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Based on document review and interview, it was determined that for 2 of 6 patients' (Pt. #2 and Pt. #3) clinical records reviewed with moderate to high risk score for developing pressure ulcer in the Intensive Care Unit (ICU), the Hospital failed to document turning/repositioning intervention, to ensure nursing care was supervised and evaluated by a registered nurse.

Findings include:

1. On 12/15/2020, the clinical record of Pt. #2 was reviewed. Pt. #2 was admitted on 12/10/2020, with a diagnosis of acute respiratory failure. The clinical record indicated that Pt. #2's Braden Score (tool used to assess risk for pressure ulcer) on 12/13/2020 and 12/14/2020 was 12 (high risk). The clinical record lacked documentation of turning or repositioning every two hours on 12/14/2020 from 12:00 AM to 7:00 AM.

2. On 12/15/2020, the clinical record of Pt. #3 was reviewed. Pt. #3 was admitted on 11/18/2020, with shortness of breath. The clinical record indicated that Pt. #3's Braden Scores were 13 (moderate risk) and 12 (high risk) respectively on 12/13/2020 and 12/14/2020. The clinical record lacked documentation of turning or repositioning every two hours from 12/13/2020 at 9:00 PM through 12/14/2020 7:00 AM.

3. On 12/17/2020, the Hospital's Job Description for the ICU Staff Nurse (undated) was reviewed and required, "Job Summary: Provide nursing care to patients... Follow policies, procedures and standards... Implement plan of care... Accurately document the patients care... Evaluate and document effectiveness of all interventions as appropriate..."

4. On 12/17/2020, the Hospitals policy titled, "Braden Scale - Pressure Injury Prevention" (revised 3/2020) was reviewed and included, "... Moderate Risk (13-14)... Reposition using turn schedule (turn/reposition every 2 hours or more frequently as needed)... High Risk (10-12)... Turn and reposition every 2 hours or more frequently as needed..."

5. On 12/15/2020 at approximately 11:00 AM, findings were discussed with E #4 (Director, Critical Care). E #4 stated that turning and repositioning should be documented every two hours. E #4 could not provide documentation that turning and repositioning provided for Pt. #2 and Pt. #3.

6. On 12/18/2020, E #1 (Chief Quality Officer) stated that there was no documentation to indicate turning and repositioning were provided to Pt. #2 and Pt. #3.

Based on document review and interview, it was determined that for 2 of 3 patients (Pt. #4 and Pt. #5) clinical records reviewed with orders for intravenous propofol (sedative), the Hospital failed to ensure that the medication was titrated or administered, in accordance with the approved medical policies and procedures.

Findings include:

1. On 12/15/2020, the clinical record of Pt. #4 was reviewed. Pt. #4 was admitted on 12/14/2020, with a diagnosis of status post cardiopulmonary arrest. The clinical record included a physician's order dated 12/14/2020, for continuous intravenous infusion of propofol, with titration parameters of 5 mcg (microgram) per kg (kilogram) every 5 minutes, with a maximum goal of 80 mcg/kg/min(minute). The clinical record lacked documentation that propofol was titrated or administered on 12/15/2020 at 3:00 AM, and from 6:00 AM to 7:00 AM.

2. On 12/15/2020, the clinical record of Pt. #5 was reviewed. Pt. #5 was admitted on 12/4/2020, with a diagnosis of acute respiratory failure. The clinical record included a physician's order dated 12/10/2020, for intravenous infusion of propofol with an hourly rate of 6.31 ml (mililiters) per hour. The clinical record lacked documentation that the medication was titrated or administered on 12/13/2020 from 7:00 AM to 4:00 PM.

3. On 12/17/2020, the Hospital's policy titled "Adult Medication Titration Policy" (revised 7/2020) was reviewed and included, "Purpose: Medicated infusion are frequently prescribed using a drug name and an order to titrate infusion to a specific outcome or clinical endpoint. Titration orders provide the nurse an opportunity to adjust infusions to meet the patient's needs... Policy... 3. Titration includes increasing and decreasing an infusion rate to achieve the endpoint specified by the physician at the most effective and safe dose... Adult Titration Guidelines... Propofol..."

4. On 12/17/2020, the Hospital's Job Description for the ICU(Intensive Care Unit) Staff Nurse (undated) was reviewed and required, "Job Summary: Provide nursing care to patients... Follow policies, procedures and standards... Implement plan of care... Accurately document the patient needs... Document the patient's response to interventions..."

5. On 12/15/2020, findings were discussed with E #4 (Director of Critical Care). E #4 stated that the intravenous order for propofol should be documented every hour. E #4 could not provide documentation if the propofol was titrated or administered.

6. On 12/18/2020, findings were discussed with E #5 (Nurse Educator, ICU). E #5 stated that propofol was ordered as continuous intravenous infusion. E #5 stated that the ICU nurses were educated to document intravenous infusion of propofol every hour. E #5 stated, "If it was not documented, it was not given."

Based on observation, document review, and interview, it was determined that for two of three crash carts (Station #1 and #3) in the Intensive Care Unit (ICU), the Hospital failed to ensure that the crash carts were checked daily, potentially affecting an average of 18-20 patients on the unit.

Findings include:

1. On 12/15/2020, an observational tour of the Hospital's ICU was conducted. During the tour, the daily crash cart log indicated that in Station #1, the crash cart was not checked on 12/3/2020, 12/4/2020, and 12/5/2020. And on 12/13/2020, the crash cart was not checked in Station #3.

2. The Hospital's policy titled, "Crash Cart Supplies and Equipment Policy" (revised 6/2020) was reviewed an included, "... 6. Inspections and functioning of the following items will be conducted and documented each day in patient care areas... a. Oxygen tank; b. Suction equipment... d. Defibrillator..."

3. On 12/15/2020, findings were discussed with E #4 (Director of Critical Care). E #4 stated that the crash carts should have been checked daily. E #4 could not provide documentation that the crash carts were checked.