinically indicated."

In an interview with personnel #27 on the afternoon of 11/07/2018 it was confirmed the above findings regarding the Interdisciplinary Treatment Plan were confirmed.

Additionally it was determined that the hospital (Arlington location) failed to ensure that the treatment plan for patient #77 was established within 72 hours per the hospital's own policy. Patient #77 was admitted to Sundance hospital on [DATE]. A review of the Interdisciplinary Treatment Plan revealed an area on page three where the Interdisciplinary Treatment Team Members sign and date the treatment plan revealed that the psychiatrist had signed on 2/23/18, a therapist had signed on 2/20/2018 and two individuals who were identified as other had signed on 2/23/2018. The area directly below contained an area where the patient participation was to be documented revealed that the parent/guardian for patient # 77 signed on 2/24/2018 (the day before discharge). Additionally the area at the top of the page where Other Treatment Information could be documented was found to be blank with no other information.

Review of hospital policy entitled: "Treatment Plan: Interdisciplinary Treatment Planning/Master Treatment Plan" stated on page 2: "5. Within 72 hours of the patient's admission the inpatient staff shall: A. Establish an interdisciplinary treatment team (IDT) for a patient." "6. The treatment plan shall be signed by all members of the IDT present in treatment team planning meetings. If the patient or the patient's LAR are not present in the treatment team planning meeting, then the treatment team plan will be reviewed with the patient. The patient or the patient's LAR's signature on the treatment team plan will document treatment plan review with the patient or the patient's LAR. If the patient or the patient's LAR is unable or unwilling to sign the treatment plan, the reason for or circumstances of such inability or unwillingness shall be documented in the patient's medical record. A. The Program Therapist will ensure communication and documentation of treatment plan review with the patient and/or the patient's LAR; and the patient's physician and other treatment team members."

A review of 9 of 9 medical records (patients #131, #133, # 137, #140, #141, #35, #83, #145, #146) revealed that Restraint/Seclusion/Emergency Medication Orders and Treatment plan modification forms were found to be incomplete and that patients or staff and had not participated in the treatment plans.

Review of "Sundance Behavioral Health Treatment Plan Modification Restraint/Seclusion" form for patient #131 dated 11/10/2018 revealed it had not been signed or dated by the patient or family or guardian, or the Therapist. The top of the form stated: "(To be completed within 8 hours of the use of all personal restraint, seclusion, emergency med episodes)."

Review of "Sundance Behavioral Health Restraint/Seclusion/Emergency Medication Orders for patient #133 revealed that on 11/12/2018 patient #133 had a physical restraint. Page 3 of 5 the order contained an areas entitled: "7. Patient Debriefing (to be completed after intervention when patient has calmed but no later than 24 hours)." This area contained several areas to be addressed including the patient's perception of the event/triggers leading to the intervention, description of patient's behaviors, patients perception of what could be done differently, did the patient feel his/her wellbeing and psychological comfort and right to privacy were maintained, was any trauma experienced by the patient, strategies to prevent repeat use of intervention and/or to address factors contributing to the incident and were staff members debriefed. There was also an area where a nurse was to sign and date/time. No information was found in Section 7 in response to areas listed above and there was no signature found from nurse.

Review of "Sundance Behavioral Health Treatment Plan Modification Restraint/Seclusion" form for patient #133 dated 11/12/2018 revealed it had not been signed or dated by the patient or family or guardian, the RN (Registered Nurse), the Therapist or the Physician. The top of the form stated: "(To be completed within 8 hours of the use of all personal restraint, seclusion, emergency med episodes)."

Review of "Sundance Behavioral Health Treatment Plan Modification Restraint/Seclusion" form for patient #137 dated 11/3/2018 revealed it had not been signed or dated by the patient or family or guardian, the Therapist or the Physician. The top of the form stated: "(To be completed within 8 hours of the use of all personal restraint, seclusion, emergency med episodes)."

Review of "Sundance Behavioral Health Treatment Plan Modification Restraint/Seclusion" form for patient #140 dated 11/10/2018 revealed it had not been signed or dated by the patient or family or guardian, or the Therapist. The top of the form stated: "(To be completed within 8 hours of the use of all personal restraint, seclusion, emergency med episodes)."

Review of "Sundance Behavioral Health Treatment Plan Modification Restraint/Seclusion" form for patient #141 dated 11/4/2018 revealed it had not been signed or dated by the patient or family or guardian, the Therapist or the Physician. The top of the form stated: "(To be completed within 8 hours of the use of all personal restraint, seclusion, emergency med episodes)."

Review of "Sundance Behavioral Health Treatment Plan Modification Restraint/Seclusion" form for patient #141 dated 11/5/2018 revealed it had not been signed or dated by the patient or family or guardian, the Therapist or the Physician. The top of the form stated: "(To be completed within 8 hours of the use of all personal restraint, seclusion, emergency med episodes)."

Master Treatment Plans were not signed by all members of the treatment team or that there was documentation of the involvement of the patient/patient family member(s).

Review of the Master Treatment Plans for patient # 35 revealed that on page four the area where patient participation is documented was blank. The treatment team members had signed the plan as of 11/02/18. The area contained several areas which could be checked to indicate that the patient contributed to the goals/plan, was aware of the plan or refused to participate, refused to sign treatment plan, was unable to sign or was unable to participate due to clinical reasons. Below these choices was an area where the patient or parent/guardian could sign and date the form. None of the areas had been checked and there was to signature found from the patient.

Review of Master Treatment Plan for patient # 83 revealed on page four that the area where the patient's participation was documented was blank as was the area where the patient or parent/guardian was to sign was blank also.

Review of Master Treatment Plan for patient # 145 revealed on page four that the nurse had not signed the treatment plan, other team members had signed on 11/7/18. The area where the patient's participation was documented was blank as was the area where the patient or parent/guardian was to sign was blank also.

Review of Master Treatment Plan for patient # 146 revealed on page four that the nurse had not signed the treatment plan, other team members had signed on 11/7/18. The area where the patient's participation was documented was blank as was the area where the patient or parent/guardian was to sign was blank also.

Review of hospital policy entitled: "Documentation Requirements" stated under the procedure section: "5. The medical record documentation must be clear, concise, complete and current." "11. The medical record must not contain blank, spaces or lines 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." "17. The attending practitioner shall be responsible for the preparation of a complete and legible record for each patient. Its content shall be pertinent and current."

Review of hospital policy entitled: "Patient Records" stated: "The facility shall establish and maintain a single record for every patient beginning at the time of admission. The content of the record shall be complete, current and well organized."

Review of hosptial policy entitled: "Patient Rights" with a revised date of 09/26/16 stated: "7. The right to participate actively in the development and periodic review of an individualized treatment plan (extending to a parent or conservator of a minor, and the legal guardian of the person when applicable); and the right to a timely consideration of any request for the participation of any other person in this process, with the right to be informed of the reasons for any denial of usch a request. (Staff must document in the medical record that the parent, guardian, conservator, or other person was notified of the date, time, and location of each meeting so that he or she could participate).

















Personnel #1, from the Garland facility was interviewed as to why the physician was allowed to continue admitting patients with so many delinquent charts. Personnel #1 stated that it was an ongoing problem with that particular physician (Personnel #11). Personnel #1 stated that Personnel #11 had his admitting privileges revoked the day before, 11-6-2018. However, review of the daily admissions for 11-7-2018 showed that Personnel #11 was continuing to be allowed to admit patients.
Delinquent Medical Records letters for Personnel #11 were reviewed. Personnel #11 was issued letters stating:

"Effective today the following may be implemented:

suspension of admitting privileges
a cap on admissions
a decreased stipend
delinquency information to part of credentialing file
reportable to Texas Medical Board"

Per the Medical Staff Rules and Regulations, suspension was to be automatic unless, "Upon the request of the suspended Practitioner, the President may temporarily lift the automatic suspension only if it is determined that an emergency exists in which the health and safety of any patient will be jeopardized by failure to allow the Practitioner to treat the patient, or there have been extenuating circumstances beyond the control of the practitioner."

Personnel #11 was issued a letter on 9-10-2018 for having 85 delinquent charts. A letter was issued on 10-3-2018 for having 142 delinquent charts. A letter was issued on 11-11-2018 for having 145 delinquent charts. A letter was issued on 11-19-2018 for having 135 delinquent charts. A letter was issued on 11-2-2018 for having 125 delinquent charts. A total of 5 letters had been issued in a 3 calendar-month period.

Personnel #1 provided a copy of an email dated 11-8-2018 that stated:

"This is being written to again confirm that as of Nov.6, 2018, ____ (Personnel #11) was to receive no patient assignments. This restriction is not to be changed without written permission from the CEO."

Other than the email, no evidence was presented that any other actions were taken due to delinquent charts.

Review of Medical Staff Rules and Regulations, Updated March 26, 2018, page 68, item 4 and 5 was as follows:

"4. More than four episodes of suspension of privileges for failure to completed records on discharge patients or failure to complete Physician Progress Notes during a period of twelve months shall result in practitioner being considered to have automatically resigned from the Medical Staff without prejudice unless an exception is made by the Medical Executive Committee.

5. A practitioner who has been considered to have automatically resigned from the Medical Staff under provision III. D, 2, 3, or 4, above shall be granted temporary privileges to complete treatment of his/her currently hospitalized patients."

This provision was not enforced by the Medical Staff or Governing Body.
VIOLATION: SUPERVISION OF CONTRACT STAFF Tag No: A0398
Based on observation, record review, and interview, nursing staff failed to evaluate the clinical activities of temporary agency nursing personnel



Findings included:


Record review of the Arlington location's staffing sheet dated 11/13/18 reflected three temporary agency nurses (Personnel #176, #, #177, #179, and #180) had assigned shifts at the hospital that day.

Record review of the agency nurses and certified nurse aides' documents of "Core Competencies" did not reflect state required hospital verified competency to manage patients' emergency medical condition, monitor patients in restraints for respiratory status, nutritional and hydration needs, or address psychological and physical status of patients in emergency restraint or seclusion.

Personnel #37 stated during an interview on 11/14/18 at 1057 that Arlington hospital administration "trust that they [the agency] sends us seasoned RNs [registered nurses]."

Personnel #179 was observed on the hospital's "Tween Unit" on 11/14/18 at 1115. Unpon surveyor inquiry, Personnel #179 denied knowledge of the location of the emergency crash cart and did know where the glucometer was to measure patients' blood sugar.
VIOLATION: SECURE STORAGE Tag No: A0502
Based on observation, review of documentation and interview it was determined that the hospital failed to ensure that medications were properly secured at the Arlington location. The Garland facility failed to ensure that medications, including controlled substances, were secured and not available for misuse.

Findings were:
Medications were not properly secured. During a tour of the girls adolescent unit on the morning of 11/14/2018, examination of an unsecured drawer in the unit nursing station revealed a hardsided notebook which contained the medication administration sheets for the day. Inside the notebook was a package of Sprintec birth control pills for patient #89. Review of hospital policy entitled: "Medication Storage Area." The policy stated under the purpose area: "Medication storage area and other medication carts shall be locked at all times when unattended by nurse." The procedure portion of the policy stated: "1. All medications will be secured by locking the medication storage area at all times." In an interview with personnel #31 who was on the unit at the time confirmed the above findings.








A tour of the Medication Room on Unit 3 was conducted 11/6/18 at approximately 10 am. The facility used an automated medication dispensing system for patient medications.

The Garland facility failed to ensure that medications, including controlled substances, were secured and not available for misuse.

A tour of the Medication Room on Unit 3 was conducted the morning of 11/6/18. The facility used an automated medication dispensing system for patient medications.

In an upper cabinet in the medication room, a small box was found at the back of the top shelf.
In the box, there was an opened, unit dose medication packet, labeled Alprazolam 1 mg. There was a partial pill, over half of a blue pill in the opened medication packet. Alprazolam is a Schedule IV medication.

The box also contained an assortment of loose unit dose medications, including the following:
Lisinopril 20 mg, quantity of 2
Lisinopril 5 mg, quantity of 2
Promethazine 25 mg, quantity of 1
Latuda 40 mg, quantity of 2
Invega 3 mg, quantity of 1
Trazadone 50 mg, quantity of 3
Trazadone 100 mg, quantity of 1
Vitamin B-1, 100 mg, quantity of 1
Quetiapine 25 mg, quantity of 2
Quetiapine 200 mg, quantity of 1
Quetiapine 100 mg, quantity of 2
Divalproex 125 mg, quantity of 1
Divalproex 500 mg, quantity of 3
Ducosate 100 mg, quantity of 1
Risperidone 1 mg, quantity of 4
Clonidine 0.1 mg, quantity of 5
Sertraline 100 mg, quantity of 1
Carvedilol 6.25 mg, quantity of 1
Simvastatin 40 mg, quantity of 2
Haloperidol 10 mg, quantity of 1
Cyclobenzaprine 10 mg, quantity of 1
Benztropine 1 mg, quantity of 1
Sulfamethoxazole/Trimethoprim 800/160 mg, quantity of 1
Amlodipine 10 mg, quantity of 1
Buspirone 10 mg, quantity of 1
Hydroxyzine 25 mg, quantity of 1
Lithium Carbonate 150 mg, quantity of 1
Lithium Carbonate 300 mg, quantity of 1
Gabapentin 600 mg, quantity of 1
Inderal 20 mg, quantity of 1
Naproxen 500 mg, quantity of 1
Aspirin chewable, 81 mg, quantity of 1
Sumatriptan Succinate 50 mg, quantity of 1
Wellbutrin XL 150 mg, quantity of 1
Dicyclomine 20 mg, quantity of 1

In the back of a cabinet underneath the counter there was a blue plastic bin which contained 3 adult diapers. Underneath the adult diapers, there was a large paper medication cup which contained an assortment of loose unit dose medications, including the following:
Hydroxyzine 50 mg, quantity of 2
Ibuprofen 400 mg, quantity of 4
Trazadone 50 mg, quantity of 3
Divalproex 500 mg, quantity of 1
Buproprion 150 mg, quantity of 1
Cyclobenzaprine 10 mg, quantity of 2
Fluoxetine 20 mg, quantity of 1
Clonidine 0.1 mg, quantity of 1
Abilify 10 mg, quantity of 1.

In the upper cabinet directly was a 3 ring binder labeled, "STOCK MEDICATION LOG". There was a wadded up brown paper towel inside the binder. Inside the paper towel were 3 loose unit dose medications, including the following:
Trazadone 50 mg, quantity of 3.

As the tour of the medication room continued, a small box was found at the back of the top shelf of an upper cabinet. The box contained another assortment of loose unit dose medications, including the following:
Lisinopril 20 mg, quantity of 2
Lisinopril 5 mg, quantity of 2
Promethazine 25 mg, quantity of 1
Latuda 40 mg, quantity of 2
Invega 3 mg, quantity of 1
Trazadone 50 mg, quantity of 3
Trazadone 100 mg, quantity of 1
Vitamin B-1, 100 mg, quantity of 1
Quetiapine 25 mg, quantity of 2
Quetiapine 200 mg, quantity of 1
Quetiapine 100 mg, quantity of 2
Divalproex 125 mg, quantity of 1
Divalproex 500 mg, quantity of 3
Ducosate 100 mg, quantity of 1
Risperidone 1 mg, quantity of 4
Clonidine 0.1 mg, quantity of 5
Sertraline 100 mg, quantity of 1
Carvedilol 6.25 mg, quantity of 1
Simvastatin 40 mg, quantity of 2
Haloperidol 10 mg, quantity of 1
Cyclobenzaprine 10 mg, quantity of 1
Benztropine 1 mg, quantity of 1
Sulfamethoxazole/Trimethoprim 800/160 mg, quantity of 1
Amlodipine 10 mg, quantity of 1
Buspirone 10 mg, quantity of 1
Hydroxyzine 25 mg, quantity of 1
Lithium Carbonate 150 mg, quantity of 1
Lithium Carbonate 300 mg, quantity of 1
Gabapentin 600 mg, quantity of 1
Inderal 20 mg, quantity of 1
Naproxen 500 mg, quantity of 1
Aspirin chewable, 81 mg, quantity of 1
Sumatriptan Succinate 50 mg, quantity of 1
Wellbutrin XL 150 mg, quantity of 1
Dicyclomine 20 mg, quantity of 1

In a drawer in the nurses station of Unit 3, there was an opened, unit dose Amlodipine 10 mg unit dose packet containing a partial pill. On the pill packet was handwritten "1/2".

There was no means to determine which patients the unsecured medications had been dispensed for, whether any patients had missed doses, whether patients had been charged for these medications or whether these medications were medications that had not been returned to the pharmacy after a patient was discharged .

From the Drug Enforcement Administration Practitioner's Manual, 2006 edition: "Practitioners are required to store stocks of Schedule II through V controlled substances in a securely locked, substantially constructed cabinet ... inventories and records of controlled substances in Schedules III, IV, and V must be maintained separately or in such a form that they are readily retrievable from the ordinary business records of the practitioner. All records related to controlled substances must be maintained and be available for inspection for a minimum of two years. A registered practitioner is required to keep records of controlled substances that are dispensed to the patient, other than by prescribing or administering, in the lawful course of professional practice."

The above findings, the unsecured medications and the unsecured controlled Schedule IV medication was observed and confirmed in an interview with Personnel #18 and Personnel #5 during the tour of the Medication Room. Personnel #5 stated that "those medications should not be in a box in a cabinet."

The Environment of Care rounds on a form entitled "INFECTION CONTROL MONITORING", revealed that unsecured medications was an ongoing issue at the facility, as it had been documented by Staff #6, Infection Control Nurse, from 8/14/18 to 11/5/18. Item 20 on the form stated, "No medications stored outside medication room" and had been checked "N" for the following dates with additional comments:
8/14/18 Unit 3 "meds drawer - removed to pharmacy"
8/20/18 Unit 3 "Nurses reminded to use med room."
8/22/18 Unit 2 "Inhalers, oints in drawers. Removed."
8/28/18 Unit 3 "items in drawer"
9/4/18 Unit 3 "Drawer - /removed"
9/21/18 Unit 3 "Removed items to pharmacy"
10/18/18 Unit 2 "Unidentified items removed to pt adv."

The Environment of Care rounds results were confirmed in an interview the afternoon of 11/8/18 with Staff #6 in the Garland facility conference room.
VIOLATION: CONTROLLED DRUGS KEPT LOCKED Tag No: A0503
Based on observation, review of documentation, and interview the facility failed to ensure all controlled drugs are locked at all times as evidenced by unsecured plastic containers for wasted controlled medications observed on the counter in medication rooms at the Arlington location. There was a controlled substance opened and unsecured at the Garland location.

Findings were:

During a tour of the Adult, Psychiatric Intensive Care Unit (PICU), and Adolescent/Girls medication rooms at the Arlington facility conducted on 11/5/18 at approximately 1500 accompanied by Pharmacist, Personnel #31 unsecured plastic containers used for wasted controlled medications were observed on counters in the medication rooms.

In an interview with the Pharmacist, Personnel #31 on the afternoon of 11/5/18 at approximately 1515 the pharmacist stated that unused or dropped controlled medications are disposed of in the plastic containers and that once the medications are put in the container there is no way to remove the medications. Personnel #31 acknowledge the plastic containers were not secured to the wall and picked up the container to demonstrate to the surveyor how it worked.







A tour of the Garland Medication Room on Unit 3 was conducted the morning of 11/6/18. The facility used an automated medication dispensing system for patient medications.

In an upper cabinet in the medication room, a small box was found at the back of the top shelf.
In the box, there was an opened, unit dose medication packet, labeled Alprazolam 1 mg. There was a partial pill, over half of a blue pill in the opened medication packet. Alprazolam is a Schedule IV medication.

From the Drug Enforcement Administration Practitioner's Manual, 2006 edition: "Practitioners are required to store stocks of Schedule II through V controlled substances in a securely locked, substantially constructed cabinet ... inventories and records of controlled substances in Schedules III, IV, and V must be maintained separately or in such a form that they are readily retrievable from the ordinary business records of the practitioner. All records related to controlled substances must be maintained and be available for inspection for a minimum of two years. A registered practitioner is required to keep records of controlled substances that are dispensed to the patient, other than by prescribing or administering, in the lawful course of professional practice."

The above findings, the unsecured controlled Schedule IV medication was observed and confirmed in an interview with Personnel #18 and Personnel #5 during the tour of the Medication Room. Personnel #5 stated that "those medications should not be in a box in a cabinet."
VIOLATION: UNUSABLE DRUGS NOT USED Tag No: A0505
Based on observation, review of documentation and interview it was determined that the hospital failed to remove expired supplies from the Arlington location.

Findings were:
Expired supplies were found at the Arlington location on nursing units and in a supply storage room area and thus potentially available for use. During a tour of the adolescent/pediatric nursing units on the afternoon of 11/05/2018 the following expired supplies were found:

On the girls unit nursing station in an unsecured over sink cabinet there was an opened container of True Track diabetic accucheck blood glucose test strips, the container had an expiration date of 2018/04/31.

In the medication room on the girls unit, there were two each containers of True Track diabetic accucheck blood glucose test strips, the expiration dates on the containers was 2018/10/31.

Inside the locked storage room located inside the patient examination room there was an opened top plastic bin containing approximately 35 each BD Vacutainer C&S Transfer Straw Kit, the expiration date on these items was 2012-04.

On the boys unit medication room there was a roll able supply cart, in one of the cart's drawers there was an unopened container of Even Care G2 blood glucose testing stripes, the expiration date was 2017-10.

In a drawer located directly beneath the counter top of the cart there were 6 each BBL Culture Swabs Plus- Collection and Transport System, the expiration date on each of the culture swabs was 2013/07. Also found was one each Remel Bactiswab with an expiration date of 2012 11 24.

On 11/07/2018 a subsequent re-examination of the locked storage room located inside the patient examination room revealed more expired supplies which included: 4 packets of suction tubing with an expiration date of 2017/09/10, a box of 35 disposable syringes with 25 gauge needles with an expiration date of 04/2018 and a box of disposable syringes and needles with an expiration date of 04/2018.

Review of hospital policy entitled: "Disposable Supplies" with a review date of 2/2016 stated: "It is the policy of Sundance Hospital to establish and maintain procedures regarding disposable medical supplies." The procedure portion of the policy stated: "5. Outdated sterile supplies will be removed and disposed of. The EOC Director will review supplies monthly." "6. The Nursing Department will notify the Infection Control Nurse when items are defective." (Note: this policy was found in section 5 of the Hospital Infection Control Plan which was provided the survey team on 11/08/2018 for review by personnel #29. Personnel #29 also confirmed that these same infection control policies were in use as of the date of the survey).

In an interview with personnel #28 (who accompanied the surveyor on the tour) on the afternoon of 11/05/2018 and also on the tour on 11/07/2018 it was confirmed that the above referenced expired supplies were found.
VIOLATION: MAINTENANCE OF PHYSICAL PLANT Tag No: A0701
During a tour of the adult outpatient facility at the Arlington location conducted on 11/6/18 at approximately 0910 accompanied by Personnel #76 Outpatient Director the following was observed;
" Kitchen area - metal warmer trays with food crumbs and spoons inside, excessive dust on horizontal surfaces including plastic ware dispenser.
" Air filter in group hallway with excessive dust and 1 stained ceiling tile in the adult patient hallway.
" Back storage room - 1 Dynamap (vital signs monitoring equipment) had an expired inspection sticker that read "next inspection date 4/16"

During a tour of the adolescent outpatient facility at the Arlington location conducted on 11/6/18 at approximately 1100 accompanied by Outpatient Director, Personnel #76, the surveyor observed excessive dust in multiple ceiling air filters in hallways.

In an interview with the Outpatient Director, Personnel #76, on 11/06/18 at approximately 1100, Personnel #76 acknowledged the above findings at the adult and adolescent outpatient facilities.





Based on observation, review of documentation and interview it was determined that the hosptial failed to ensure that the physical environment of the Arlington location was maintained.

Findings were:
The physical environment at the Arlington location was not maintained. During a tour of the girls and boys unit on the afternoon of 11/05/2018 the following observations were made:

The refrigerator in the nutrition room on the girls unit contained 13 individual snack sized containers of cubed yellow cheese. None of the containers had a date on them indicating when the cheese snack had been prepared or when it had been placed in the refrigerator.

The wall by the sink was stained in appearance as if a liquid had splashed against the wall and run down.

Food particles (appeared to be from broken crackers) were found in the pull out drawer by the sink and there was also 3-4 strands of what appeared to be human hair approximately 4-5 inches in length.

In an adjacent drawer there were approximately 75 individual sugar substitute/ salt and pepper packets found, some of which appeared to have been stained as if exposed to moisture and there was particulate matter of some kind (appeared to be broken crackers) in the corners of the drawer along with what appeared to be a human hair approximately 2 inches in length.

The bottom two plastic see through drawers in the refrigerator had visible particulate matter in them.

On the inner door shelving of the refrigerator there was an unopened 32 ounce container of Hormel Med Pass Fortified Nutritional Shake with a patient label affixed to it. The patient label contained the name of a patient # 143. The admitted was listed as 10/08/2018 at 17:44 hours. In an interview with personnel #28 on the afternoon of 11/05/2018 it was confirmed that this patient had been discharged .

In the girls unit nursing station in an unsecured cabinet there was one each unused diabetic lancet (used to perform diabetic accucheck).

In an unlocked (lock core had been removed) over sink cabinet there was a pill cutter which was used to split pills (the pill cutter was made of plastic and contained a sharp edged piece of metal which could potentially be broken out of the plastic and used for self-injurious behaviors).

One of the lower cabinet doors had a broken hinge. The keys to the unit medication room were found lying in an unsecured drawer in the nurse's station.

Both of the overhead ceiling mounted fluorescent light fixtures in the nrusing station were dirty in appearance.

The ceiling vent adjacent to the small wall mounted storage lockers had a significant amount of visible dust. In the clean linen room both of the overhead ceiling mounted fluorescent light fixtures were dirty in appearance with discoloration which had the potential appearance of mold and addtionally there were two discolored ceiling tiles. In the hallway outside of room 326 the wall mounted hand sanitizer was empty.

The ceiling overhead ceiling mounted fluorescent light fixtures by the television in the day room area was dirty in appearance.

In the storage room (used for storing patient belongings and unit art activities, ie: crayons, games) on the girls unit both of the overhead ceiling mounted fluorescent light fixtures were dirty in appearance.

In the fish bowl room (common room for group processing) there were 6 stained ceiling tiles.

In the patient examination room one of the cabinet doors located below the counter top/sink area had a broken hinge. The oxygen concentrator had a biomedical inspection sticker which indicated that re inspection was due Jun 2018.

The suction machine located on top of the emergency cart had a biomedical inspection sticker which indicated that re inspection was due Jun 2018.

In the storage room on the boys unit, the overhead ceiling mounted fluorescent light fixtures were dirty in appearance. The floor appeared dirty and there was a dirty white towel on the floor as well as pieces of what appeared to be paper activity projects and small pieces of trash were noted.

In an over sink unlocked cabinet in the nurses station, one of the lower cabinet doors had a broken hinge and there was one stained ceiling tile noted.

In the boys unit medication room there was a roll able supply cart, the top of the cart was dirty in appearance. A pill splitter was found inside one of the drawers of the cart. An examination of the pill splitter revealed that it still contained a piece of the last pill (white in color) that had been split by the pill splitter.

In an interview with personnel #28 on the afternoon of 11/05/2018 the above findings were confirmed.

The following was observed during the tour of the recreational therapy room on 11/5/2018 at 2:30 pm accompanied by personnel # 43 recreational therapist.

Multiple brownish stain ceiling tiles, one tile look as if it was about to fall Lower walls were blackish grimy material. Multiple areas of paint peeling from the wall. The floors contained grimy blackish material build-up. Multiple floor tiles were discolored and crack Baseboards contained dirt buildup. 3 black chairs material crack, split, some areas exposing the foam underneath making it impossible to clean. The findings were confirmed during the tour by personnel # 43.

During a tour of the intake unit conducted on 11/6/18 9:05 am accompanied by personnel #32 intake director the following was observed; intake rooms 1, 2,3,4 lower walls were dirty blackish substance observed.

Paint was peeling on multiple walls. 9 cm hole was observed in the wall in Intake 3. Large irregular shape peeling paint areas were observed, exposing white plaster. Intake 2 wall left side contain large areas of missing paint exposing the white crumbling areas. Intake 3 multiple stain ceiling tiles were observed.

A tour of emergency exam room next to intake department was conducted on 11/6/18 at 10:05 am accompanied by personnel #32, the following was observed; Multiple brownish stained ceiling tiles and 2 green chairs containing multiple cracks in the covering. The following was observed in the bathroom inside the emergency exam room, 12 by 12-inch area uncovered exposing the pipes and unknown materials under the sink. Uncovered smoke alarms exposing the batteries in the ceiling. A tour of the intake staff office revealed missing ceiling tiles exposing pipes, and pink color insulation, causing potential for skin, respiratory irritations. During the tour the findings were confirmed by personnel #32.

Review of hospital policy entitled: "Hosptial Wide - Housekeeping (1207)" with a revised date of 07/2018 stated: "Sundance Hospital is committed to ensuring the health, safety and welfare of all individuals. An important component of protecting the health, safety and welfare of all individuals includes actively encouraging good housekeeping services." "The facility environment is always maintainted in a safe, clean and orderly manner. Sundance Hospital's physical environments are routinely checked for cleanliness and disinfection." Also found in the policy was: "It is everyone's responsiblity to pick up and clean up." "Work areas, storage areas and amenities will be kept and maintained in a clean and hygienic manner."

Review of hospital policy entitled: "Hospital Wide - General Faciltiy Safety and Patient Management (1204)" with a revised date of 07/2018 stated under the purpose section: "To ensure a safe and secure environment of care." "To report unsafe conditions to appropriate level of managment and/or primary physician." "To maintain an apporpriate therapeutic milieu for treatment services." The policy section stated: The facility is maintained in a safe, clean and orderly manner at all times. The facility is routinely checked to protect patients, visitors and personnel from potential safety hazards." "All patients admitted to the facility are considered at risk for potential injury due to acuity of illness, medication and unfamiliar environment. Therefore, the patient will be assessed each shift and the care plans will incorporate goals and interventions to provide the optimal safe environment for the pateint." The procedure portion stated: "Personnel are to report all potential safety hazards to their supervisor immediatley."
VIOLATION: TIMELY DISCHARGE PLANNING EVALUATIONS Tag No: A0810
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on review and interview the facility failed to:

a.) ensure a timely discharge assessment was completed to allow for arrangements for post-hospital care to be made in 6 of 6 (#1,3, 4, 18, 19, and 150) charts reviewed.

b.) ensure discharge planning was started at admission and keep the patient, and, when applicable, the patient's representatives informed throughout the development of the discharge plan.

1.) Review of patient #1's chart revealed he was a nine-year-old male. He was admitted to the facility on [DATE] at 14:46 (1:46PM). Review of the chart revealed patient#1 was brought to the facility by a police officer with an Apprehension by Peace Officer Without Warrant (APOWW). The APOWW stated, " Subj had a breakdown at school jumping on desks and being a danger to himself where he had to be restrained by school resource officer w/handcuffs subj observed to be sweating profusely. When asked he said he lost control and couldn't think." (sic)
Review of the complaint revealed the mother of the patient was upset that after four days, no doctor had touched base with her about a plan to get her son stabilized and back to his family. Review of patient #1's chart revealed a physician order dated 11/7/18 (with no time) that stated, "Family therapy ASAP." Review of the chart revealed there was no documentation of any family therapy provided. The patient's treatment team plan dated 11/5/16 revealed the 9 y/o patient attended, but there was no documentation that the family was notified of the meeting. There was no documentation found in the patient's chart that the physician ever communicated with the family. A Discharge /Aftercare plan was found on the chart the day of discharge. The discharge plan dated 11/10/16 at 1324 (1:24pm). The plan was signed by the mother and the discharge nurse. The form stated the following:

Axsis I:DMDD
Diet: Regular
Prescriptions sent and reviewed: The "Patient Verbalized Understanding" was marked but not the family.
Universal Medication List reviewed: The "Patient Verbalized Understanding" was marked but not the family.
Copy of universal medication list give to: Patient, family, other, was left blank.

Follow up with primary physician was left blank.

A resource of the PHP Garland Sundance was given to the mother. There was no other documented contact from physician, therapy staff, or discharge planner found. There was no evidence found that patient #1's parent was not involved in any multidisciplinary discharge planning until the child was picked up from the facility.

Review of patient #150's chart revealed she was a 15 y/o white female admitted on [DATE] at 14:44 (2:44PM).
Review of patient #150's chart revealed the physician orders dated 11/2/18 at 1800 (5:00PM) revealed she was involuntary with a diagnosis of suicidal ideation with a plan. The telemedicine physician documented, " per intake staff: Pt. presents SI with a plan to jump off school balcony. Pt reports she was upset with her sister and made the statement that she wanted to kill herself. Pt reports her 16 y/o sister is abusive to her and her grandparents and she was upset today." There was no documentation that the telemedicine physician ever spoke with the patient. The physician referred to "per intake staff" when documenting the physical exam.

Patient #15 asked to speak to the surveyor. An interview with patient #150 was conducted on afternoon of 11/5/17. Patient #150 reported that she wanted to leave the facility and go in CPS. Patient #150 stated she was afraid they would send her back home to her grandmother's house. Patient #150 reported that her older sister lives there and is very physically abusive and she is afraid of her. Patient #150 showed the surveyor where she cuts herself on her arms for relief of anxiety. Patient #150 was asked if she had shared her concerns and fears with her physician and personnel. Patient #150 stated, "No. I haven't seen a doctor yet. I had some lady nurse come in my room and stand in the doorway. She asked me a few medical questions. She didn't even touch me. I really don't know who she was. That's the only person that even talked to me." The survey asked the patient again if she had talked to the personnel or asked to see the grievance officer and she stated, "yes, I have told the nurses several times that I didn't want to go back to my home and they totally ignored me."

Review of patient #150's chart revealed the treatment team plan was filled out on 11/5/18 with no discharge planning. There was no documentation found concerning patient #150's concerns at discharge, her fears of discharge, or contact with her responsible party.

An interview was conducted with personnel #4, Clinical Services Coordinator on 11/9/18 in the afternoon. Personnel #4 was asked when discharge planning should begin. Personnel #4 stated at admission. Personnel #4 reported the facility was "short staffed" for social workers and discharge planners. Personnel #4 reported there was really no set plan on who followed up with patients at this time. Personnel #4 was unable to give the surveyor any direction on who and how the discharge planning was to be followed.
VIOLATION: QUALIFIED PERSONNEL Tag No: A0818
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review and interview the facility failed to:
a.) have adequate personnel trained and prepared to counsel, collaborate, or provide care to the patients for discharge.

b.) ensure discharge planning was started at admission and keep the patient, and, when applicable, the patient's representatives informed throughout the development of the discharge plan in 2 (#1 and #150) of 2 charts reviewed.

1.) Review of patient #1's chart revealed he was a nine-year-old male. He was admitted to the facility on [DATE] at 14:46 (1:46PM). Review of the chart revealed patient#1 was brought to the facility by a police officer with an Apprehension by Peace Officer Without Warrant (APOWW). The APOWW stated, " Subj had a breakdown at school jumping on desks and being a danger to himself where he had to be restrained by school resource officer w/handcuffs subj observed to be sweating profusely. When asked he said he lost control and couldn't think." (sic)
Review of the complaint revealed the mother of the patient was upset that after four days, no doctor had touched base with her about a plan to get her son stabilized and back to his family. Review of patient #1's chart revealed a physician order dated 11/7/18 (with no time) that stated, "Family therapy ASAP." Review of the chart revealed there was no documentation of any family therapy provided. The patient's treatment team plan dated 11/5/16 revealed the 9 y/o patient attended, but there was no documentation that the family was notified of the meeting. There was no documentation found in the patient's chart that the physician ever communicated with the family. A Discharge /Aftercare plan was found on the chart the day of discharge. The discharge plan dated 11/10/16 at 1324 (1:24pm). The plan was signed by the mother and the discharge nurse. The form stated the following:

Axsis I:DMDD
Diet: Regular
Prescriptions sent and reviewed: The "Patient Verbalized Understanding" was marked but not the family.
Universal Medication List reviewed: The "Patient Verbalized Understanding" was marked but not the family.
Copy of universal medication list give to: Patient, family, other, was left blank.

Follow up with primary physician was left blank.

A resource of the PHP Garland Sundance was given to the mother. There was no other documented contact from physician, therapy staff, or discharge planner found. There was no evidence found that patient #1's parent was not involved in any multidisciplinary discharge planning until the child was picked up from the facility.

Review of patient #150's chart revealed she was a 15 y/o white female admitted on [DATE] at 14:44 (2:44PM).
Review of patient #150's chart revealed the physician orders dated 11/2/18 at 1800 (5:00PM) revealed she was involuntary with a diagnosis of suicidal ideation with a plan. The telemedicine physician documented, " per intake staff: Pt. presents SI with a plan to jump off school balcony. Pt reports she was upset with her sister and made the statement that she wanted to kill herself. Pt reports her 16 y/o sister is abusive to her and her grandparents and she was upset today." There was no documentation that the telemedicine physician ever spoke with the patient. The physician referred to "per intake staff" when documenting the physical exam.

Patient #150 asked to speak to the surveyor. An interview with patient #150 was conducted on afternoon of 11/5/17. Patient #150 reported that she wanted to leave the facility and go in CPS. Patient #150 stated she was afraid they would send her back home to her grandmother's house. Patient #150 reported that her older sister lives there and is very physically abusive and she is afraid of her. Patient #150 showed the surveyor where she cuts herself on her arms for relief of anxiety. Patient #150 was asked if she had shared her concerns and fears with her physician and personnel. Patient #150 stated, "No. I haven't seen a doctor yet. I had some lady nurse come in my room and stand in the doorway. She asked me a few medical questions. She didn't even touch me. I really don't know who she was. That's the only person that even talked to me." The survey asked the patient again if she had talked to the personnel or asked to see the grievance officer and she stated, "yes, I have told the nurses several times that I didn't want to go back to my home and they totally ignored me."

Review of patient #150's chart revealed the treatment team plan was filled out on 11/5/18 with no discharge planning. There was no documentation found concerning patient #150's concerns at discharge, her fears of discharge, or contact with her responsible party.

An interview was conducted with personnel #4, Clinical Services Coordinator on 11/9/18 in the afternoon. Personnel #4 reported the facility was "short staffed" for social workers and discharge planners. Personnel #4 reported there was really no set plan on who followed up with patients at this time. Personnel #4 was unable to give the surveyor any direction on who and how the discharge planning was to be followed.
VIOLATION: DIRECTOR OF RESPIRATORY SERVICES Tag No: A1153
Findings for the Arlington location included:

During a tour of the Arlington facility conducted on 11/6/18 and 11/7/18 accompanied by the Assistant Director of Nurses, Personnel #37, there were 2 oxygen concentrators observed in a storage room on the Psychiatric Intensive Care unit (PICU) that were dusty and without any inspection stickers. Oxygen cylinders were observed on crash carts

An interview with the Assistant Director of Nurses, Personnel #37 was conducted on 11/7/18 at approximately 1430. Personnel #37 was asked who was the medical director over the respiratory care services and she replied "There's not one."

An interview with the facility Medical Director, Personnel #12 was conducted on 11/13/18 at 0940 in the facility conference room. When Personnel #12 was asked who was the director of the respiratory care services at the facility, Personnel #12 stated "The internal medical physicians are over medical services here." Personnel #12 confirmed that there was no appointed respiratory care services medical director that ensured respiratory care services were administered correctly.
VIOLATION: REASSESSMENT OF DISCHARGE PLANNING PROCESS Tag No: A0843
Based on review and interview the discharge planning in the Garland facility has not been reassessed and reviewed in the Quality Assessment Performance Improvement (QAPI) process.

Review of the Process Improvement Committee Agenda dated September 20,2018 revealed there was no documentation concerning the issues with discharge planning and has not been monitored on a on-going basis.

An interview was conducted with personnel #4, Clinical Services Coordinator on 11/9/18 in the afternoon. Personnel #4 reported the facility was "short staffed" for social workers and discharge planners. Personnel #4 reported there was really no set plan on who followed up with patients at this time. Personnel #4 was unable to give the surveyor any direction on who and how the discharge planning was to be followed. Personnel #4 reported they have discussed the issue but was unaware if it was addressed in quality.
VIOLATION: ORGANIZATION OF RESPIRATORY CARE SERVICES Tag No: A1152
Findings included:

During a tour of the Arlington facility conducted on 11/6/18 and 11/7/18 accompanied by the Assistant Director of Nurses, Personnel #37, there were 2 oxygen concentrators observed in a storage room on the Psychiatric Intensive Care unit (PICU) that were dusty and without any inspection stickers. Oxygen cylinders were observed on crash carts

An interview with the Assistant Director of Nurses, Personnel #37 was conducted on 11/7/18 at approximately 1430. Personnel #37 was asked if there was a respiratory care services policy and Personnel #37 stated "There isn't a policy." Personnel #37 was asked what type of respiratory care services the facility provides. Personnel #37 stated the nursing staff administer nebulizer treatments, continuous positive airway pressure (CPAP) therapy, and sometimes oxygen as ordered. Personnel #37 stated "When patients come in requiring neb (nebulizer) treatments or CPAP they physicians write the order and then we order the respiratory supplies from the DME (Durable Medical Equipment) company."

Review of the "Sundance Behavioral Health System Organizational Chart Updated 10/29/18" did not include documentation of a respiratory care service. Review of the facility policies and procedures during the survey revealed no respiratory services policies or procedures. The review of the documents did not reveal a written scope of respiratory services offered by the Arlington facility that had been approved by the Medical staff.

An interview with the facility Medical Director, Personnel #12 was conducted on 11/13/18 at 0940 in the facility conference room. When Personnel #12 was asked if there were written policies for the delivery of respiratory services at the facility that were approved by the medical staff, Personnel #12 stated "I was not aware that policies are required. Personnel #12 acknowledged that there was no written scope of respiratory services that were offered at the Arlington facility that had been approved by the Medical staff.
VIOLATION: RESPIRATORY CARE SERVICES POLICIES Tag No: A1160
Findings for the Arlington location included:

During a tour of the Arlington facility conducted on 11/6/18 and 11/7/18 accompanied by the Assistant Director of Nurses, Personnel #37, there were 2 oxygen concentrators observed in a storage room on the Psychiatric Intensive Care unit (PICU) that were dusty and without any inspection stickers. Oxygen cylinders were observed on crash carts

An interview with the Assistant Director of Nurses, Personnel #37 was conducted on 11/7/18 at approximately 1430. Personnel #37 was asked if there was a respiratory services policy and Personnel #37 stated "There isn't a policy." Personnel #37 was asked what type of respiratory care services the facility provides. Personnel #37 stated the nursing staff administer nebulizer treatments, continuous positive airway pressure (CPAP) therapy, and sometimes oxygen as ordered. Personnel #37 stated "When patients come in requiring neb (nebulizer) treatments or CPAP they physicians write the order and then we order the respiratory supplies from the DME (Durable Medical Equipment) company."

Review of the hospital policies and procedures during the survey revealed no respiratory policies or procedures.

An interview with the facility Medical Director, Personnel #12 was conducted on 11/13/18 at 0940 in the facility conference room. When Personnel #12 was asked if there were written policies for the administration of respiratory services at the facility that were approved by the medical staff, Personnel #12 stated "I was not aware that policies are required."
VIOLATION: RESPIRATORY CARE PERSONNEL POLICIES Tag No: A1161
Findings for the Arlington location included:

During a tour of the Arlington facility conducted on 11/6/18 and 11/7/18 accompanied by the Assistant Director of Nurses, Personnel #37, there were 2 oxygen concentrators observed in a storage room on the Psychiatric Intensive Care unit (PICU) that were dusty and without any inspection stickers. Oxygen cylinders were observed on crash carts

An interview with the Assistant Director of Nurses, Personnel #37 was conducted on 11/7/18 at approximately 1430. Personnel #37 was asked if there was a respiratory services policy and Personnel #37 stated "There isn't a policy." Personnel #37 was asked what type of respiratory care services the facility provides. Personnel #37 stated the nursing staff administer nebulizer treatments, continuous positive airway pressure (CPAP) therapy, and sometimes oxygen as ordered. Personnel #37 stated "When patients come in requiring neb (nebulizer) treatments or CPAP they physicians write the order and then we order the respiratory supplies from the DME (Durable Medical Equipment) company."

Review of the list of nursing training and competencies revealed that there was no specific training or competencies for the delivery of respiratory services to patients that included the care, cleaning and storage of respiratory equipment.