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Based on hospital policy and procedure review, medical record reviews, staff and physician interviews, the nursing staff failed to demonstrate safe administration of medication (Propofol) by not following physicians orders and hospital policy in 2 of 3 patients sampled in the Intensive Care Unit (Patient #5 and #6).

The findings include:

Review of policy titled, "VERBAL/TELEPHONE/TEXT ORDERS" last revised February 2017 revealed, "...Computerized provider order entry (CPOE) is the preferred method for submitting orders into the electronic medical record (EMR); however, (Named Hospital) recognizes the importance of patient safety and effective communication among caregivers. All verbal orders should be limited to emergency situations and during procedures only. In this organization verbal and telephone orders may be taken by Nurses ... When a verbal ... order is received the personnel taking the order will write down the order in its entirety (within the paper medical record); and read the order back to the provider for verification. The order is then entered into the EMR ... These orders must be electronically signed in the EMR by the individual who gave the order within 48 hours ..."

Review of policy titled, "DIPRIVAN (PROPOFOL) FOR SEDATION OF THE MECHANICALLY VENTILATED PATIENTS" last reviewed October 29, 2015 revealed, :....Procedure.... 7. In the ICU: Initiate Propofol as a continuous infusion at 5 mcg/kg/min (microgram per kilogram per minute) and titrate to effect, generally in increments of 5 mcg/kg/min every 5 min or as ordered by physician..."

1. Closed medical record review of Patient #5 revealed a 53 year old female admitted to the facility on 01/21/2019 with acute/chronic respiratory failure. Record review revealed Patient #5's recorded weight as 100 kg (kilograms). Record review of telephone orders for Propofol protocol (paper order set) on 01/21/2019 at 1836 revealed "..Begin Propofol infusion at 30 mcg/kg/min (Usual initial dose is 10-15 mcg/kg/min); Titrate infusion rate in increments of 10mcg/kg/min every 15 minutes as needed to achieve target RASS (Richmond Agitation and Sedation Score); Target RASS score -2 (light sedation) Note: Usual goal is 0 to -3 (moderate sedation) for ventilated patients requiring high-level sedation.. " Review of CPOE orders on 01/21/2019 at 1923 "...Protocol Text Edited: ED,OR & ICU Use only with Mechanically Ventilated Patients Propofol 1000mg/100ml beginning dose 0.5mcg/kg/min Titrate by 5mcg/kg/min q (every) 5 minutes to maintain sedation goals... Sedation Goals: RASS 0 to -1 from 0500-2200 RASS -1 to -2 from 2200-0500..." Record review of medication administration on 01/21/2019 at 2233 revealed Propofol started at a rate of 33.66 mls/hr which is equal to 56mcg/kg/min. Record review revealed the medication was not initiated according to physician order.

Interview with the Director of Informatics on 02/05/2019 at 1500 revealed there are 2 different protocols for the administration of Propofol. Interview revealed no one realized the two protocols were different. Interview revealed the paper order set should not be used. Interview revealed the protocols for administration of Propofol was changed approximately 1 year ago. Interview revealed the nurses should be following the physician orders entered via CPOE. Interview revealed the ICU nurses were not educated on the change of protocols.

Interview with MD #2 on 02/06/2019 at 0915 revealed he is the Medical Director of the ICU. Interview revealed he was not aware of the 2 different protocol sets. Interview revealed the patients need to be less sedated in the morning for evaluation of neurological status. Interview revealed 70% of the time the patients on Propofol are overseddated to do an neurological exam.

Interview with RN #3 on 02/06/2019 at 1018 revealed she always follows the paper protocol order set and not what is entered in CPOE. Interview revealed she did start the medication at the lower rate but the patient was not responding to the sedation. Interview revealed she called the provider and received a clarification order which she did not document.

2. Closed medical record review of Patient #6 revealed a 54 year old male admitted to the facility on 12/05/2018 with respiratory failure. Record review revealed Patient #6's recorded weight as 167.3 kg (kilograms). Record review of telephone orders for Propofol protocol (paper order set) on 12/05/2018 at 1800 revealed "..Begin Propofol infusion at 10mcg/kg/min (Usual initial dose is 10-15 mcg/kg/min); Titrate infusion rate in increments of 10mcg/kg/min every 15 minutes as needed to achieve target RASS (Richmond Agitation and Sedation Score); Target RASS score -2 (light sedation) Note: Usual goal is 0 to -3 (moderate sedation) for ventilated patients requiring high-level sedation... " Review of CPOE orders on 12/05/2018 at 1807 "...Protocol Text Edited: ED,OR & ICU Use only with Mechanically Ventilated Patients Propofol 1000mg/100ml beginning dose 0.5mcg/kg/min Titrate by 5mcg/kg/min q (every) 5 minutes to maintain sedation goals... Sedation Goals: RASS 0 to -1 from 0500-2200 RASS -1 to -2 from 2200-0500..." Record review of medication administration on 12/05/2018 at 2018 revealed Propofol started at a rate of 10.1 mls/hr which is equal to 9.9 mcg/kg/min. Review of medication administration revealed the medication was increased to 22.98 mcg/kg/min at 2019 and 30.52 mcg/kg/min on 12/06/2018 at 0421. Record review revealed no documentation of a RASS score until 12/11/2018 at 2000 (6 days after start of medication). Record review revealed the medication was not titrated according to physician order.

Interview with the Director of Informatics on 02/05/2019 at 1500 revealed there are 2 different protocols for the administration of Propofol. Interview revealed no one realized the two protocols were different. Interview revealed the paper order set should not be used. Interview revealed the protocols for administration of Propofol was changed approximately 1 year ago. Interview revealed the nurses should be following the physician orders entered via CPOE. Interview revealed the ICU nurses were not educated on the change of protocols.

Interview with MD #2 on 02/06/2019 at 0915 revealed he is the Medical Director of the ICU. Interview revealed he was not aware of the 2 different protocol sets. Interview revealed the patients need to be less sedated in the morning for evaluation of neurological status. Interview revealed 70% of the time the patients on Propofol are overseddated to do an neurological exam.

Interview on 02/06/2019 at 0940 with RN #4 revealed she was the nurse who initiated Propofol on Patient #6. Interview confirmed she failed to document the patient's RASS score during her titration of the medication.

Based on policy review, medical record review, staff and physician interview, and review of Medications Removed From the Pyxis (a medication storage machine) by Override report, the facility failed to enter an order into the electronic medical record, for a medication that was administered to a patient based on a verbal order in 1 of 1 (Patient #4) patient that received Propofol (a sedative medication).

Findings included:

Review of policy titled, "VERBAL/TELEPHONE/TEXT ORDERS" last revised February 2017 revealed, "...Computerized provider order entry (CPOE) is the preferred method for submitting orders into the electronic medical record (EMR); however, (Named Hospital) recognizes the importance of patient safety and effective communication among caregivers. All verbal orders should be limited to emergency situations and during procedures only. In this organization verbal and telephone orders may be taken by Nurses ... When a verbal ... order is received the personnel taking the order will write down the order in its entirety (within the paper medical record); and read the order back to the provider for verification. The order is then entered into the EMR ... These orders must be electronically signed in the EMR by the individual who gave the order within 48 hours ..."

Open medical record review conducted on 02/06/2019 revealed Patient #4 was a 60-year-old female that presented to the hospital's Emergency Department (ED) on 01/27/2019 at 0918 in severe respiratory distress, and requiring intubation (insertion of a tube into the airway to assist with breathing. Review revealed a bottle of Propofol was removed from the ED Pyxis by Registered Nurse (RN) #1 on 01/27/2019 at 0931. Review revealed a Propofol infusion was initiated at a dose of 25 micrograms per kilograms per minute (mcg/kg/min) for Patient #4 on 01/27/2019 at 1140 by RN #1 (2 hours 9 minutes after the medication was removed from storage). Review revealed an order to "TITRATE (alter) FOR SEDATION" was entered into the EMR for a Propofol infusion by Hospitalist #1 on 01/27/2019 at 1159 (19 minutes after initiation of the Propofol infusion).

Telephone interview conducted with RN #1 on 02/06/2019 at 1438, who recalled Patient #4. Interview revealed she received a verbal order for a Propofol infusion to keep Patient #4 sedated, from ED Medical Doctor (MD) #1 shortly after the patient's intubation. Interview revealed Patient #4 required no sedation medication until 1149 at which time the medication infusion was initiated. Interview revealed RN #1 expected MD #1 to enter the medication order into the EMR. Interview revealed, "For meds (medications) like Propofol or Versed (another sedative medication), doctors are expected to go back in themselves and put orders in the computer."

Telephone interview was conducted on 02/07/2019 at 0930 with MD #1. Interview revealed after an intubation generally the nurses will either request that the provider enter medication orders, or the nurses will enter the medication orders, and the orders would appear in a queue to be electronically signed by the provider later. If not entered into the EMR at all, nothing will appear in the queue to be signed, even if the medication was obtained and administered. If a verbally ordered medication was entered into the EMR, and never administered, the medication will appear in the providers queue as "Discontinued." Interview revealed MD #1 did not know if or how Patient #4's Propofol medication administration order was entered into the EMR.

Review of a facility report titled "Medications Removed from the Pyxis by Override Report" revealed that during the month of 11/2018, there were 50 instances of various medications removed by override (without an order) from the Pyxis machines, after which a provider order was never placed into the EMR. Review revealed 43 of these instances were in the ED.

NC00146823