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Based on interview and record review, the hospital failed to ensure three of 31 sampled patients (Patients 1, 4, and 21 ) were fully informed of their rights as patients in the hospital when the Conditions of Admission and Patient Rights Acknowledgement forms were not fully completed for the patients. This failure created the risk of the patients not being informed about their rights.

Findings:

Review of the hospital's P&P titled Patient Registration/Admission Forms reviewed 5/17 showed the following:

* This policy will review the documents that will require signatures by patients, or designee and the registration/admission representative. The documents or forms include the Conditions of Admission (COA), Patient Rights Acknowledgement, and An Important Message from Medicare about Your Rights. In the event that the patient is unable to sign as a result of the patient's medical condition, the admitting or registration representative must indicate the reason. Follow up by the admitting staff will occur frequently during the patient's hospital confinement to secure signature, and ensure that the patient had copies of all signed documents.

* By signing the Condition of Admission, the patient or the patient's legal representative certified that they have read and received a copy of this document.

* The Patient Rights Acknowledgement serves as an acknowledgement of patient rights information and the receipt of several other patient education and patient information document.

* The Admitting/Registration representative must review An Important Message from Medicare about Your Rights form with the patient and will secure the patient's signature and date indicating that the patient has received this notice and that they understand their rights as outlined within this notice.

1. On 1/29/19 at 1400 hours, an interview and concurrent review of Patient 4's medical record was conducted with the CNO and Application Analyst.

Patient 4's medical record showed the patient came to the ED on 1/26/19 at 1059 hours, admitted to the hospital on 1/26/19 at 1558 hours, and discharged on 1/28/19 at 1820 hours.

Review of the Conditions of Admission showed there was no signature obtained from Patient 4 or the patient's representative to indicate the patient or the patient's representative had read and understood the terms and conditions of the services as required. Further review showed the form was signed by the hospital staff as the witness on 1/26/19 at 1134 hours, with a notation showing Patient 4 was "unable to sign: due to medical condition."

Review of the Patient Rights Acknowledgement showed there was no signature obtained from Patient 4 or the patient's representative to show the patient acknowledged the patient had been provided the required education materials and healthcare directive information. Further review showed the hospital staff signed the form on 1/26/19 at 1134 hours, with a notation showing the patient was "unable to sign due to shortness of breath."

However, review of the ED Provider Notes dated 1/26/19 at 1153 hours, showed Patient 4 came to the ED with a complaint of shortness of breath and increased fatigue. The section of ROS (Review of System) showed the patient had negative for cough and shortness of breath. The patient was awake, alert, and oriented. The patient had normal speech. The patient's respiratory rate was normal and had no respiratory distress. At 1201 hour, the patient was well-appearing and talkative, had no distress, and had some mild right flank pain.

Review of the H&P dated 1/26/19 at 1709 hours, showed Patient 4 was alert and oriented. The patient had no distress.

The CNO confirmed the above forms were not completed for Patient 4 as required.

2. On 1/28/19 at 1350 hours, an interview and concurrent review of Patient 1's medical record was conducted with the CNO, PI Coordinator, and ICU/CCU Director.

Patient 1's medical record showed the patient was admitted to the hospital on 1/22/19 at 0228 hours.

Review of the H&P examination dated 1/22/19 at 0554 hours, showed Patient 1 had altered mental status and had a family member as the patient's DPOA.

Review of the Conditions of Admission signed by the hospital staff on 1/22/19 at 0318 hours, showed the section of "PATIENT/PARENT/CONSERVATOR/GUARDIAN PARTY" showing the patient was unable to sign.

Review of the Patient Rights Acknowledgement signed by the hospital staff on 1/22/19 at 0319 hours, showed the section of "Signature of Patient/Patient's Representative" showing the patient was unable to sign.

The above forms did not show a signature from Patient 1's DPOA was obtained.

The CNO, PI Coordinator, and ICU/CCU Director confirmed the above forms were not completed for Patient 1.


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3. The medical record for Patient 21 was reviewed on 1/30/19. Patient 21's medical record showed the patient was presented to the ED on 1/24/19 at 0939 hours.

The ED Provider Notes dated 1/24/19 at 0939 hours, showed Patient 21's mood, affect, awareness, and insight were normal. The patient was awake and oriented times four. The form also showed the history was obtained from the patient.

Review of the nursing assessment notes showed the following:

* On 1/24/19 at 1023 hours, Patient 21's cognition was WDL (Within Defined Limits).
* On 1/25/19 at 0725 hours, the patient was alert and oriented times three.
* On 1/26/19 at 0800 hours, on 1/27/19 at 0800 hours and on 1/28/19 at 0740 hours, the patient was alert and oriented times four.

However, there was no documented evidence to show Patient 21 or the patient's responsible party had signed the Condition of Admission until 1/30/19 at 1230 hours, or six days later.

During an interview on 1/30/19 at 1440 hours, the PI Coordinator acknowledged the Condition of Admission was not signed by Patient 21 or the patient's responsible party upon admission or until 1/30/19.

Based on interview and record review, the hospital failed to ensure the informed consents for admission and use of psychotropic medications were fully completed for two of 31 sampled patients (Patients 14 and 25) as per the hospital's P&P. This created the risk of the patients not being fully informed about the treatment plans and possible side effects from the use of psychotropic medications.

Findings:

1. Review of the hospital's P&P titled Informed Consent for Psychotropic Medications reviewed date 6/18 showed the following:

- Upon admission or the introduction of psychotropic medication, the prescribing physician will give the patient information regarding the medication.

- The psychiatrist will present the drug treatment information to the patients for the purpose of obtaining informed consent.

- The patient, psychiatrist, and witness will sign the consent form.

On 1/30/19 at 1456 hours, an interview and concurrent medical record review for Patient 25 was conducted with the RN A. Patient 25 was admitted to the hospital on 1/18/19.

Review of the Psychotropic Medication Consent dated 1/18/19 at 1320 hours, showed signatures in the sections of "PATIENT SIGNATURE/LEGAL GUARDIAN" and "WITNESS SIGNATURE." However, the sections of psychiatrist/physician signature, date/time were left blank.

RN A verified the finding.

2. Review of the hospital's P&P titled Consents: Decision-Making Requirements for Medical Treatment/Informed Consent revised 5/17 showed the following:

* Patient is presumed to have and able to make decision until the contrary is determined.

* The section of adults with impaired capacity/lack capacity showed

-The attending/primary physician has initial responsibility for determining the patient's capacity to make healthcare decisions.

- This decision is reached independently of whether or not the patient is refusing or consenting to treatment. Concern regarding the capacity evaluation are referred to the hospital's ethics Committee for consultation.

- Consent may be provided with or on behalf of the patient by alternative/surrogate decision maker(s) according to a continuum of decision making capacity and based on how the patient would have made the decision if capable.

On 1/30/19 at 1025 hours, an interview and concurrent medical record review for Patient 14 was conducted with the Behavior Health Director.

Patient 14's medical record showed the patient was admitted to the hospital on 1/24/19. The patient had a family member as the emergency contact person.

Review of the Voluntary Admission to Behavioral Health dated 1/24/19 at 1510 hours, showed two licensed staff signed the form as the witnesses. The section of patient or LPS conservator signature showed the patient verbalized "yes" but was unable to sign. The section of Certificate of Attending Physician (no date/time documented) showed the physician signed the area of physician's signature indicating the physician had examined the patient; and based on that examination, it was the physician's opinion that the patient understood the nature of the admission and the care and treatment to be rendered and the patient was mentally competent at the time of the examination to make this application for admission.

However, review of the H&P examination dated 1/24/19 at 1825 hours, showed Patient 14 had a history of dementia, was minimally verbal at baseline and nonsensical rambling speech.

Review of the psychiatry note dictated on 1/26/19 at 0404 hours, showed Patient 14 had confusion and disorganized thought process.

Review of the Psychotropic Medication Consent dated 1/24/19, Authorization for Use or Disclosure of Health Information dated 1/24/19, Seclusion/Restraint Advisement dated 1/24/19, and An Important Message from Medicare about Your Rights dated 1/24/19, showed Patient 14 was unable to sign and agitated.

Review of the Consent to Acknowledge Presence in Hospital Or Request for Non-Disclosure of Presence dated 1/24/19, Consent to Release information dated 1/24/19, Behavior Health Program Patient and Family Confidentiality Statement dated 1/24/19, and Behavioral Health Restraint Philosophy dated 1/24/19, showed Patient 14 was unable to sign.

The above forms failed to show the signature from Patient 14's family member was obtained when the patient was unable to sign these forms.

The Behavior Health Director verified the findings.

Based on observation, interview, and record review, the hospital failed to ensure the care plans were developed to address the use of restraints for three of 31 sampled patients (Patients 5, 6, and 14). This failure posed the potential for substandard healthcare outcomes to the patients in the hospital.

Findings:

Review of the hospital's P&P titled Restraints: Non-Violent Behavior reviewed on 5/17 showed the use of restraint is in accordance with a written modification to the patient's plan of care.

1. Review of Patient 5's medical record was initiated on 1/29/19. The patient was admitted to the hospital on 1/21/19.

Review of the Flowsheets for restraint showed the following:

* On 1/22/19 at 0800 hours, bilateral soft wrist restraints were applied on Patient 5 for pulling on tubes. The patient was restrained on the right and left wrists on 1/22/19 at 1000, 1200, 1400, 1600, 1800, 2000, 2200 hours, and on 1/23/19 at 0000 hours.

* The bilateral soft wrist restraints were reapplied on Patient 5 on 1/27/19. The patient was restrained on the right and left wrists on 1/27/19 at 2000 and 2200 hours; on 1/28/19 at 0000, 0200, 0400, 0600, 1000, 1200, 1400, 1600, 1800, 2000, and 2200 hours; and on 1/29/19 at 0000 and 0200 hours.

However, further review of Patient 5's medical record failed to show a care plan was developed to address the use of the bilateral soft wrist restraints when Patient 5 was restrained on 1/22, 1/27, and 1/28/19.

During an interview and concurrent review of Patient 5's medical record with the PI Coordinator on 1/29/19 at 1520 hours, the PI Coordinator confirmed the finding.


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2. On 1/29/19 at 1400 hours, an interview and concurrent review of Patient 6's medical record was conducted with RN A. Patient 6 was admitted to the hospital on 1/26/19. A posey vest restraint had been ordered and applied to the patient on 1/26 and 1/28/19.

Review of Patient 6's plan of care showed a care plan problem dated 1/26/19, to address the risk for fall. The plan of care did not show the plan of care was updated when the physician ordered for the use of the posey vest restraints.

RN A was asked to show a care plan addressing the use of the posey vest. RN A was unable to find the plan of care to address the use of the posey vest restraints. When asked for the reason why the posey vest restraint was applied to Patient 6, the RN stated Patient 6 tried to get out of bed, wanted to ambulate and walk around; however, the patient was unable to walk.

On 1/29/19 at 1520 hours, Patient 6 was observed sleeping in his bed and wearing a posey vest restraint.

3. On 1/30/19 at 1025 hours, an interview and concurrent review of Patient 14's medical record was conducted with the Behavior Health Director. Patient 14 was admitted to the hospital on 1/24/19. A posey vest restraint and side rails were ordered and applied to the patient on 1/24 and 1/30/19.

The Behavior Health Director was asked for the care plan addressing the use of the restraints for Patient 14. The Behavior Health Director could not find the care plan for the use of the posey vest and side rails for the patient.

On 1/30/19 at 1335 hours, Patient 14 was observed wearing a posey vest restraint, sitting on the side of the bed with both legs over the side rails, trying to get out of bed, rocking back and forth continuously, and making incomprehensible sound. The patient did not answer when asked what her name was and did not make eye contact. CNA 1 was observed asked Patient 14 if the patient wanted to go to the chair, the patient did not answer and continued to make incomprehensible sound.

Based on interview and record review, the hospital failed to ensure the physician's orders were obtained for the use of restraints for two of 31 sampled patients (Patients 1 and 5 ) within one hour as per the hospital's P&P. This failure could result in providing inappropriate care to the patients.

Findings:

Review of the hospital's P&P titled Restraints: Non-Violent Behavior reviewed 5/17 showed if restraints are applied by an RN, the attending physician is consulted as soon as possible and no longer than one hour of initiation and an order is obtained at that time.

1. On 1/28/19 at 1350 hours, an interview and concurrent review of Patient 1's medical record was conducted with the CNO, PI Coordinator, and ICU/CCU Director.

Patient 1's medical record showed the patient was admitted to the hospital on 1/22/19 at 0228 hours.

Review of the H&P examination dated 1/22/19 at 0554 hours, showed Patient 1 had left sided paresis (a condition of muscular weakness or partial loss of muscle function).

Review of the Flowsheets for Restraint Monitoring Every 2 Hours showed Patient 1 was restrained to the right and left wrist with the soft restraints on 1/22/19 at 1400, 1600, 1800 and 2000 hours.

Review of the Flowsheets for Restraint Order showed the section of "order upon application" showing "Yes."

However, review of the Restraint Non-Violent or Non-Self Destructive showed the physician's telephone order was obtained on 1/22/19 at 1852 hours, to use bilateral soft wrist restraints on Patient 1.

The ICU/CCU Director stated the bilateral soft wrist restraints were applied on Patient 1 on 1/22/19 at 1400 hours.

On 1/31/19 at 0840 hours, an interview and concurrent review of Patient 1's medical record was conducted with the CNO and Application Analyst. The CNO confirmed the bilateral soft wrist restraints were applied to Patient 1 on 1/22/9 at 1400 hours; the patient's left wrist was restrained when the patient had left sided weakness or flaccid; and the physician's order was obtained on 1/22/19 at 1852 hours, or four hours and 52 minutes after the initiation of the restraints.


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2. On 1/29/19 at 1400 hours, Patient 5's medical record was reviewed. Patient 5 was admitted to the hospital on 1/21/19 at 1936 hours.

Review of the Flowsheets for restraint showed on 1/27/19 at 2000 hours, bilateral soft wrist restraints were applied on Patient 5.

However,the physician's telephone order to use bilateral soft wrist restraints for Patient 5 was not obtained until 1/27/19 at 2135 hours, one hour and 35 minutes after the initiation of bilateral soft restraints for the patient.

On 1/29/19 at 1520 hours, during an interview and concurrent review of Patient 5's medical record with the PI Coordinator, the PI Coordinator acknowledged the finding.

Based on interview and record review, the hospital failed to ensure the physician's order for restraints used for one of 31 sampled patients (Patient 16) was renewed as per the hospital's P&P, creating the increased risk of the loss of freedom of movement to this patient.

Findings:

Review of the hospital's P&P titled Restraints: Non-Violent Behavior reviewed 5/17 showed the time limits for orders for non-violent restraints or non-self destructive include the continued use of restraint beyond the first 24 hours is authorized by the physician after examination of the patient and renewing the original order or issuing a new order. This is done no less than once each calendar day.

On 1/30/19 at 1335 hours, an interview and concurrent review of Patient 16's medical record was conducted with the CNO and Application Analyst.

Patient 16's medical record showed the patient was admitted to the hospital on 1/25/19 at 1759 hours.

Review of the document titled Restraint Non-Violent or Non-Self Destructive showed a physician's telephone order dated 1/26/19 at 2215 hours, for the use of bilateral soft wrist restraints. The section of Process Instructions showed the duration should not exceed 24 hours or one day, the order must be renewed every calendar day or when discontinued.

Review of the Flowsheet showed Patient 16 was restrained to the right and left wrists by using the soft restraints on 1/27/19 at 2200 hours.

Further review of the Flowsheet showed on 1/28/19 at 0000 and 0200 hours, Patient 16 was restrained to the right and left wrists by using soft restraints. This was 24 hours after the restraint was ordered on 1/26/19 at 2215 hours. A new order for the use of the restraints was not obtained until 1/28/19 at 0149 hours.

There was no physician's order for the use of bilateral wrist restraints on Patient 16 for three hours and 34 minutes, or from 1/27/19 at 2215 hours to 1/28/19 at 0149 hours.

The CNO confirmed the above finding.

Based on interview and record review, the hospital failed to ensure PA 1 was trained or provided the hospital's P&P for the use of restraints prior to the PA ordering the use of restraints for one of 31 sampled patients (Patient 11) . This failure could lead to the lack of knowledge to provide appropriate care to the patients.

Finding:

Review of the hospital's P&P titled Restraints: Non-Violent Behavior revised 5/17 showed at a minimum, physicians and other licensed independent practitioners authorized to order restraints by the hospital's policy must have a working knowledge of the hospital's policy regarding the use of restraint.

On 1/30/19 at 1100 hours, an interview and concurrent review of Patient 11's medical record was conducted with the CNO and Application Analyst.

Patient 11's medical record showed the patient was admitted to the hospital on 1/28/19 at 0752 hours.

Review of the physician's order dated 1/29/19 at 0927 hours, showed PA 1 ordered to use the "locked restraint" to the patient's right and left upper extremities. PA 1 canceled this restraint order on 1/29/19 at 1042 hours.

Review of another physician's order dated 1/29/19 at 1042 hours, showed PA 1 ordered to use bilateral soft wrist restraints for Patient 11.

The CNO and Application Analyst confirmed the above documents.

On 1/31/19 at 1045 hours, an interview and concurrent review of the credential file for PA 1 was conducted with the Director of Medical Staff.

Review of PA 1's credential file showed the PA was reappointed on 11/18. When asked if the PA was trained about the use of restraint, the Director stated, no.

The Director stated the hospital's P&P related to the use of restraints would be included in the package that were provided to the medical staff during the initial appointment. The Director was asked to provide the initial appointment package that was provided to PA 1.

On 1/31/19 at 1500 hours, during the exit conference, no further information or document was provided as requested.

Based on interview and record review, the hospital failed to ensure the RN evaluated the nursing care for two of 31 sampled patients (Patients 3 and 16) when the nursing staff did not assess Patient 16's respiratory rate and blood pressure after the completion of a procedure and when the nursing staff did not check Patient 3's blood sugar level before dinner meal on 1/28/19 as ordered. These failures created the risk of substandard health outcomes to these patients.

Findings:

1. Review of the Nursing section of the hospital's P&P titled Plan for the Assessment of Patients revised 5/17 showed vital signs (heart rate, respiratory rate, blood pressure and oxygen saturation) are done pre, intra, and post procedure for patients having procedure without sedation.

On 1/30/19 at 1335 hours, an interview and concurrent review of Patient 16's medical record was conducted with the CNO, Application Analyst, Director of Cath Lab/Cardiology, and RN D.

Patient 16's medical record showed the patient was admitted to the hospital on 1/25/19 at 1759 hours, and had a chest tube insertion on 1/27/19.

Review of the IR Documentation dated 1/27/19 from 1352 hours to 1415 hours, the Nurse Note dated 1/27/19 at 1356 hours, and the Flowsheet for vital signs, showed the following:

* At 1352 hours, IR documentation was started.

* At 1346 hours, Patient 16's vital signs was assessed.

* At 1400 hours, a chest tube was placed to the right side for the patient.

* At 1415 hours, the IR documentation was ended.

There was no documented evidence to show Patient 16's respiratory rate and blood pressure were assessed until 1600 hours, or about two hours after the procedure was completed.

The Director of Cath Lab/Cardiology confirmed the finding. The Director stated the patient's vital signs should be assessed after the completion of the procedure.

2. On 1/29/19 at 1509 hours, an interview and concurrent review of Patient 3's medical record was conducted with the CNO and Application Analyst.

Patient 3's medical record showed the patient was admitted to the hospital on 1/28/19 at 1636 hours.

Review of the ED Provider Notes dated 1/28/19 at 1222 hours, showed Patient 3 had a history of diabetes.

Review of the physician's order dated 1/28/19 at 1636 hours, showed to check Patient 3's blood sugar four times daily, before meals and at bedtime.

Review of the ED notes dated 1/28/19 at 1729 hours, showed Patient 3 was transferred to the nursing unit.

Review of the Flowsheets for Intake showed Patient 3 had 75% meal intake on 1/28/19 at 1800 hours.

Review of the POC (Point of Care) Glucose (sugar) showed Patient 3's blood sugar was checked on 1/28/19 at 1223 and 2025 hours. There was no documented evidence to show the nursing staff checked Patient 3's blood sugar before the dinner meal on 1/28/19 as ordered.

The CNO confirmed the finding.

Based on interview and record review, the hospital failed to ensure the nursing staff administered propofol (a sedative medication) as per the physician's orders for two of 31 sampled patients (Patients 22 and 26). This failure could lead to unsafe care and poor health outcomes to these patients.

Findings:

Review of the hospital's P&P titled Medication Administration revised 1/18 showed a medication will be administered only upon the order of physicians, or other members of the medical staff who are authorized to write such orders and under guidelines of their respective scopes of practices. The individual administering a medication will be aware of the following information concerning each medication before administration of the medication:
* Therapeutic action.
* Untoward actions and side effects.
* Normal dosage and maximum safe dosage.
* Precautions.
* Any contraindications that would preclude the administration of the medication.

RASS (Richmond Agitation Sedation Scale, a scale used to assess the patient's sedation level) score is determined by the following:

- Score of minus one indicates drowsy when the patient is not fully alert, but has sustained awakening with eye opening/eye contact to voice more than 10 seconds.

- Score of minus two indicates light sedation when the patient is briefly awake with eye contact to voice less than 10 seconds.

- Score of minus three indicates moderate sedation when the patient moves or opens eyes, and has no eye contact.

- Score of minus four indicates deep sedation when the patient has no response to voice, but movement or eye opening to physical stimulation.

1. On 1/30/19 at 1455 hours and 1/31/19 at 0900 hours, an interview and concurrent review of Patient 22's medical record was conducted with the CNO and Application Analyst.

Patient 22's medical record showed the patient was admitted to the hospital on 1/28/19 at 0809 hours.

The physician's telephone order dated 1/29/19 at 1446 hours, showed to start propofol IV infusion at 5 mcg/kg/min for five minutes; if target not achieved after 10 minutes, increase the infusion by 10 mcg/kg/min every 10 minutes to a maximum of 50 mcg/kg/min or target achieved; if target overachieved, reduce infusion by 5 mcg/kg/min every 10 minutes until target score achieved; RASS target is minus two or light sedation.

a. Review of the Medication Administration Report showed on 1/29/19, Patient 22 received propofol IV at the rate of 20 mcg/kg/min at 2000 hours. At 2300 hours, the rate of the propofol was increased to 30 mcg/kg/min from 20 mcg/kg/min.

Review of the Flowsheet for the sedation scales showed Patient 22's RASS score was documented as minus three on 1/29/19 at 2100 hours and 2300 hours, and on 1/30/19 at 0000 hours.

According to the physician's order, the rate of the propofol should be reduced by 5 mcg/kg/min every 10 minutes when the target was overachieved or when Patient 22's RASS score was documented as minus three on 1/29/19 at 2100 hours and 2300 hours, and on 1/30/19 at 0000 hours.

However, the nursing staff documented the rate of the propofol was increased to 30 mcg/kg/min from 20 mcg/kg/min when Patient 22's RASS score was overachieved, or was minus three on 1/29/19 at 2300 hours. There was no documented evidence to show the nursing staff reduced the rate of the propofol when the patient's RASS score was minus three or was overachieved on the above date and time. In addition, there was no documented evidence to show the nursing staff reassessed the patient's RASS score on 1/29/19 at 2310 hours, or 10 minutes after increasing the rate of the propofol on 1/29/19 at 2300 hours.

b. Review of the Medication Administration Report showed on 1/30/19, the rate of the propofol was reduced to 25 mcg/kg/min at 0100 hours and was again reduced to 20 mcg/kg/min at 0500 hours.

Review of the Flowsheet for the sedation scales showed Patient 22's RASS score was documented as minus three on 1/30/19 at 0000 hours, minus four on 1/30/19 at 0100 hours, and minus two on 1/30/19 at 0400, 0500, and 0613 hours.

However, there was no documented evidence to show the nursing staff reassessed Patient 22's RASS score 10 minutes after the rate of the propofol was reduced on 1/30/19 at 0100 and 0500 hours.

The CNO confirmed the above findings. The CNO stated Patient 22's RASS score should be reassessed 10 minutes after changing the rate of propofol.

2. On 1/31/19 at 0945 hours, an interview and concurrent review of Patient 26's medical record was conducted with the CNO and Application Analyst.

Patient 26's medical record showed the patient was admitted to the hospital on 1/29/19 at 0504 hours.

The physician's order dated 1/29/19 at 2153 hours, showed to start propofol IV infusion at 5 mcg/kg/min for five minutes; if target not achieved after 10 minutes, increase the infusion by 10 mcg/kg/min every 10 minutes to a maximum of 50 mcg/kg/min or target achieved; if target overachieved, reduce the infusion by 5 mcg/kg/min every 10 minutes until target score achieved; RASS target is minus two or light sedation.

a. Review of the Medication Administration Report showed on 1/30/19, Patient 26 received propofol at the rate of 20 mcg/kg/min at 0557 hours. The rate of the propofol was increased to 25 mcg/kg/min at 0757 hours.

Review of the Flowsheet for the sedation scales showed on 1/30/19, Patient 26's RASS score was documented as minus two at 0557, 0757, and 0800 hours; minus one at 1115 hours; and minus two at 1200 hours.

Patient 26's RASS target score was achieved on 1/30/19 at 0757 hours, as per the physician's orders. However, the nursing staff increased the rate of the propofol to 25 mcg/kg/min from 20 mcg/kg/min on this date and time. There was no documented evidence to show why the propofol was increased to 25 mcg/kg/min from 20 mcg/kg/min on 1/30/19 at 0757 hours.

b. Review of the Medication Administration Report showed Patient 26 received propofol at the rate of 30 mcg/kg/minute on 1/30/19 at 1115 and 1303 hours. At 1724 hours, the rate of propofol was increased to 35 mcg/kg/min.

Review of the Flowsheet for the sedation scales showed on 1/30/19, Patient 26's RASS score was documented as minus two at 1200 hours; minus three at 1303 and 1600 hours; and minus one at 1724 hours.

According to the physician's order, the rate of propofol should be reduced by 5 mcg/kg/min every 10 minutes when the target was overachieved or when Patient 26's RASS score was documented as minus three on 1/30/19 at 1303 and 1600 hours.

However, there was no documented evidence to show the nursing staff reduced the rate of propofol by 5 mcg/kg/min every 10 minutes when the patient's RASS score was minus three, or was overachieved on 1/30/19 at 1303 and 1600 hours.

c. Review of the Medication Administration Report showed Patient 26 received propofol at the rate of 35 mcg/kg/min on 1/30/19 at 2241 hours. On 1/31/19 at 0113 hours, the rate of the propofol was increased to 45 mcg/kg/min.

Review of the Flowsheet for the sedation scales showed Patient 26's RASS score was documented as minus two on 1/31/19 at 0000, 0113, 0355, 0500, and 0636 hours.

According to the physician's order, Patient 26's RASS score was minus two or the RASS target score was achieved on 1/31/19 at 0113 hours. However, the nursing staff increased the rate of the propofol to 45 mcg/kg/min when the patient's RASS target score was achieved on 1/31/19 at 0113 hours. There was no documented evidence to show why the propofol was increased from 35 mcg/kg/min to 45 mcg/kg/min on 1/31/19 at 0113 hours.

In addition, there was no documented evidence to show the nursing staff reassessed Patient 26's RASS score 10 minutes after increasing the propofol rate on 1/31/19 at 0113 hours.

The CNO confirmed the above findings.