HospitalInspections.org

The Condition of Participation for Governing Body has not been met.

Based on a clinical record review, staff interviews and a review of hospital documentation for one sampled patient reviewed for the administration and titration of a sedative medication (Patient #17), the governing body failed to ensure that physician's were accountable for the quality of care provided to a patient when a physician's order was not written for the administration of Propofol when a paralytic agent was initiated.

Based on a review of clinical records, staff interviews and a review of hospital documentation for ten of ten patients reviewed for the administration and titration of sedative medications (Patient #15, #16, #17, #20, #22, #23, #24, #25, #26 and #27), the governing body failed to ensure that the hospital's quality assurance and performance improvement (QAPI) program collected data to monitor the effectiveness and safety of services and quality of care related to the safe administration, titration and patient reassessments of titratable sedative medications in the Intensive Care Unit.


Based on a clinical record review, staff interviews, and a review of hospital documentation for ten of ten patients reviewed for the administration and titration of sedative medications (Patient #15, #16, #17, #20, #22, #23, #24, #25, #26 and #27), the governing body failed to ensure that Registered Nurses (RN's) in the Intensive Care Unit (ICU) followed physician's orders for the titration of sedative medications and failed to ensure that nursing reassessments were conducted in accordance with the physician orders.


Based on a tour of the hospital, review of hospital policies, hospital documentation and staff interviews, the governing body failed to ensure that the psychiatric unit including sleeping rooms were maintained in such a manner as to promote the safety and well-being of patients when multiple ligature points were identified resulting in a finding of Immediate Jeopardy.


Please refer to A049, A263, A273, A385, A405, A700 and A701

Based on a clinical record review, staff interviews and a review of hospital documentation for one sampled patient reviewed for the administration and titration of a sedative medication (Patient #17), the governing body failed to ensure that physician's were accountable for the quality of care provided to a patient when a physician's order was not written for the administration of Propofol when a paralytic agent was initiated. The finding included:


Patient #17 was admitted to the hospital on 8/29/17 with vomiting. While hospitalized the patient became hypoxic secondary to aspiration pneumonia that required mechanical ventilation and sedation. A physician's order dated 8/29/17 at 10:30 AM directed Propofol to be administered. Concentration=1,000 mg/100 ml. Infusion dose: 5 mcg/kg/min. Dose to be increased or decreased every 5 minutes by 5 mcg/kg/min. increments unless otherwise specified by the ordering physician to a Ramsey Sedation Scale of 4-5. Maximum dose of 35 mcg/kg/min. A physician's order dated 8/29/17 at 5:09 PM directed Vecuronium 50 milligrams (mg) in 50 ml of 0.9% Sodium Chloride with a loading dose of 0.05mg/kg. Infusion to be administered at 1 mcg/kg/min. The dose may be increased or decreased by 1 mg/hour every hour to a train of four 2/4/twitches unless otherwise specified by the physician. Review of the ICU frequent vital sign flow sheet identified on 8/29/17 at 5:30 PM Propofol was infusing at 35 mcg/kg/min. when Vecuronium was initiated absent a documented Ramsey Score. Interview with the Medical Director of the ICU on 9/7/17 at 2:00 PM indicated when Vecuronium was administered to Patient #17 the Ramsey score would be 6 as the medication was a paralytic agent.


The Medical Director identified new orders for Propofol should have been written and were not as the parameters and titration for Propofol would not apply when Propofol and Vecuronium were administered simultaneously.

The Condition of QAPI has not been met.

Based on a review of clinical records, staff interviews and a review of hospital documentation for ten of ten patients reviewed for the administration and titration of sedative medications (Patient #15, #16, #17, #20, #22, #23, #24, #25, #26 and #27), the hospital's quality assurance and performance improvement (QAPI) program failed to collect data to monitor the effectiveness and safety of services and quality of care related to the administration, titration and patient reassessments in the Intensive Care Unit.


Refer to A 273

Based on a review of clinical records, staff interviews and a review of hospital documentation for ten of ten patients reviewed for the administration and titration of sedative medications (Patient's #15, #16, #17, #23, #24, #25, #26, and #27), the hospital's quality assurance and performance improvement (QAPI) program failed to collect data to monitor the effectiveness and safety of services and quality of care, to ensure compliance with the safe administration of titratable sedative medications. The findings included:


A review of the clinical records of Patient's #15, #16, #17, #23, #24, #25, #26, and #27 was conducted between 9/4/17 and 9/7/17. It was identified that Intensive Care Nurses (ICU) RN's did not follow physician orders for the administration and titration of sedative medications.


During the review of the clinical records of Patient's #15, #16, #17, #23, #24, #25, #26, and #27 it was also identified that nursing staff failed to conduct reassessments of the patients following the administration and titration of sedative medications.


In addition, it was identified that for Patient #17, a physician's order for the administration of Propofol was not obtained when a paralytic agent was initiated.


Review of Quality Assurance and Performance Improvement Committee Minute Meetings dated January 2016 through June of 2017 failed to identify that the titration and/or administration of sedative medications were reviewed as a quality indicator.


Interview with the Director of Quality on 9/7/17 at 1:10 PM indicated he/she did not know why titratable medications were not tracked and monitored to ensure safe practice. However, the Director of Quality identified that subsequent to surveyor inquiry, titratable medications would be reviewed as a part of the Quality Program.


Review of the Intensive Care Meeting Minutes from January of 2016 through June of 2017 with the Director of Patient Services on 9/7/17 at 1:30 PM failed to identify that titratable sedative medications were monitored to ensure they were administered in accordance with physician's orders. The Director of Patient Services identified she did not conduct formal audits to ensure titratable medications were administered in accordance with physician's orders and/or that reassessments were completed timely. The Director of Patient Services indicated she intermittently reviewed a record and if she noted a problem with titration she remediated the problem with the individual staff member immediately.


Interview with the Director of Nursing on 9/7/17 at 1:00 PM indicated she did not know why the administration of titratable sedatives were not tracked and/or monitored to ensure compliance.



The hospital developed an immediate action plan dated 9/6/17 that included measures to ensure that the administration, titration, and patient assessments related to sedative medications were conducted in accordance with physician orders and in accordance with standards of care.

The Condition of Participation for Nursing services has not been met.

Based on a clinical record review, staff interviews, and a review of hospital documentation for ten of ten patients reviewed for the administration and titration of sedative medications (Patient #15, #16, #17, #20, #22, #23, #24, #25, #26 and #27), the hospital failed to ensure that Registered Nurses (RN's) in the Intensive Care Unit (ICU) followed physician's orders for the titration of sedative medications and failed to ensure that nursing reassessments were conducted in accordance with the physician orders.

Please refer to A395 and A405

Based on clinical record reviews, staff interviews and a review of hospital documentation for ten of ten patients reviewed for the administration and titration of a sedative medication (Patient's #15, #16, #17, #20, #22, #23, #24, #25, #26 and #27), the hospital failed to ensure that nursing reassessments were conducted in accordance with the physician orders. The findings included:


a. Patient #15 was admitted to the hospital on 8/24/17 after he/she was found unresponsive with agonal breathing in a skilled nursing facility and required mechanical ventilation. A physician order dated 8/24/17 at 2:45 PM directed Propofol to be administered. Concentration=1,000 mg/100 ml. Infusion dose: 5 mcg/kg/min. Dose to be increased or decreased every 5 minutes by 5 mcg/kg/min. increments unless otherwise specified by the ordering physician to a Ramsey Sedation Scale of 3-4. Maximum dose of 100 mcg/kg/min. Review of the ICU frequent vital sign flow sheet identified on 8/24/17 at 8:00 PM the Ramsey score was 4 with Propofol infusing at 15 mcg/kg/min. At 11:30 PM the Ramsey score continued to be 4 and Propofol was increased to 20mcg/kg/min. A subsequent Ramsey score was conducted on 8/25/17 at 12:00 AM, thirty minutes after the titration. A reassessment was not conducted subsequent to a titration change every five minutes in accordance with the physician's order.


b. Patient #16 was admitted to the hospital on 8/26/17 with ulcerating erosive esophagitis suspicious for bleeding who experienced respiratory hypoxic failure that required mechanical ventilation and sedation. A physician order dated 8/27/17 at 1:15 AM directed Propofol to be administered. Concentration=1,000 milligrams (mg)/100 milliliter (ml). Infusion dose: 5 mcg/kg/min. Dose to be increased or decreased every 5 minutes by 5 mcg/kg/min. increments unless otherwise specified by the ordering physician to a Ramsey Sedation Scale of 3-4. Maximum dose of 100 mcg/kg/min. Review of the ICU frequent vital sign flow sheet identified on 8/27/17 at 1:15 AM, 1:25 AM, 1:30 AM, 2:15 AM, 3:30 AM, 4:45 AM, 5:45 AM and at 6:00 AM the Ramsey score was 1. Propofol was infusing at 5 mcg/kg/min at 1:15 AM AM and increased by 5mcg/kg/min every 5 minutes to one hour instead of every 5 minutes as identified in the order without the benefit of the intended sedation level. A reassessment was not conducted every five minutes in accordance with the physician's order.



c. Patient #17 was admitted to the hospital on 8/29/17 with vomiting. While hospitalized the patient became hypoxic secondary to aspiration pneumonia that required mechanical ventilation and sedation. A physician's order dated 8/29/17 at 10:30 AM directed Propofol to be administered. Concentration=1,000 mg/100 ml. Infusion dose: 5
mcg/kg/min. Dose to be increased or decreased every 5 minutes by 5 mcg/kg/min. increments unless otherwise specified by the ordering physician to a Ramsey Sedation Scale of 3-4. Maximum dose of 35 mcg/kg/min. Review of the ICU frequent vital sign flow sheet identified on 8/29/17 at 10:30 AM Propofol was initiated at 5 mcg/kg/min with a Ramsey score of 1. At 10:35 AM Propofol was increased to 10mcg/kg/min with a Ramsey score of 1. At 10:40 AM Propofol was increased to 20 mcg/kg/min and at 11:00 AM Propofol was increased to 30 mcg/kg/min. At 10:40 AM and at 11:00 AM a Ramsey score was not completed. A reassessment was not conducted every five minutes in accordance with the physician's order.


d. Patient #20 was admitted to the hospital on 8/5/17 with a history of chronic obstructive pulmonary disease in respiratory failure requiring mechanical ventilation and sedation. A physician order dated 8/6/17 at 10:02 AM. A physician's order dated 8/29/17 at 10:30 AM directed Propofol to be administered. Concentration=1,000 mg/100 ml. Infusion dose: 5 mcg/kg/min. Dose to be increased or decreased every 5 minutes by 5 mcg/kg/min. increments unless otherwise specified by the ordering physician to a Ramsey Sedation Scale of 3-4. Maximum dose of 100 mcg/kg/min. Review of the ICU frequent vital sign flow sheet dated 8/6/17 at 10:15 AM identified Propofol was infusing at 5mcg/kg/min with a Ramsey score of 4. At 10:25 AM Propofol was increased to 10 mcg/kg/min due to Ramsey score of 1. A subsequent Ramsey score was not conducted until 1:00 PM, two hours and 25 minutes after a titration change was made. A reassessment was not conducted every five minutes in accordance with the physician's order.



e. Patient #22 was admitted to the hospital on 8/9/17 with a change in mental status. The patient was found to have pneumonia and required mechanical ventilation and sedation. A physician's order dated 8/9/17 at 12:35 PM directed Propofol to be administered. Concentration=1,000 mg/100 ml. Infusion dose: 5 mcg/kg/min. Dose to be increased or decreased every 5 minutes by 5 mcg/kg/min. increments unless otherwise specified by the ordering physician to a Ramsey Sedation Scale of 3-4. Maximum dose of 35 mcg/kg/min. Review of the ICU frequent vital sign flow sheet identified on 8/9/17 from 3:05 PM through 7:45 PM Propofol was infusing at 5mcg/kg/min absent Ramsey scores. At 8:00 PM, 4 hours and 55 minutes later a Ramsey score was documented as 6. A reassessment was not conducted every 5 minutes in accordance with the physician's order.



f. Patient #23 was transferred to the hospital on 7/18/17 after he/she was mechanically ventilated for respiratory distress. A physician's order dated 7/18/17 at 4:20 PM directed Propofol to be administered. Concentration=1,000 mg/100 ml. Infusion dose: 5 micrograms mcg/kg/min. Dose to be increased or decreased every 5 minutes by 5 mcg/kg/min. increments unless otherwise specified by the ordering physician to a Ramsey Sedation Scale of 3-4. Maximum dose of 100 mcg/kg/min. Review of the ICU frequent vital sign flow sheet identified on 7/18/17 at 5:00 PM Propofol was infusing at 40 mcg/kg/min with a Ramsey score of 1. At 5:30 PM Propofol was titrated to 35 mcg/kg/min with a Ramsey score of 1 and at 6:00 PM a titration change was not made however the Ramsey score remained a 1. A reassessment was not conducted every five minutes in accordance with the physician's order when a titration change was made.


g. Patient #24 was admitted to the hospital on 8/6/17 with pneumonia and was mechanically ventilated and sedated. A physician's order dated 8/9/17 at 5:05 PM directed Propofol to be administered. Concentration=1,000 mg/100 ml. Infusion dose: 5 mcg/kg/min. Dose to be increased or decreased every 5 minutes by 5 mcg/kg/min. increments unless otherwise specified by the ordering physician to a Ramsey Sedation Scale of 3-4. Maximum dose of 100 mcg/kg/min. Review of the ICU frequent vital sign flow sheet identified on 8/9/17 at 8:15 PM Propofol was infusing at 5 mcg/kg/min with a Ramsey score of 2. At 8:30 PM a Ramsey score of 1 was noted and Propofol was increased to 10 mcg/kg/min. At 10:15 PM a Ramsey score of 3 was identified and Propofol was decreased to 5 mcg/kg/min. A reassessment was not conducted every five minutes in accordance with the physician's order when a titration change was made.


h. Patient #25 was admitted to the hospital on 7/26/17 status post laparotomy the patient was unable to be extubated and admitted to the ICU. A physician's order dated 7/26/17 at 5:45 PM directed Propofol to be administered. Concentration=1,000 mg/100 ml. Infusion dose: 5 mcg/kg/min. Dose to be increased or decreased every 5 minutes by 5 mcg/kg/min. increments unless otherwise specified by the ordering physician to a Ramsey Sedation Scale of 3-4. Maximum dose of 100 mcg/kg/min. Review of the ICU frequent vital sign flow sheet identified on 8/26/17 at 5:30 PM Propofol was infusing at 5 mcg/kg/min with a Ramsey score of 1. At 5:45 PM Propofol was increased to 10 mcg/kg/min with a Ramsey score of 1 and at 6:00 PM Propofol was increased to 15 mcg/kg/min with a Ramsey score of 1. A subsequent Ramsey score was conducted two hours later at 8:00 PM with a score of 3. A reassessment was not conducted every five minutes in accordance with the physician's order when a titration change was made.


i. Patient #26 was admitted to the hospital on 7/22/17 experienced respiratory arrest likely due to aspiration pneumonia that required mechanical ventilation and sedation. A physician's order dated 7/31/17 at 1:40 PM directed Propofol to be administered. Concentration=1,000 mg/100 ml. Infusion dose: 5 mcg/kg/min. Dose to be increased or decreased every 5 minutes by 5 mcg/kg/min. increments unless otherwise specified by the ordering physician to a Ramsey Sedation Scale of 3-4. Maximum dose of 35 mcg/kg/min. Review of the ICU frequent vital sign flow sheet identified on 7/31/17 at 4:00 PM, Propofol was infusing at 5 mcg/kg/min. with a Ramsey score of 5. Propofol continued to infuse at 5 mcg/kg/min at 5:00 PM, 5:05 PM, 5:50 PM, 5:53 PM, 7:45 PM absent a Ramsey score until 8:00 PM, four hours later. A reassessment was not conducted every five minutes in accordance with the physician's order when a titration change was made.


j. Patient #27 was admitted to the hospital on 7/27/17 with a history of advanced chronic obstructive pulmonary disease who experienced respiratory distress and required mechanical ventilation and sedation. A physician's order dated 8/4/17 at 11:35 AM directed Propofol to be administered. Concentration=1,000 mg/100 ml. Infusion dose: 5 mcg/kg/min. Dose to be increased or decreased every 5 minutes by 5 mcg/kg/min. increments unless otherwise specified by the ordering physician to a Ramsey Sedation Scale of 3-4. Maximum dose of 35 mcg/kg/min. Review of the ICU frequent vital sign flow sheet identified on 8/4/17 at 12:30 PM Propofol was infusing at 5 mcg/kg/min with a Ramsey score of 1. At 2:30 PM Propofol was increased to 10 mcg/kg/min. with a Ramsey score of 1. A subsequent Ramsey score was not conducted until 8:00 PM, 5 hours and 30 minutes after a titration change was made. A reassessment was not conducted every five minutes in accordance with the physician's order when a titration change was made.

Based on clinical record reviews, staff interviews and a review of facility documentation for eight of ten patients reviewed for the administration and titration of a sedative medication (Patient's # 15, #16, #17, #23, #24, #25, #26, and #27), the hospital failed to ensure that Intensive Care Nurses (ICU RN's) followed physician orders. The findings included:



a. Patient #15 was admitted to the hospital on 8/24/17 after he/she was found unresponsive with agonal breathing in a skilled nursing facility and ultimately required mechanical ventilation and sedation. A physician order dated 8/24/17 at 2:45 PM directed Propofol to be administered. Concentration=1,000 milligrams (mg)/100 milliliter (ml). Infusion dose: 5 micrograms (mcg)/ kilogram (kg)/minute (min). Dose to be increased or decreased every 5 minutes by 5 mcg/kg/min. increments unless otherwise specified by the ordering physician to a Ramsey Sedation Scale of 3-4. Maximum dose of 100 mcg/kg/min. Review of the ICU frequent vital sign flow sheet identified on 8/24/17 at 8:00 PM the Ramsey score was 4 with Propofol infusing at 15 mcg/kg/min. At 11:30 PM the Ramsey score continued to be 4 and Propofol was increased to 20mcg/kg/min when the Ramsey score was within the defined parameters of the order. The Propofol infusion was not administered in accordance with the physician's order.



b. Patient #16 was admitted to the hospital on 8/26/17 with ulcerating erosive esophagitis suspicious for bleeding who experienced respiratory hypoxic failure that required mechanical ventilation and sedation. A physician order dated 8/27/17 at 1:15 AM directed Propofol to be administered. Concentration=1,000 mg/100 ml. Infusion dose: 5 mcg/kg/min. Dose to be increased or decreased every 5 minutes by 5 mcg/kg/min. increments unless otherwise specified by the ordering physician to a Ramsey Sedation Scale of 3-4. Maximum dose of 100 mcg/kg/min. Review of the ICU frequent vital sign flow sheet identified on 8/27/17 at 1:15 AM, 1:25 AM, 1:30 AM, 2:15 AM, 3:30 AM, 4:45 AM, 5:45 AM and at 6:00 AM the Ramsey score was 1. Propofol was infusing at 5 mcg/kg/min at 1:15 AM AM and increased by 5mcg/kg/min every 5 minutes to one hour instead of every 5 minutes as identified in the order without the benefit of the intended sedation level. The Propofol infusion was not titrated every five minutes to the Ramsey parameter directed by the physician's order.



c. Patient #17 was admitted to the hospital on 8/29/17 with vomiting and gastrointestinal complaints. While hospitalized the patient became hypoxic secondary to aspiration pneumonia that required mechanical ventilation and sedation. A physician's order dated 8/29/17 at 10:30 AM directed Propofol to be administered. Concentration=1,000 mg/100 ml. Infusion dose: 5 mcg/kg/min. Dose to be increased or decreased every 5 minutes by 5 mcg/kg/min. increments unless otherwise specified by the ordering physician to a Ramsey Sedation Scale of 3-4. Maximum dose of 35 mcg/kg/min. Review of the ICU frequent vital sign flow sheet identified on 8/29/17 at 10:30 AM Propofol was initiated at 5 mcg/kg/min with a Ramsey score of 1. At 10:35 AM Propofol was increased to 10mcg/kg/min and the Ramsey score remained 1. At 10:40 AM Propofol was increased to 20 mcg/kg/min and at 11:00 AM Propofol was increased to 30 mcg/kg/min. At both 10:40 AM and 11:00 AM a Ramsey score was not documented. The Propofol infusion was not titrated every five minutes and/or in 5 mcg/kg/min increments and/or absent a consistent Ramsey score in accordance with the physician's order.



d. Patient #23 was transferred to the hospital on 7/18/17 after he/she was mechanically ventilated for respiratory distress. A physician's order dated 7/18/17 at 4:20 PM directed Propofol to be administered. Concentration=1,000 mg/100 ml. Infusion dose: 5 mcg/kg/min. Dose to be increased or decreased every 5 minutes by 5 mcg/kg/min. increments unless otherwise specified by the ordering physician to a Ramsey Sedation Scale of 3-4. Maximum dose of 100 mcg/kg/min. Review of the ICU frequent vital sign flow sheet identified on 7/18/17 at 5:00 PM Propofol was infusing at 40 mcg/kg/min with a Ramsey score of 1. At 5:30 PM Propofol was titrated to 35 mcg/kg/min with a Ramsey score of 1 and at 6:00 PM a titration change was not made however the Ramsey score remained a 1. The Propofol infusion was not titrated to the Ramsey parameter directed by the physician's order.



e. Patient #24 was admitted to the hospital on 8/6/17 with pneumonia and was mechanically ventilated and sedated. A physician's order dated 8/9/17 at 5:05 PM directed Propofol to be administered. Concentration=1,000 mg/100 ml. Infusion dose: 5 mcg/kg/min. Dose to be increased or decreased every 5 minutes by 5 mcg/kg/min. increments unless otherwise specified by the ordering physician. Maximum dose of 100 mcg/kg/min. Sedation level by a Ramsey Scale of 3-4. Review of the ICU frequent vital sign flow sheet identified on 8/9/17 at 8:15 PM Propofol was infusing at 5 mcg/kg/min with a Ramsey score of 2. At 8:30 PM a Ramsey score of 1 was noted and Propofol was increased to 10 mcg/kg/min. At 10:15 PM a Ramsey score of 3 was identified and Propofol was decreased to 5 mcg/kg/min. The Propofol infusion was not titrated in accordance with the physician's order.


f. Patient #25 was admitted to the hospital on 7/26/17 status post laparotomy the patient was unable to be extubated and admitted to the ICU. A physician's order dated 7/26/17 at 5:45 PM directed Propofol to be administered. Concentration=1,000 mg/100 ml. Infusion dose: 5 mcg/kg/min. Dose to be increased or decreased every 5 minutes by 5 mcg/kg/min. increments unless otherwise specified by the ordering physician to a Ramsey Sedation Scale of 3-4. Maximum dose of 100 mcg/kg/min. Review of the ICU frequent vital sign flow sheet identified 8/26/17 at 5:30 PM Propofol was infusing at 5 mcg/kg/min with a Ramsey score of 1. At 5:45 PM Propofol was increased to 10 mcg/kg/min with a Ramsey score of 1 and at 6:00 PM Propofol was increased to 15 mcg/kg/min with a Ramsey score of 1. A subsequent Ramsey score was conducted at 8:00 PM with a Ramsey score of 3. The Propofol infusion was not titrated every five minutes and/or in 5 mcg/kg/min increments and/or was not titrated to the Ramsey parameter directed by the physician's order.



g. Patient #26 was admitted to the hospital on 7/22/17 experienced respiratory arrest likely due to aspiration pneumonia that required mechanical ventilation and sedation. A physician's order dated 7/31/17 at 1:40 PM directed Propofol to be administered. Concentration=1,000 mg/100 ml. Infusion dose: 5 mcg/kg/min. Dose to be increased or decreased every 5 minutes by 5 mcg/kg/min. increments unless otherwise specified by the ordering physician to a Ramsey Sedation Scale of 3-4. Maximum dose of 35 mcg/kg/min. Review of the ICU frequent vital sign flow sheet identified on 7/31/17 at 4:00 PM, Propofol was infusing at 5 mcg/kg/min. with a Ramsey score of 5. Propofol continued to infuse at 5 mcg/kg/min at 5:00 PM, 5:05 PM, 5:50 PM, 5:53 PM, 7:45 PM absent a Ramsey score. The Propofol infusion was not titrated to the Ramsey parameter directed by the physician's order and the record failed to reflect additional orders as the Ramsey score was above the intended parameter with a dose that could not be decreased.



h. Patient #27 was admitted to the hospital on 7/27/17 with an advanced history of chronic obstructive pulmonary disease who experienced respiratory distress and required mechanical ventilation and sedation. A physician's order dated 8/4/17 at 11:35 AM directed Propofol to be administered. Concentration=1,000 mg/100 ml. Infusion dose: 5 mcg/kg/min. Dose to be increased or decreased every 5 minutes by 5 mcg/kg/min. increments unless otherwise specified by the ordering physician to a Ramsey Scale of 3-4. Maximum dose of 35 mcg/kg/min. Review of the ICU frequent vital sign flow sheet identified on 8/4/17 at 12:30 PM Propofol was infusing at 5 mcg/kg/min with a Ramsey score of 1. At 2:30 PM Propofol was increased to 10 mcg/kg/min. with a Ramsey score of 1. The Propofol infusion was not titrated every five minutes and/or in 5 mcg/kg/min increments and/or was not titrated to the Ramsey parameter directed by the physician's order.


Interview with the Director of Patient Services on 9/6/17 at 1:00 PM identified the hospital followed the Lippincott, 2017 procedure for the administration of intravenous Propofol that directed in part when titrating the dose, leave an adequate interval (3 to 5 minutes) between dose adjustments to allow for clinical effects. The procedure also directed to document changes made to the infusion rate based on the patient's clinical condition. The Director of Patient Services indicated the Propofol procedure did not identify a frequency of assessments and/or reassessments when titrating Propofol. The Director of Patient Services identified she expected the nurses to follow the physician's orders when titrating Propofol in include assessments every five minutes during titration and once the Ramsey score parameter was achieved an hourly documentation of the Propofol dose with a corresponding Ramsey score.

Further interview with the Director of Patient Services on 9/7/17 at 1:30 PM identified she did not conduct formal audits to ensure titratable medications were administered in accordance with physician's orders and/or that reassessments were completed timely. The Director of Patient Services indicated she intermittently reviewed a record and if she noted a problem with titration she remediated the problem with the individual staff member immediately.




An immediate action plan dated 9/6/17 directed titration of medications to be completed in accordance with a current documented order. Any modifications to the orders must be in writing by a licensed provider. Ramsey scores would be assessed and documented on the frequent vital sign sheet every 5 minutes following all rate adjustments until the desired Ramsey was achieved. Ramsey scores would be assessed regardless of titration at least hourly. If a patient was receiving medications with conflicting targets for sedation, the RN and licensed provider would review the patients' needs and a written order must be documented to reflect the desired patient sedation goal. Communication would be provided to all staff prior to the beginning of each shift during the huddle and beginning on 9/7/17, a daily audit would be conducted to confirm adherence to provider orders for titration.

The Condition of Participation for the Physical Environment has not been met.

Based on a tour of the hospital, review of hospital policies, hospital documentation and staff interviews, the hospital failed to ensure that the psychiatric unit including sleeping rooms were maintained in such a manner as to promote the safety and well-being of patients when multiple ligature points were identified resulting in a finding of Immediate Jeopardy.


Please see A701

Based on a tour of the hospital, review of hospital policies, hospital documentation and staff interviews, the hospital failed to ensure that the psychiatric unit including sleeping rooms were maintained in such a manner as to promote the safety and well-being of patients when multiple ligature points were identified resulting in a finding of Immediate Jeopardy. The findings include:


On 09/05/17 at 10:00 AM and various times throughout the day, tours of the 7th floor adult psychiatric unit were conducted with the Quality Coordinator, Nurse Manager and/or unit staff and the following was observed:


a. The bathroom shower heads in patient rooms throughout the unit were not ligature resistant. An undated unit risk assessment document identified that the shower heads were assessed by hospital staff as a category 5 (1 = minor risk, 5 = catastrophic risk). The document identified an action plan to "replace ASAP". Interviews on 9/5/17 with the President/CEO at 11:30 AM, the VP of Operations at 11:45 AM and the Director of Quality at 12:55 PM identified that the psychiatric unit risk assessment was probably conducted in July 2017. Additional interviews with the Director of Facilities and Support Services and the Nursing Director of the unit indicated that they were aware that the shower heads were identified as a risk and that as of 7/5/17, the shower heads had not been replaced and no other remedies or mitigation steps had been instituted.


b. The unit contained two small corridors to medical offices and staff bathrooms that couldn't be readily observed by staff. The hallway contained door handles, door hinges, and door closer's with arms that posed a potential hanging hazard (ligature point) and were not designed to a psychiatric/ institutional standard. Review of the unit risk assessment document identified that multiple door handles, door hinges, and door closures posed a risk of a category 4 or 5 (1 = minor risk, 5 = catastrophic risk). However, as of 9/5/17, the door handles, door hinges, and door closures had not been replaced and no other remedies or mitigation steps had been instituted.

c. Observations made on the psychiatric unit identified that a paper towel dispenser lock was missing in the patient bathroom in room 720 creating an area that could be used as a ligature point. Subsequent to this observation the bathroom was locked and staff identified that the patient bedroom would not be utilized until the paper towel dispenser was repaired.


d. Observations made on the psychiatric in-patient unit and in the psychiatric treatment area of the emergency department identified hard plastic soap dispensers used throughout the areas that were not designed for use in a psychiatric/ institutional standard.


d. Additional review of the undated unit risk assessment document identified 25 areas of concern that had a risk factor of 5 (1 = minor risk, 5 = catastrophic risk) with no identified action plan or other mitigation steps identified or instituted.



The hospital policy for the environment of care surveillance rounds identified that (staff) were to continuously monitor environmental conditions that would impact patient safety, all findings would be reported to management, and department managers would correct the deficiencies.