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ST MARY MEDICAL CENTER 18300 HIGHWAY 18 APPLE VALLEY, CA 92307 Feb. 21, 2020
VIOLATION: HOSPITAL PROCEDURES Tag No: A0410
Based on observation, interview, and record review, the facility failed to ensure safe medication practices were implemented for two of 16 sampled patients (Patient 5 and Patient 6) when:

1. For Patient 5, the desired Richmond Agitation Sedation Score (RASS - a medical scale used to measure the patient's level of sedation or agitation) was not clarified with the prescribing practitioner for Diprivan (brand name for the sedative medication Propofol) infusion (drip) titrations (the process of adjusting the dose of a medication for the maximum benefit without adverse effects) and Versed (brand name for the anti-anxiety medication midazolam) infusion titrations.

This failure had the potential for Patient 5 to be exposed to oversedation (adverse effect-an unexpected negative reaction to a medication) and result in prolonged hospitalization .

2. For Patient 6, the facility did not follow the prescribing practitioner orders for Versed infusion titrations or flow rates and did not clarify the desired RASS level.

This failure resulted in medication errors and had the potential to adversely affect the health and wellbeing of Patient 6.

Findings:

1. During an observation with the Intensive Care Unit (ICU- a unit for critically ill patients) Manager (ICUM), on February 20, 2020, at 10:50 AM, in Patient 5's room, Patient 5 was receiving a Propofol drip and a Versed drip intravenous (into the vein) through a central venous catheter (CVC-a tube placed into a large vein to administer medications, blood products, and fluids).

During a review of Patient 5's "Physician's Order" for intravenous Propofol, dated February 10, 2020, the Physician's Order indicated the initial rate for Propofol was 10 micrograms (mcg - a unit of measurement)/kilogram (kg - a unit of measurement for body weight)/minute (min) and to titrate Propofol by 10 mcg/kg/min every 10 minutes to achieve a RASS score of a minus three (-3: moderate sedation with no eye contact) sedation level.

During a review of Patient 5's "Physician's Order" for intravenous Versed, dated February 18, 2020, the Physician's Order indicated the initial rate was three milligrams/hour (mg/hr - a unit of measurement) and to titrate Versed by one mg/hr every 60 minutes to achieve a RASS score of a minus three sedation level.

During a concurrent interview and review of Patient 5's "Physician's Order" for intravenous Propofol dated February 10, 2020, and "Physician's Order" for intravenous Versed, dated February 18, 2020, with the ICUM, on February 20, 2020, at 2:45 PM, in the conference room, the ICUM stated conflicting medication titration orders for Versed and Propofol were
implemented for Patient 5, on February 18, 2020, through February 20, 2020 and should have been clarified with the prescribing physician. The ICUM stated Patient 5's titration orders should have been clarified prior to administering Versed to ensure Patient 5 did not experience an adverse effect.

During a review of the facility's policy and procedure (P&P), titled, "Medication-Administration," revised September 23, 2019, the P&P indicated, "Purpose: To establish safe, effective systems of distribution, dispensing, administration, monitoring and documentation of drugs or chemical within [Name of Facility] ... Procedure/Guideline: A. Medication Administration: ...H. Medication Administration via (by way of) IV ...6. Notify physician of concerns prior to administering ..."

2. During an observation with the ICUM, on February 20, 2020, at 11:04 AM, in Patient 6's room, Patient 6 was receiving an intravenous Versed drip through a CVC.

During a concurrent interview and review of Patient 6's "Physician's Order" for intravenous Versed dated February 13, 2020, with the ICUM, on February 20, 2020, at 2:59 PM, in the conference room, the ICUM stated the physician order for Versed indicated the initial rate was three mg/hr and to titrate Versed by one mg/hr every 60 minutes to achieve a RASS score of a minus three sedation level. The ICUM stated the desired RASS goal was minus one (-1- awakens to voice) and minus two (-2- light sedation). The ICUM stated Registered Nurse 1 (RN 1) did not follow the physician's medication orders for sedation on the following day and times:

1. February 16, 2020, at 2:00 PM, the rate was five mg/hr, the RASS sedation score was minus three (-3: moderate sedation with no eye contact).

2. February 16, 2020, at 3:00 PM, the rate was five mg/hr, the RASS sedation score was minus three.

3. February 16, 2020, at 4:00 PM, the rate was five mg/hr, the RASS sedation score was minus three.

4. February 16, 2020, at 5:00 PM, the rate was five mg/hr, the RASS sedation score was minus three.

5. February 16, 2020, at 6:00 PM, the rate was five mg/hr, the RASS sedation score was minus three.

The ICUM stated, "It's a medication error." The ICUM stated RN 1 should have titrated Versed to achieve the desired RASS sedation level and programmed the infusion pump to deliver the correct medication dose and correct flow rate. The ICUM stated the sedation levels are conflicting and the desired RASS level should have been clarified to indicate either minus one or minus two.

During a review of the facility's policy and procedure (P&P) titled, "Medication-Administration" revised September 23, 2019, the P&P indicated, "Purpose: To establish safe, effective systems of distribution, dispensing, administration, monitoring and documentation of drugs or chemical within [Name of Facility] ... Procedure/Guideline: A. Medication Administration: ...H. Medication Administration via (by way of) IV ...2. Assure proper programming of infusion pump, including a. concentration. b. flow rate. c. Dose ...6. Notify physician of concerns prior to administering ..."