HospitalInspections.org

Based on interview and record review, the Governing Body (GB- a group of people or a committee that leads a health care organization's compliance and quality oversight efforts) failed to ensure quality of care was provided for 30 of 30 patients when, the GB did not provide oversight of quality improvement measures implemented for Intravenous (IV- into a vein) drip continuous medication administration assessment and reassessment, or ensure an effective safety and quality improvement program of the Operating Room (OR) staff for surgical counts(checking inventory throughout the surgery to make sure everything is accounted for and none are accidentally left inside the patient's body) and electrocautery (a surgical tool that uses electricity to cut and seal tissue, which flows through an electrical current, from one electrode, through the tissue to a grounding pad) safety. (Refer to A-0049)

The cumulative effect of this systemic problem resulted in the hospital's inability to ensure the provision of quality health care in a safe environment.

Based on interview and record review, the facility failed to maintain an effective and ongoing hospital wide, Quality Assessment and Performance Improvement (QAPI) program for a universe of 30 patients, when:

1. QAPI failed to monitor, collect and analyze quality data when a surgical counts (checking inventory throughout the surgery to make sure everything is accounted for and none are accidentally left inside the patient's body), are accurately counted and electrocautery (a surgical tool that uses electricity to cut and seal tissue, which flows through an electrical current, from one electrode, through the tissue to a grounding pad) safety during surgery . Refer to A-273).

2. The facility failed to identify the collected data to utilize the opportunities for improvement to measure its success, and to ensure that the improvements are sustained when the issues regarding the continuous Intravenous (IV- into a vein) drip medication administration assessment and reassessment was not monitored. (Refer to A-283)

The cumulative effects of these systemic problems resulted in the hospital's inability to identify problem prone areas (likely to cause errors) and ensure the provision of quality health care and nursing services in a safe environment and had the potential to cause adverse health outcomes (undesirable and harmful effects on someone's health) which could interfere with the patients' medical care and may jeopardize the health and safety of other patients undergo the surgeries.

Based on interview, and record review, the facility failed to maintain an organized nursing services to patients for two of 30 sampled patients (Patient 1 and Patient 27), as evidenced by:

1a. For Patient 27, the nursing staff did not perform surgical counts (checking inventory throughout the surgery to make sure everything is accounted for and none are accidentally left inside the patient's body) are accurately counted per facility policy and procedure, which lead to a retained surgical laparotomy sponge (a surgical gauze that is accidentally left inside the body), a secondary surgery to remove the item and had acquired infection. (Refer to A-0395)

1b. For Patient 27, the nursing staff did not document the Electro surgical settings(a surgical tool that uses electricity to cut and seal tissue, which flows through an electrical current, from one electrode, through the tissue to a grounding pad) safety, including cautery settings (amount of electricity used to cut and seal tissue during surgery) and grounding pad (a pad placed on the body before the surgery to protect the person from the harmful effects of the electricity) during the surgery. (Refer to A-0395)

2. For Patient 1, the nursing staff did not document an assessment on a dexmedetomidine (Precedex -a sedative medication) drip (continuous Intravenous [IV-going into a vein] infusion) for 4 hours on June 2, 2025. (Refer to A-0410)

The cumulative effects of these systemic problems resulted in the hospital's inability to ensure the provision of safe and quality nursing care in a safe environment and potentially resulted inadequate patient monitoring prolonged discomfort, infection and delayed healing which significantly jeopardized the health and safety.

Based on interview and record review, the Governing Body (GB-a group of people or a committee that leads a health care organization's compliance and quality oversight efforts) failed to identify and ensure a safe environment and provide quality of care for 30 of 30 sampled patients when the Quality Council Committee (QCC) did not have a tracking system for data collections and monitoring patients with a continuous sedative (a drug used to calm or induce sleep) intravenous (IV-into the vein) medication assessment and identifying surgical counts (checking inventory throughout the surgery to make sure everything is accounted for and none are accidentally left inside the patient's body) and electrocautery ( a surgical tool that uses a high temperature by a direct electrical current to cut and seal tissue) safety measures in the operating room.

This failure resulted in the facility's inability to identify and prevent a retained surgical item (objects left unintentionally inside patient's body after surgery) and monitor patients with a continuous sedative IV medication which had the potential to cause adverse health outcome such as inadequate monitoring, infection, overdosing medication, and could negatively affect patients' health, safety, and/or lead up to death.

Findings:

During a review of the facility document titled, "Governing Board Meeting Minutes" dated May 7, 2025, the meeting minutes under "1st Quarter 2025 PI [Performance Improvement] Dashboard Summary" indicated, "4. Departmental Performance Improvement Measures" was not monitoring IV medication drip assessments or surgical counts and surgical safety processes and documentation and were not identified as a problem prone area or focus by the GB. A further review of the record indicated the performance data that was collected and presented, did not identify what was discussed regarding the results or progress of the root cause analysis and further implementation to address patient care areas without meeting goal. The "Action/Comments/Follow-Up" section of the minutes indicated, "Report was accepted as presented.", and did not include quality care measures discussed, improvement opportunities identified, or implementation of corrective actions.

During an interview on June 5, 2025, at 11:55 AM, in the conference room, with three members of the GB: Board Member 1, Board Member 2 and Board Member 3, the survey team's findings was discussed. The GB's Board Member 3 stated, the GB is ultimately responsible for the Quality Council Committee (QCC) and the Medical Executive Committee (MEC).

- Board Member 3 stated, IV drip medications and assessments were a focus after the previous survey, but after six months of focus on the dashboard (program used to track and analysis data) and meeting goal, that metric was no longer a focus. Board Member 3 stated, since it was identified (continuous sedative drip assessment and monitoring) during this survey, it needs to continue to be a focus.

- Board Member 3 stated, the facility was blind-sided by the retained surgical item (RSI- something that is left in a patient's body after surgery), as the facility was not made aware of the incident by the secondary hospital. Board Member 3 stated, there have been areas of improvement identified by the survey related to missed surgical counts and electrocautery safety not being documented or conducted as often as required per policy and these processes will now be monitored by the GB.

During an interview and record review on June 5, 2025, at 12:10 PM, with the GB, the facility document titled, "Governing Board Meeting Minutes" dated May 7, 2025, was reviewed. The "Governing Board Meeting Minutes" indicated, the "Action/Comments/Follow-Up" section of the minutes indicated, "Report was accepted as presented.", and did not include any quality care measures discussed, improvement opportunities identified, or implementation of corrective actions. Board Member 3 stated, data collected by the committee's is present to the board and improvement opportunities and interventions are discussed at length and an action plan is developed. Board Member 2 reviewed the minutes and stated, the discussion held during the GB meeting was not reflected in the GB meeting minutes and needed to what was discussed during the meeting.

During a review of the facility's document titled, " Performance Improvement Plan 2025" dated January 2025, the "Performance Improvement Plan 2025" indicated, " ...A. Governing Board the Governing Board of [ Name of Facility] has the authority and responsibility for: 1. Determining priorities regarding which processes to monitor (indicators and frequency) with data collection and the subsequent development of planned improvement efforts. 2. Assuring patient safety and quality of patient care and services, including the reduction of medical errors through organization-wide mechanisms and related policies; 3. Systemic evaluation of the effectiveness of the organization-wide performance improvement function; 4. Appropriate delegation of adequate resources for measuring, assessing, improving and sustaining [Name of Hospital} performance and the reduction of risks to patients; 5. Delegation of responsibility for performance improvement functions to MEC and the Performance Improvement/Risk Management Committee ...".

Based on interview and record review, the Quality Assessment and Performance Improvement (QAPI) program failed to monitor, collect and analyze quality data for 30 of 30 patients, when surgical nursing quality indicators including surgical counts(checking inventory throughout the surgery to make sure everything is accounted for and none are accidentally left inside the patient's body), and electrocautery (a surgical tool that uses electricity to cut and seal tissue, which flows through an electrical current, from one electrode, through the tissue to a grounding pad) safety were not part of the QAPI tracked performance measures.

This failure resulted in the hospital's inability to identify problem prone areas (likely to cause errors) and ensure the provision of quality health care and nursing services in a safe environment and one patient (Patient 27) suffering from infection and an avoidable secondary surgery to remove a retained surgical item (RSI- something that is left unintentionally in a patient's body after surgery).

Findings:

During a concurrent interview and record review on June 5, 2025, at 11:00 AM, with the Performance Improvement Manager (PIM), the facility document titled, "2025 Performance Improvement Dashboard [the Name of Hospital]" was reviewed. The "2025 Performance Improvement Dashboard [the Name of Hospital]" indicated, the facility was monitoring surgical procedure, complications (0%), unplanned return to OR (if a patient had to go back to the OR due to an unexpected complication or error from the initial surgery was -0%), anesthesia complications (0%) and all informed consents (process of communication between patient and healthcare provider for the permission of treatment or services)completed prior to procedure (100%). The PIM stated, in the 3rd Quarter of 2024, the time frame for Patient 27's Cesarean Section (C-Section- a surgery where a baby is delivered through incisions made in the mother's abdomen and uterus, instead of through the birth canal) rate was being monitored, but no other additional surgical quality measures.

The PIM stated surgical counts and electrocautery safety were not a performance measure being tracked by QAPI. The PIM stated, the facility was not made aware of the retained surgical item (RSI- something that is left in a patient's body after surgery) by Patient 27 or the secondary hospital, this facility did implement interventions. The PIM stated, the facility became aware of the RSI upon entrance for this survey, approximately nine months after the closure of the labor and delivery unit. The PIM further stated, there was a lack of documentation in Patient 27's "Surgical Case Record" to show surgical counts were not implemented per the policy and procedure and no documentation noted regarding electrocautery settings.

During a review of the facility's document titled, "Performance Improvement Plan 2025" dated January 2025, the "Performance Improvement Plan 2025" indicated, "C. Quality Council Committee (PI [Performance Improvement]/Risk management) ...3. The Performance Improvement/Risk Management Committee of [Name of Hospital] is responsible for: a. Recommending for approval of the MEC [Medical Executive Committee], plans for maintaining quality patient care within the [Name of Hospital]. These may include mechanisms to: 1) Establish systems to identify potential problems in patient care; 2) Set priorities for action on problem correction; 3) Refer priority problems for assessment and corrective action to appropriate departments or committees; 4) Monitor the results of quality improvement activities throughout the [Name of Hospital]; 5) Coordinate performance assessment activities. B. Document what quality projects are being conducted, the reasons for conducting these projects and measurable progress achieved on the projects ...".

Based on interview and record review, the hospital failed to maintain an effective and ongoing hospital wide, Quality Assessment and Performance Improvement (QAPI) program for 30 of 30 patients, when a continuous Intravenous (IV- into a vein) drip medication administration assessment and reassessment was not identified as a focus area and the areas identified by QAPI did not include an action plan in the meeting minutes to measure it's success, track performance and to ensure that improvements are sustained.

This failure resulted in the hospital's inability to focus the already identified problem prone areas and set priorities to improve quality nursing care and ensuring a safe environment for their patients.

Findings:

During a concurrent interview and record review on June 5, 2025, at 10:45 AM, with the Performance Improvement Manager (PIM), the facility document titled, "2025 Performance Improvement Dashboard [the Name of Hospital]" was reviewed. The "2025 Performance Improvement Dashboard [Name of the Hospital]" indicated, ICU performance measures did not include IV drip continuous medication administration assessment and reassessment. The PIM stated, the IV drip continuous medication administration assessment and reassessment was a focus after issues were found with the last survey. The PIM stated, the continuous IV drip was monitored for six months after nurses had been re-educated and then once compliance was observed, that metric was no longer a focus. The PIM stated, the issue has been identified again during this survey and will need to become a focus again with education and audits.

During an interview and record review, on June 5, 2025, at 11:15 AM, with the PIM, the facility document titled, "Performance Improvement/Patient Safety Committee" dated September 20, 2024, was reviewed. The "Performance Improvement/Patient Safety Committee" included the meeting minutes and the quality measures discussed with data collected from department directors. The document further indicated, each of the quality measures the had a section titled "Comments/Follow/UP/Monitor/Track/Trend" with "Report accepted as presented." The document did not include specific comments on the quality measures regarding action plans, trends, interventions, evaluations. The PIM stated, these discussions do take place during QAPI meetings and need to be included in the meeting minutes. The PIM stated, the meeting minutes do not reflect the process and interventions used to improve the quality measures identified and discussed.

During a review of the facility's document titled, "Performance Improvement Plan 2025" dated January 2025, the "Performance Improvement Plan 2025" indicated, "C. Quality Council Committee (PI [Performance Improvement]/Risk management) ... 3. The Performance Improvement/Risk Management Committee of [Name of Hospital] is responsible for: a. Recommending for approval of the MEC [Medical Executive Committee], plans for maintaining quality patient care within the [Name of Hospital]. These may include mechanisms to: 1) Establish systems to identify potential problems in patient care; 2) Set priorities for action on problem correction; 3) Refer priority problems for assessment and corrective action to appropriate departments or committees; 4) Monitor the results of quality improvement activities throughout the [Name of Hospital]; 5) Coordinate performance assessment activities. B. Document what quality projects are being conducted, the reasons for conducting these projects and measurable progress achieved on the projects ...".

Based on interview and record review, the facility failed to ensure licensed nurses maintained and implemented acceptable standards of care per the facility's policies and procedures (P&P) for one of 30 sampled patients (Patient 27) when:

1a.The surgical counts (checking inventory throughout the surgery to make sure everything is accounted for and none are left accidentally left inside the patient's body) are accurately counted and was not documented and instead of the minimum of four counts, three counts were conducted during a Cesarean Section (C-Section - a type of surgery where a baby is delivered through a cut made in the mother's belly and uterus) for one patient (Patient 27).

This failure resulted in an avoidable, secondary surgery to remove a retained laparotom y sponge (a sterile, super-absorbent pad used in surgery, especially in operations on the abdomen) and treatment for an abdominal abscess and potentially contributed to a third surgical procedure to control bleeding prolonged discomfort, infection and delayed healing which significantly jeopardized the health and safety.

1b. There was no documentation of Electro Surgical (a surgical tool that uses electricity to cut and seal tissue, which flows through an electrical current, from one electrode, through the tissue to a grounding pad) safety, including cautery settings (amount of electricity used to cut and seal tissue during surgery) and grounding pad (a pad placed on the body before the surgery to protect the person from the harmful effects of the electricity) for one patient (Patient 27).

This failure resulted in lack of documentation for Patient 27 was grounded and had ordered cautery settings and had the potential to cause burns to Patient 27 during the C-Section.

Findings:

1a. During a review of Patient 27's, "History and Physical" (H&P- a document containing patient history and current medical issues) from Facility A, dated July 2, 2024, the "H&P" indicated, Patient 27 was admitted to Facility A's Labor and Delivery Unit on July 2, 2024, for a C-Section.

During a review of Patient 27's, "Complete Operation Note" from Facility B, dated December 11, 2024, the "Complete Operative Note" indicated, " ...Post Operative Diagnosis: 1. Intra-abdominal abscess (a pocket of pus that forms in the body, usually as a result of an infection) associated with retained laparotomy sponge (lap sponge - a surgical sponge or gauze that is accidentally left inside a patient's body after a surgical procedure) ...Indication (reason) for Operation ...found to have retained foreign object on CT [Computed Tomography- an X-ray machine that uses a computer to create detailed images of the inside of your body] imaging suspicious for retained laparotomy sponge from cesarean section 5 months ago at outside hospital ...".

During a review of Patient 27's, "Surgical Case Record" from Facility A, dated July 2, 2024, the "Surgical Case Record" indicated, Patient 27 had a planned cesarean section. The "Surgical Case Record" indicated, there were a total of three counts performed during the surgery. The "Initial Count" for lap sponge was left blank, the "Second Count" for lap sponge was marked as correct, and the "Final Count" for lap sponge was marked as correct, no other counts were documented.

During an interview on June 3, 2025, at 3:23 PM, with Surgical Technician 1 (ST 1), ST 1 stated, the Circulating Registered Nurse (CRN) and the Surgical Technician (ST) will conduct an initial count prior to the patient's arrival to the Operating Room (OR - a sterile room where surgical procedures are performed)to establish a baseline count of lap sponges and instruments. ST 1 stated, all other counts are performed with the entire surgical team and each of the counts are documented by the CRN. ST 1 further stated, a C-Section requires at least four counts by the surgical team during the operation including the initial count, closure of the uterus count, closure of the abdominal cavity count, and Final count.

During an interview on June 4, 2025, at 11:20 AM, with Circulating Registered Nurse 1 (CRN 1), CRN 1 stated, counts are performed by the surgical team before the beginning of the surgery and throughout the surgery to ensure no surgical devices are mistakenly left behind in the patient. CRN 1 stated, it is the nurse's responsibility to communicate with the surgical team and to document the counts in the patient's chart. CRN 1 stated, a retained surgical item could cause bleeding and infection.

During a concurrent interview and record review on June 5, 2025, at 9:12 AM, with the Director of Operating Room (DOR), the facility's policy and procedure (P&P) titled, "Counts: Surgical" dated October 2022, was reviewed. The P&P indicated, "Purpose: To provide accountability for sponges, sharps, instruments, miscellaneous and any other small items that have the potential for being retained in a surgical wound. Implementation of accurate count procedures helps perioperative patient safety by preventing retained surgical items (RSI) ...Counts shall coincide with the number per packages ...Count Boards and instrument count sheets shall be used to track counts ...Counting ...Initial count before the procedure to establish a baseline and identify manufacturing package errors ...at anytime during the procedure when an item (s) is opened, it shall be added to the count ...Closing count upon closure of a cavity or within a cavity ...Final count immediately before completion of the surgical incision ...Documentation: 7. All Sponge, needle, instrument and miscellaneous item counts are the responsibility of a registered nurse and shall be documented on the patient's intra-operative record 8. Types of counts ...10 results of counts ...". The DOR stated, the facility does not have a specific instrument count sheet. It may be a scrap paper or an instrument count sheet that comes with the surgical kit, but that these papers are thrown away after the procedure. The DOR stated, the circulating OR nurse is responsible for documentation of counts: either correct or incorrect, not a numerical entry. The DOR stated, counts are done initially, before the patient enters the OR to establish a baseline count. Subsequent counts are based on addition of sponges or instrument to count, closure of each cavity, closure and final count. The DOR stated, anyone can initiate a count at any time there is a concern. The DOR further stated, based on the facility P&P, a c-section would require a minimum of four counts during the operative procedure.

During a concurrent interview and record review on June 5, 2025, at 9:20 AM, with the DOR, Patient 27's "Surgical Case Record" dated July 2, 2024, was reviewed. The "Surgical Case Record" indicated, a Cesarean Section was performed. The initial count for lap sponge was left blank, the "Second count" was marked as correct, and the "Final Count" was marked as correct. There were no other counts documented. The DOR stated, there was no documented evidence of the "Initial Count", and it was the CRN's responsibility to document the "Initial Count" and compare all subsequent counts. The DOR further stated, there are only three "Counts" noted to the documentation and a Cesarean Section requires at the minimum four: initial, closure of uterus, closure of abdominal cavity and final count. The DOR stated, a retained surgical sponge would result in Patient 27 requiring a secondary surgery, to remove the sponge and would likely cause pain and infection.

During a telephone interview on June 5, 2025, at 9:38 AM, with the [ Name of Managed Health Care] Quality Review Nurse (QRN), the QRN stated, she had verified per claims that Patient 27 did not have any other documented surgical procedures between July 2, 2024 (d ate of c-section) and December 12, 2024 (date of surgery to remove laparotomy sponge).

During a review of the facility document titled, "Job Description: Registered Nurse OR" (JD), dated January 2014, the "JD" indicated, " ...The Registered Nurse coordinates the care of the patient with the surgeon and anesthesiologist, directs and guides the OR Technician and other personnel while maintaining standards of professional nursing ...Responsible for adherence to regulation, standards and hospital or unit policies and procedures ...B. Duties and Responsibilities ...3. Detects, corrects and/or reports incorrect instrument, sponge or needle counts ...".

1b. During a review of Patient 27's, "Surgical Case Record" from Facility A, dated July 2, 2024, the "Surgical Case Record" indicated, Patient 27 had a planned cesarean section. The "Surgical Case Record" indicated, the electrocautery settings and grounding of the electrocautery unit were not documented.

During an interview on June 4, 2025, at 11:25 AM, with Circulating Registered Nurse 1 (CRN 1), the CRN 1 stated, the electrocautery settings need to be verified by the nurse and the doctor and grounding of the patient needs to be documented by the circulating RN. CRN 1 stated, these checks are part of patient safety in the OR, verifying settings and grounding to ensure the patient does not get burned.

During a concurrent interview and record review on June 5, 2025, at 8:45 AM, with the Chief Nursing Officer (CNO) the facility's policy and procedure (P&P) titled, "Electrocautery Safety" dated October 2022, and Patient 27's "Surgical Case Record" dated July 2, 2024, was reviewed. The P&P indicated, "The intent of this policy is to establish guidelines for safe use of electrocautery during surgical procedures ...All electrosurgical generators shall meet the performance and safety standards of the facility. It is extremely important to provide for safe operation of electrosurgical units, used for the purpose of cutting and coagulation of body tissue with a high frequency electrical current during surgical procedures ...Documentation in [Name of electronic health record] -Electrocautery unit number & settings. - Grounding Pad lot number. - Any reddened areas, burn, marks or no problems ...". The CNO stated, the electro cautery settings need to be documented in the patient chart per the P&P. The CNO further verified and stated, she reviewed Patient 27's "Surgical Case Record" dated July 2, 2024, and stated, the CRN did not document these settings in Patient 27's chart.

During a concurrent interview and record review on June 5, 2025, at 9:25 AM, with the DOR, Patient 27's "Surgical Case Record" dated July 2, 2024, was reviewed and indicated, a Cesarean Section was performed. There was no documented evidence of Electrocautery Unit ID (surgical device identification), Grounding Pad # (ground pad identification) or coagulation settings in Patient 27's chart. The DOR stated, the coagulation settings and grounding unit were not documented. The DOR stated, it is the CRN's responsibility to document these settings in the patient's chart. The DOR further stated, per P&P these should be documented to ensure all is connected and working properly to prevent the patient from being burned.

During a review of the facility document titled, "Job Description: Registered Nurse OR" (JD), dated January 2014, the "JD" indicated, " ...The Registered Nurse coordinates the care of the patient with the surgeon and anesthesiologist, directs and guides the OR Technician and other personnel while maintaining standards of professional nursing ...Responsible for adherence to regulation, standards and hospital or unit policies and procedures ...B. Duties and Responsibilities ...7. Monitors all patient care equipment during use, ...electrocautery ...ensuring they are set with the appropriate parameters for the patient and that any/all alarms are audible at all times ...".

Based on interview and record review, the facility failed to ensure the nursing staff assessed and documented continuously for one of 30 sampled patients (Patient 1), when a dexmedetomidine (Precedex -a sedative medication) drip (continuous Intravenous [IV-going into a vein] infusion) for 4 hours in an acceptable standard of practices on June 2, 2025.

This failure had the potential to leave the patient unmonitored and under sedated which would compromising patient safety and possibly lead to undo discomfort.

Findings:

During a review of Patient 1's History and Physical (H&P) dated, May 21,2025, the H&P indicated, Patient 1 was admitted to the facility on May 21,2025, with history of Dementia (neurodegenerative diseases that cause a decline in mental abilities), Parkinsons(a progressive brain disorder that primarily affects movement, causing symptoms like tremors, slowness of movement), Schizophrenia(a chronic brain disorder characterized by a disconnection from reality, including hallucinations and delusions) and malnutrition transferred from a skilled nursing facility for failure to thrive and urinary tract infection.

During an interview on June 2,2025, at 9:55 AM, with Registered Nurse (RN2), RN2 stated, "we need to document on our IV drips every 2 hours if we are not adjusting the dose."

During a concurrent interview and record review on June 2, 2025, at 2:02PM with Registered nurse (RN1), Patient 1's "Medications Administration Record" (MAR) dated June 2, 2025, was reviewed. Patient 1's MAR indicated, "dexmedetomidine (Precedex- a sedative medication) 400 microgram (mcg a unit of mass in the metric system) in 100 milliliter (mL- unit of measurement ) infusion, Initiated dexmedetomidine infusion at 0.2mcg/kg/hr, ( the amount of medication in micrograms that is administered per kilogram of patient weight per hour ), titrate(adjust medication dose) by 0.1mcg/kg/hr every 15 minutes to achieve desired level of sedation. Titrate for RASS (Richmond agitation and sedation scale- a scale to measure levels of sedation or agitation, -1 (drowsy), -2 (light sedation), -3 (moderate sedation), -4 (deep sedation), -5 (unarousable sedation)) of -2. Administration documentation on June 2,2025 indicated:
2:41AM rate: 0.3mcg/kg/hr. Rass -2
4:00AM rate: 0.3mcg/kg/hr. Rass-2
6:00AM rate: 0.3mcg/kg/hr. Rass-2
8:00AM rate: 0.3mcg/kg/hr. Rass-2
10:00AM rate: 0.3mcg/kg/hr. Rass-2

After 10:00 AM, there was no documentation of the continuous IV drip infusion RASS score could be identified. RN1 verified and stated, there is missing documentation, there should be documentations at 12:00PM and 2:00 PM by now.

During a concurrent interview and record review on June 4,2025 at 10:10AM, with the Director of Intensive Care Unit (DICU), Patient 1's MAR dated June 2,2025 was reviewed. Patient 1's MAR indicated, there was no nursing documentation on the dexmedetomidine drip including the RASS score on June 2,2025 after 10:00AM till 2:00PM. The DICU stated, "Yes, the nurse responsible has been spoken too about it, and per facility policy the nurse should have documented at minimum of every two hours per the intensive care unit (ICU) charting policy."

During a review of the facility policy and procedure (P&P) titled, "Charting for ICU (24hr Critical Care)" dated February 2024, the P&P indicated, "Data shall be collected continuously on all critically ill patients wherever they may be located. It consists of a baseline full body system assessment each shift and the following: ...5. Nursing documentation ... G. Chart reassessment of affected system q2(every 2) hours."