Scott Gordon

Inspectors Found Repeated Violations at Arlington Psychiatric Hospital

Reviews uncovered unsafe, unsanitary conditions at Sundance Hospital

Over the past two years, state inspectors have repeatedly documented unsafe and unsanitary conditions at an Arlington mental health hospital which is under criminal indictment, but the owner has only been fined twice.

The hospital, Sundance Behavioral Health, was charged last month with holding patients against their will.

The company denied the allegations.

Under the Texas open records law, NBC DFW obtained hundreds of pages of inspection reports of the hospital from the Texas Health and Human Services Commission, which licenses private psychiatric facilities.

The records showed inspectors had visited Sundance numerous times, often unannounced.

And time after time, according to their reports, they found examples of inadequate care and substandard conditions.

On Sept. 13, a staff member kicked a patient and it "appeared to be on purpose." The employee was fired.

Just two days later, inspectors faulted staff members for failing to monitor a suicidal patient who was found "without a pulse approximately 90 minutes after the last contact with staff." The patient died. According to the inspection report, a hospital employee acknowledged he had "not made rounds that morning."

In June, a young suicidal patient was allowed access to a razor blade, placed it in his mouth and threatened to swallow it. The same patient later escaped from the hospital and did not return, according to the report.

The reviews documented cases where nurses did not follow doctors' orders and failed repeatedly to monitor patients.

In one case last year, a patient fell and hit her head.

"First assessment of vital signs was nine hours after the patient's fall," the report said. Even though the patient was found to have high blood pressure, "nursing did not reassess vital signs for another 15 hours."

The inspections also found problems with cleanliness at the hospital.

In April, an inspector noticed an 8-inch "smear of brown substance" on the handrails in a lobby restroom. The inspector reported it to a receptionist, but "it was not blocked off to prevent further patients and the public from using it."

The same day, inspectors found "black mold" growing behind a sink in the cafeteria. They also saw an "open package of instant pudding mix sitting next to raw chicken."

Despite repeated violations, the hospital has only paid two fines in the past two years: $28,500 in August 2016 for violations dating to the previous year and $650 in 2017 for not holding required fire drills.

A press officer for the Texas Health and Human Services Commission, Christine Mann, called some of the incidents at the hospital "very disturbing."

She said the agency conducted a two-week "top to bottom" review of Sundance last month. The results are not yet publicly available.

"We expect the facility to make improvements," Mann said. "Every patient has a right to a safe environment."

Attorneys for Sundance declined to comment on the state inspection reports obtained by NBC DFW. 

But in the past, they've called the criminal charges an "unprecedented overreach."

"The allegations, while shocking to those unfamiliar with behavioral health, are not unique to Sundance or mental health facilities and do not fall below the standard of care for mental health facilities," the lawyers said in a statement.

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