HospitalInspections.org

Based on record review and staff interview, it was determined that the Registered Nurse failed to ensure compliance with plan of care for repositioning for 1 (#15) of 15 sampled patients. This practice may result in failure to achieve goal of the patient plan of care.



Findings include:

Review of the medical record for patient #15 revealed that the patient was assessed as being at risk for skin breakdown, resulting in the care plan calling for repositioning every two hours. Review of nursing documentation revealed that the nursing staff failed to comply with the plan of care on the following occasions:
11/26/11 6 a.m. - 3 hours between repositioning
11/26/11 9:45 a.m. - 3.75 hours between repositioning
11/26/11 2:30 p.m.- 5 hours between repositioning
11/27/11 12:40 a.m. - 3 hours between repositioning
11/27/11 - 8:27 p.m. - 3 hours between repositioning
12/8/11 - 2:17 p.m. - 6 hours between repositioning
12/9/11 - 1:30 p.m. - 3. 5 hours between repositioning

Based on record review, policy review and staff interview, it was determined the facility failed to ensure medications were administered as ordered by the physician and according to facility protocol for 2 (#14,#15) of 15 sampled patients. This practice does not ensure safe administration of medication.

Findings include:

1. Review of the facility's policy "Propofol Infusion," #H-MM60-011, stated that an order for Propofol drip must include titration parameters including desired level of sedation using the modified Ramsay scale. The results of the Ramsay assessment are to be documented every 2 hours. There is also a matrix, which directs the nurse to change the rate of infusion, based upon the Ramsay scale assessment. It further instructs the nurse to initiate the infusion at 5 micrograms (mcg) per kilogram per minute and to increase the rate by 5 mcg per kilograms per minute every 5 minutes until the level of sedation is achieved.

2. Review of the medical record for patient #14 revealed an order for Propofol Intravenous drip and to titrate to keep patient sedated. Review of Ramsay Sedation Scale flow sheet revealed the nurse started the infusion on 12/7/11 at 5:13 p.m. 20 mcg per kilogram per minute instead of 5 as per policy. The next documentation at 5:45 p.m. revealed that the infusion was at 50 mcg per kilogram per minute. There was no level of sedation documented at this time. There was no evidence that the infusion was increased at 5 mcg per minute every 5 minutes as per policy. There was also no documentation that the physician gave the order to start the infusion at 20 mcg per minute instead of 5.

3. Review of the medical record of patient #15 revealed an order for Propofol 40 mcg per kilogram and to titrate per protocol. Review of the Ramsay Sedation Scale revealed no documentation of sedation level after the infusion was started. Documentation indicated the infusion was discontinued at 8:00 a.m.

4. The nurse manager was present during the review of the records on 12/9/11 and confirmed the above findings.