HospitalInspections.org

Based on document review and interview, the facility nurses failed to follow a sedation order on 1 of 10 patients reviewed (P10).

Findings include:

1. Facility policy titled, Critical Drip: Continuous Infusion of Dexmedetomidine, policy number: C47-N, last revised 07/23, indicated indicated the infusion rate will be adjusted to maintain an adequate level of sedation per the Richmond Agitation-Sedation Scale (RASS). The policy defines "0" as alert and calm, "-1" as drowsy, and "-2" as light sedation. The policy indicted assess the sedation level and adjust per LP order.

2. Facility policy titled, Critical Drip: Propofol, policy number: C39-N, last revised 10/23, indicated the infusion rate will be adjusted to maintain an adequate level of sedation per the RASS. The policy defines "0" as alert and calm, "-1" as drowsy, and "-2" as light sedation. The policy indicated assess the sedation level and adjust per LP order.

3. Facility order for Dexmedetomidine (Precedex), placed 4/4/24 at 11:05 am, indicated Sedation Goal: 0 to -1, alert, calm to drowsy.

4. Facility order for Propofol, placed 4/5/24 at 8:12 pm, indicated Sedation Goal: 0 to -1, alert, calm to drowsy.

5. Review of P10's medical record (MR) pain/sedation flowsheet indicated, 4/8/24 through 4/12/24, the RASS scores were documented at -2, included but not limited to: 4/8/24 at 1:30 pm, 4/8/24 at 2:32 pm, 4/9/24 at 10:19 am, 4/9/24 at 11:08 am, 4/10/24 at 7:50 am, 4/10/24 at 8:26 am, 4/10/24 at 9:54 am, 4/11/24 at 11:43 am, 4/11/24 at 12:31 pm, and 4/12/24 at 10:33 am.

6. In interview, on 5/20/24 at approximately 4:00 pm, A4 (Registered Nurse, Quality Coordinator/Infection Control [RN, QCIN]) verified from 4/8/24 through 4/12/24, the RASS scores were documented at -2. A4 verified the orders for sedation did not change to reflect a sedation goal of -2.