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Based on review of the patient's medical record (MR) and interview with facility staff (EMP), it was determined that the facility failed to obtain complete written orders for the administration of Propofol in one of one medical record (MR26) reviewed and failed to ensure that Propofol was administered only upon written order of a practitioner in one of one medical record (MR26) reviewed.

Findings Include:

1) Review of MR26 on August 27, 2014, at 11:00 AM revealed electronic physician order dated May 24, 2014, at 10:13 PM, "... PROPOFOL 100. ML IV @ 5.67 ML/HR ... CALC PARAM: 15 MICROGRAM/KG/MIN ... PROPOFOL 10MG/ML DRIP-100ML ... ."

Continued review of MR26 on August 27, 2014, revealed, "Nursing Activity Record ... 5/25/14 0230 ... Diprovan [sic] increased to 20 mic/kg/min ... 5/25/14 1230 ... propofol increased to 9.5 mL/hr per titration parameters ... 5/25/14 2130 ... diprovan [sic] increased to 30mcg/kg/min. ... ."

Interview with EMP2 on August 27, 2014, at 11:00 revealed, "We don't have a policy or procedure for ventilated patients on sedation mainly because we don't use it very often ... Ninety-percent of the doctors do not indicate in the order the RASS titration scale number." EMP2 confirmed that MR26 did not indicate a physician order for the titration of Propofol and that nursing documentation reflected titration of Propofol.