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Based on record review and staff interview, the facility failed to ensure orders were authenticated promptly by the ordering practitioner or other practitioner for 3 of 20 patients reviewed (#13, #16 and #17).

The findings were:

Patient #13
During review of physician orders for patient #13 it was noted that several telephone/verbal orders were not signed by the physician. They were as follows:
8/15/2018: Restraint order
8/14/2018: Restraint order
8/11/2018: Hold dialysis today
8/11/2018: Apply skin barrier prep, then barrier cream (purple) to left upper arm abrasion two times per day and as needed
8/12/2018: Basic Metabolic Panel, Complete Blood Count, Phosphorus (laboratory studies) in the morning
5/9/2018: Hold dialysis today (This order was imbedded with other orders from August 2018)
8/7/2018: There was an entire order for dialysis (This consists of the types and quantities of electrolytes needed for the dialysis solution, the amount of time to be on the machine, the type of dialyzer, the rate at which the blood and dialysis fluid run through the machine, how much heparin to use, if any, and the ultrafiltration goal)

Patient #16
During review of physician orders for patient #16 it was noted that there was an order dated 7/26/2018, that stated, "puree thin liquid diet, 1 to 1 feeder, pills crush in puree."


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Patient #17
During a record review of patient #17, four physician telephone orders were noted that had not been signed by the physician. The orders were documented as telephone orders read back (TORB) and were noted for 8/1/2018 at 12:20PM, 8/1/2018 at 2:30PM, 8/1/2018 at 7:00PM, and on 8/2/2018 at 2:05AM.

In an interview with the medical records representative she stated that orders were expected to be signed by physicians within 30 days of patient discharge, in accordance with hospital policy.

Based on observation, interview and policy review, the facility failed to meet standards of care regarding the sterilization of hinged surgical instruments creating a potential risk of infection to patients undergoing procedures using hinged instruments.

Findings Include:

On 8/15/2018 at approximately 11:30AM, during a tour of the surgical suite, sterilized surgical instruments were observed in a storage area. The majority of these instruments were hinged instruments, including needle holders, scissors, and clamps. These instruments were in peel packs and were observed in the closed position (photo evidence obtained). At least one package of instruments was dated indicating the sterilization process had occurred on September 5, 2017.

An interview with the acting operating room nurse revealed that she had not been trained to open the instruments when placing them in packs for sterilization and was not aware that this was a requirement.

A review of facility policy and procedure SP II-04, "Cleaning and Care of Surgical Instruments," dated 10/15/2005 and last reviewed on 04/01/2016, failed to include instructions that hinged instruments must be placed in the open position during sterilization. The policy did state that "staff involved with decontamination/sterilization will be trained in all aspects of the procedure. Competency will be verified during orientation and annually thereafter."

The Centers for Disease Control and Prevention (CDC) Guidelines for Disinfection and Sterilization in Healthcare Facilities (2008) and most recently revised in 2017 (https://www.cdc.gov/infectioncontrol/guidelines/disinfection/sterilization/sterilizing-practices.html) stated, "Once items are cleaned, dried, and inspected, those requiring sterilization must be wrapped or placed in rigid containers and should be arranged in instrument trays/baskets according to the guidelines provided by the AAMI (Association for Advancement of Medical Instrumentation) and other professional organizations. These guidelines state that hinged instruments should be opened."

Failure to sterilize instruments creates a potential risk for infection to any patient undergoing a surgical procedure in which these instruments are used.