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Based on record review, staff interview and facility policy review the facility failed to ensure 2 of 2 sampled patients (Patient 11 and 29) who had medical restraints utilized had the restraint usage incorporated into their nursing plan of care. The total sample was 44. The facility census was 70. Findings are:

A. Record review of restraint documentation by nursing and physician orders revealed Patient 11 was placed in bilateral soft wrist restraints from 8/6/11 at 9:37 AM until 8/9/11 when they were discontinued at 4:29 PM. Review of the nursing care plan failed to find the medical restraint mentioned or incorporated into the patient's plan of care. Interview with the Director of Inpatient Nursing confirmed this finding on 11/29/11 at 12:20 PM.

B. Record review of restraint documentation by nursing and physician orders revealed Patient 29 was placed in medical restraints on 9/11/11 at 6:22 PM. The restraints were discontinued a few hours later at 9:25 PM. Review of the nursing plan of care failed to find the medical restraint use mentioned or incorporated into the patient's plan of care. Interview with the Director of Inpatient Nursing confirmed this finding on 11/29/11 at 1:30 PM.

C. Record review of facility policy titled "Seclusion/Restraint (Chemical, Physical, & Manual" last revised 11/04/11 states ""Modification made to care plan" under the Behavior Management section of documentation. The Acute Medical-Surgical section of required documentation fails to include a requirement to make a modification to the care plan.

Based on review of policies and procedures, review of physician credential files, review of Administrative documents and staff interview, the facility failed to ensure that 10 of 13 sampled medical staff reviewed(Physicians A, B, C, D, E, F, H I, J and M) had a working knowledge of the hospital's restraint policies and procedures. The Medical Staff Roster dated 9/28/11 listed 70 Active, Provisional Active, Emergency Room and Provisional Emergency Room physicians (physicians with potential to order restraints). The hospital census on the first day of the survey was 70. Findings are:

A. Review of the policy and procedure titled Seclusion/Restraints with a date of 11/04/11 revealed the following concerning physician education:
"Review with physician and licensed independent practitioner's role in the assessment and treatment of a patient in restraints or seclusion. Physicians and licensed independent practitioner's will have a working knowledge of the Restraint & Seclusion Policies and Procedures."

B. Review of 13 physician credential files revealed only 2 of the files contained evidence of orientation to the facility's restraint and seclusion policy and procedure (Physicians G & K). Also review were signed documents that said:
"I,____________________, have received the Mary Lanning restraint/Seclusion policy and acknowledge my understanding of the responsibilities of the policy relating to the management of a patient in seclusion or restraints."
Underneath this statement was a line for the individual to sign and to date. Review of all of these documents provided by the hospital revealed only Physician L from the sample medical staff reviewed had signed one of these statements. The hospital was unable to provide evidence that Physicians A, B, C, D, E, F, H I, J and M had a working knowledge of the hospital's restraint and seclusion policies and procedures.

C. Interview with the Director of Behavioral Services on 12/1/11 from 1:45 PM to 2:05 PM revealed the following:
-All physicians had received a copy of the restraint and seclusion policy and procedure; and
-The physicians were to sign a document that indicated they had reviewed this policy; and
-Indicated they had not received a number of the documents back, and
-Indicated that the plan did not state time frames for education but the plan was to educate whenever the regulations changed.

Based on record review and interviews the facility failed to ensure post surgical patients at high risk for post surgical infection had the problem included on the care plan for 2 of 2 post surgical patients sampled [Patients 6 and 37]. The facility census was 70.

Findings are:

A. Patient 6 was admitted from the emergency department on 12/3/2011 for appendicitis. The operative report documented the appendix has perforated with purulent discharge in the abdomen. A Jackson Pratt drain was placed in the surgical wound for the drainage during the closing of the surgical incision. Review of the nursing care plan for the patient initiated on 12/3/2011 and reviewed on 12/5/2011 revealed problems identified were " Knowledge Deficit (Actual), " " Orient Patient To Environment, " and " Pain (Actual). " Review of all of the interventions for the identified problems failed to reveal any interventions related to risk of post surgical infection, and the care plan did not identify risk of infection as a problem even though the appendix had perforated and there was pus in the abdomen during the operation.
An interview with the Unit Manager on 12/5/2011 during the record review confirmed the care plan did not identify risk of infection and agreed this patient was at high risk to develop a serious post surgical infection and that it should have been included in the nursing care plan.
B. Patient 37 was admitted on 12/5/2011 with abdominal pain that was diagnosed as appendicitis. Patient 37 was taken to the operating room for a laproscopic appendectomy. The operative report indicated there had been inflammation in the abdominal cavity around the appendix but the appendix was still intact. Review of the nursing care plan on 12/6/2011 revealed the patient had 2 problems identified, " Knowledge Deficit, ' and " Pain. " The unit manager for this patient indicated she had written the nursing care plan for this patient, and stated " I should've put risk of infection in the care plan.

Based on record reviews, staff interview and facility medical record policy review the facility failed to ensure 9 of 44 sampled patient records had dated/timed/or authenticated physician orders (Patient records 5, 7, 9, 11, 15, 26, 27, 28 and 29). The total sample was 44. The facility census was 70. Findings are:

A. Record review of Medical Staff Rules and Regulations dated 1/17/11 states "Verbal or telephone orders will be dated, timed and signed by the ordering physician (or designee) as soon as is practical but no later than 48 hours of the order. All orders on drugs, IV's [Intravenous], restraints and Code status shall be signed." The policy for physician orders was revised effective 11/28/11. The new policy titled "Nursing Policy SOP 1X-2 Physician Orders" states "verbal orders must be signed by the physician/provider prior to leaving the care area." The new policy also states "Telephone orders are co-signed by the physician within 48 hours of receipt in conjunction with the incomplete record process. All orders shall be dated, times and signed."

B. Staff interview with the Health Information Manager on 11/30/11 at 2:00 PM related that a medical records staff member reviews records on the floors and flags them in the electronic medical record so the physician knows what needs to be signed and can access to authenticate orders online. When that is done electronically the electronic stamp dates and times the signature. The manager related they want orders signed the same day. The medical records department has an ongoing quality study to collect data on physicians and enforce the facility record completion policy.


C Record review of physician orders for Patient 11 revealed the following.
? Orders dated 8/4/11 for medication, laboratory studies, cultures and catheter were not timed by the practitioner.
? Verbal/Telephone orders taken from the physician for nasogastric tube/suction on 8/4/11 at 8:00 PM were not authenticated by the practitioner until 8/12/11 at 9:26 PM.
? Verbal/Telephone order dated 8/4/11 at 11:30 AM for medication was not authenticated by the practitioner until 8/10/11 at 8:14 AM.
? Verbal/Telephone order taken 8/4/11 at 11:45 AM for cardiac studies was not authenticated by the practitioner until 8/19/11 at 8:55 AM.
? Telephone order dated 8/8/11 at 11:00 PM for medical restraint was not authenticated until 9/13/11 at 11:20 AM.
? Verbal order authentication for medical restraint originally written 8/6/11 at 9:37 AM was authenticated by the practitioner on 8/7/11 but the authentication was not timed.
? Verbal order for medical restraint originally written 8/7/11 at 9:37 AM was authenticated by the practitioner on 8/7/11 but the authentication was not timed.
D. Record review of physician orders for Patient 26 revealed the following:
? Telephone order for behavioral restraint and medications dated 10/24/11 at 2:59 PM were not authenticated by the practitioner until 11/7/11 at 9:33 AM.
? Telephone order for behavioral restraint and medications dated 10/28/11 at 9:30 AM was hand signed by the practitioner however there is no date or time of that authentication.
E. Record review of physician orders for Patient 27 revealed the following:
? Telephone order for behavioral restraint dated 10/7/11 at 11:30 PM was not authenticated by the practitioner until 10/13/11 at 9:14 AM.
F. Record review of physician orders for Patient 28 revealed the following:
? Telephone order taken by nursing for admission to Behavioral Services dated 10/6/11 at 2:10 PM was not authenticated by the practitioner until 10/10/11 at 11:48 AM.
? Telephone order for behavioral restrain on 10/7/11 at 10:45 PM contains a hand signed practitioner signature but the signature is not dated or timed.
? Discharge order written by the practitioner dated 10/11/11 is not timed.

G. Record review of physician orders for Patient 29 revealed the following:
? Order dated 9/11/11 at 8:00 PM for medical restraint from the physician as a verbal /telephone order failed to be authenticated by the physician until 10/1/11 at 9:35 AM.
? Orders dated 9/12/11 and transcribed by nursing at 10:05 AM are for laboratory studies and medication. The practitioner dated and signed the orders but did not time them.

Based on record review, staff interview, and facility policy review the facility failed to ensure 4 of 44 sampled patient records had verbal orders were dated/timed and or authenticated by the practitioner (Patients 11, 26, 28, 29). The total sample was 44. The facility census was 70. Findings are:

A. Record review of Medical Staff Rules and Regulations dated 1/17/11 states "Verbal or telephone orders will be dated, timed and signed by the ordering physician (or designee) as soon as is practical but no later than 48 hours of the order. All orders on drugs, IV's [Intravenous], restraints and Code status shall be signed." The policy for physician orders was revised effective 11/28/11. The new policy titled "Nursing Policy SOP 1 X-2 Physician Orders" states "verbal orders must be signed by the physician/provider prior to leaving the care area." The new policy also states "Telephone orders are co-signed by the physician within 48 hours of receipt in conjunction with the incomplete record process. All orders shall be dated, times and signed."

B. Staff interview with the Health Information Manager on 11/30/11 at 2:00 PM related that a medical records staff member reviews records on the floors and flags them in the electronic medical record so the physician knows what needs to be signed and can access to authenticate orders online. When that is done electronically the electronic stamp dates and times the signature. The manager related they want orders signed the same day. The medical records department has an ongoing quality study to collect data on physicians and enforce the facility record completion policy.

C Record review of physician orders for Patient 11 revealed the following.
? Orders dated 8/4/11 for medication, laboratory studies, cultures and catheter were not timed by the practitioner.
? Verbal order authentication for medical restraint originally written 8/6/11 at 9:37 AM was authenticated by the practitioner on 8/7/11 but the authentication was not timed.
? Verbal order for medical restraint originally written 8/7/11 at 9:37 AM was authenticated by the practitioner on 8/7/11 but the authentication was not timed.
D. Record review of physician orders for Patient 26 revealed the following:
? Telephone order for behavioral restraint and medications dated 10/28/11 at 9:30 AM was hand signed by the practitioner however there is no date or time of that authentication.
E. Record review of physician orders for Patient 28 revealed the following:
? Telephone order for behavioral restrain on 10/7/11 at 10:45 PM contains a hand signed practitioner signature but the signature is not dated or timed.
? Discharge order written by the practitioner dated 10/11/11 is not timed.
F. Record review of physician orders for Patient 29 revealed the following:
? Orders dated 9/12/11 and transcribed by nursing at 10:05 AM are for laboratory studies and medication. The practitioner dated and signed the orders but did not time them.

Based on record reviews, staff interview and facility policy review the facility failed to ensure 10 of 44 sampled patient records had verbal/telephone orders authenticated within 48 hours ( Patients 11, 26, 27, 28, 29, 5, 7, 9, 15, and 16). The total sample was 44 . The facility census was 70.

Findings are:

A. Record review of Medical Staff Rules and Regulations dated 1/17/11 states "Verbal or telephone orders will be dated, timed and signed by the ordering physician (or designee) as soon as is practical but no later than 48 hours of the order. All orders on drugs, IV's [Intravenous], restraints and Code status shall be signed." The policy for physician orders was revised effective 11/28/11. The new policy titled "Nursing Policy SOP 1X-2 Physician Orders" states "verbal orders must be signed by the physician/provider prior to leaving the care area." The new policy also states "Telephone orders are co-signed by the physician within 48 hours of receipt in conjunction with the incomplete record process. All orders shall be dated, times and signed."

B. Staff interview with the Health Information Manager on 11/30/11 at 2:00 PM related that a medical records staff member reviews records on the floors and flags them in the electronic medical record so the physician knows what needs to be signed and can access to authenticate orders online. When that is done electronically the electronic stamp dates and times the signature. The manager related they want orders signed the same day. The medical records department has an ongoing quality study to collect data on physicians and enforce the facility record completion policy.

C Record review of physician orders for Patient 11 revealed the following.
? Verbal/Telephone orders taken from the physician for nasogastric tube/suction on 8/4/11 at 8:00 PM were not authenticated by the practitioner until 8/12/11 at 9:26 PM.
? Verbal/Telephone order dated 8/4/11 at 11:30 AM for medication was not authenticated by the practitioner until 8/10/11 at 8:14 AM.
? Verbal/Telephone order taken 8/4/11 at 11:45 AM for cardiac studies was not authenticated by the practitioner until 8/19/11 at 8:55 AM.
? Telephone order dated 8/8/11 at 11:00 PM for medical restraint was not authenticated until 9/13/11 at 11:20 AM.
D. Record review of physician orders for Patient 26 revealed the following:
? Telephone order for behavioral restraint and medications dated 10/24/11 at 2:59 PM were not authenticated by the practitioner until 11/7/11 at 9:33 AM.
E. Record review of physician orders for Patient 27 revealed the following:
? Telephone order for behavioral restraint dated 10/7/11 at 11:30 PM was not authenticated by the practitioner until 10/13/11 at 9:14 AM.
F. Record review of physician orders for Patient 28 revealed the following:
? Telephone order taken by nursing for admission to Behavioral Services dated 10/6/11 at 2:10 PM was not authenticated by the practitioner until 10/10/11 at 11:48 AM.
G. Record review of physician orders for Patient 29 revealed the following:
? Order dated 9/11/11 at 8:00 PM for medical restraint from the physician as a verbal /telephone order failed to be authenticated by the physician until 10/1/11 at 9:35 AM.




12049


H. Record review of physician orders for Patient 5 on 12/5/2011 at 2:30 PM revealed:
? Verbal order written 12/3/2011 at 8:05 AM for Newman's Creme had not been authenticated by a physician.
? Orders for Inpatient Obstetrics admission given on 12/2/2011 at 8:45 AM had not been authenticated by the physician.
An interview with the Nursing Manager for Obstetrics during review of the patient's record confirmed the orders had not been authenticated and she provided copies of the orders.

I. Record review of physician orders for Patient 7 on 12/5/2011 at 3:30 PM revealed:
? Verbal orders written 12/3/2011 at 12:55 PM for Demerol 25 mg iIV [intravenous], Zofran 4 mg IV and sequential compression devices [SCD] per protocol were not authenticated by the physician within 48 hours.
? On 12/2/2011 at 0900 a verbal order for "Remote telemetry" had not been authenticated.
? On 12/2/2011 at 2:14 PM a telephone order for "Regular diet today, NPO at midnight, Type and crossmatch 2 more units of PRBC's [packed red blood cells] for a total of 4 units, give 1 unit of blood when blood becomes available, CBC in AM [complete blood count] had not been authenticated within 48 hours.
An interview with the Nursing Manager for 6 floor med/surg unit confirmed these orders had not been authenticated within the 48 hours during the review of the patient's record and she provided copies of the orders not authenticated.

J. Record review of physician orders for Patient 9 on 12/5/2011 at 1:45 PM revealed:
? Verbal orders given on 12/3/201 at 12:30 PM by anesthesia to obtain consent for anesthesia, and to apply SCD per protocol had not been authenticated within 48 hours.
An interview with the Nursing Manager for orthopedic unit confirmed the order for patient 9 had not been authenticated during the review of the patient's record and she provided a copy of the order.

K. Record review of the physician orders for Patient 15 in the NICU on 12/5/2011 at 10:30 AM revealed:
? A verbal order written 12/2/2011 at 10:35 PM for CBG @ 2300 [blood gases at 11:00 PM had not been authenticated.
? A telephone order given on 12/2/2011 at 11:45 PM for CBG @ 3:00 AM had not been authenticated by a physician.
? Another telephone order given on 12/2/2011 at 11:45 PM "Change vent settings - Rate increased to 28/min and pressure support increased to cmpfH2O.
? A telephone order was given on 12/3/2011 at 3:30 AM directing to "Obtain ordered labs at 0800 [8:00 AM] this am." The order had not been authenticated at the time of the review.

L. Record review of the physician orders for Patient 16 in the NICU on 12/5/2011 at 11:00 AM revealed:
? A telephone order was obtained on 11/26/2011 at 8:30 PM for Decrease rate 20, wean O2 as tolerate, CBG in AM with morning lab, chest x-ray in AM-1 view, decrease rate 15C 2:00 AM if stable. The order had not been authenticated.
? A telephone order was given on 11/29/2011 at 9:10 PM for "NCP in AM" and had not been authenticated.
An interview with the Nursing Manager of the NICU on 12/5/201 between 10 and 11:30 AM confirmed these orders had not been authenticated and provided copies of the unsigned orders for Patients 15 and 16.

Based on observation, record review and interviews the facility failed to ensure implementation of a corrective action plan when an infection control problem was discovered in the nuclear lab of the Radiology Department during safety rounds in mid 2010 at which time the infection control department became aware that they were using a 100ml bag of normal saline to draw up flushes for intravenous use on multiple patients. This could impact up to 10 patients for each bag used. The census was 70.

Findings are:

On 11/29/11 at 1:30 PM in the Radiology Department Hot Lab, the facility had their nuclear radiopharmaceutical medications stored that would be used in various nuclear radiography tests. The Radiology Tech [RT] present in the Hot Lab was interviewed at this time. She stated she had worked there for 35 years and did have certification [CNMT]. She revealed when they give a nuclear radiopharmaceutical intravenously to a patient they must flush the intravenous catheter to ensure all of the medication is infused and there is none left in the intravenous catheter. In the Hot Lab room it was observed that they have a 100 ml bag of normal saline for injection hanging from a hook. The RT stated they obtain a 5 or a 10 ml sterile syringe from a drawer under the cabinet that the bag is hanging from and draw up the needed amount for the flush from the 100 ml bag. The RT demonstrated the process they follow. When they open a new bag they will date and initial the bag. The number of patients that may get a flush from the same bag can vary from 5 to 10 patients as some patients required 20ml of flush. The RT then revealed there had been safety rounds in the past, but she didn ' t remember when, but at least 9 months prior. She said the Registered Nurse [RN] that made the rounds questioned the use of the bag for multiple patients and told her they would get back to her, but she has not heard any more about it. She was not aware there were single dose flush syringes that could be used. She said that would really be nice and would save a lot of time.
The RT revealed they did not have a policy on how to do the flushes. She provided copies of their policies on injection procedures and their radiopharmaceuticals used for tests such as " Hepatobiliary with EF " . Review of the policies confirmed they did not describe how to obtain or draw up a flush for the radiographic procedures.
An interview was completed with one of the Infection Control Department staff on 12/1/2011 at 4:15 PM. The report of the safety rounds could not be located, but the Infection Control nurse had noticed the process of using the 100 ml bag of normal saline in mid 2010. She had thought she had sent an email to the Director of Radiology about it, but no other action or follow-up had been taken.
Even though the Infection Control Department had become aware of the practice of reusing the same normal saline solution on numerous patients, action and follow up to ensure this practice was changed did not take place leaving patients receiving radiopharmaceuticals tests at risk for serious infection.

Based on record reviews, staff interview and facility policy review the facility failed to ensure 10 of 44 sampled patient records had verbal/telephone orders authenticated within 48 hours ( Patients 11, 26, 27, 28, 29, 5, 7, 9, 15, and 16). The total sample was 44 . The facility census was 70.

Findings are:

A. Record review of Medical Staff Rules and Regulations dated 1/17/11 states "Verbal or telephone orders will be dated, timed and signed by the ordering physician (or designee) as soon as is practical but no later than 48 hours of the order. All orders on drugs, IV's [Intravenous], restraints and Code status shall be signed." The policy for physician orders was revised effective 11/28/11. The new policy titled "Nursing Policy SOP 1X-2 Physician Orders" states "verbal orders must be signed by the physician/provider prior to leaving the care area." The new policy also states "Telephone orders are co-signed by the physician within 48 hours of receipt in conjunction with the incomplete record process. All orders shall be dated, times and signed."

B. Staff interview with the Health Information Manager on 11/30/11 at 2:00 PM related that a medical records staff member reviews records on the floors and flags them in the electronic medical record so the physician knows what needs to be signed and can access to authenticate orders online. When that is done electronically the electronic stamp dates and times the signature. The manager related they want orders signed the same day. The medical records department has an ongoing quality study to collect data on physicians and enforce the facility record completion policy.

C Record review of physician orders for Patient 11 revealed the following.
? Verbal/Telephone orders taken from the physician for nasogastric tube/suction on 8/4/11 at 8:00 PM were not authenticated by the practitioner until 8/12/11 at 9:26 PM.
? Verbal/Telephone order dated 8/4/11 at 11:30 AM for medication was not authenticated by the practitioner until 8/10/11 at 8:14 AM.
? Verbal/Telephone order taken 8/4/11 at 11:45 AM for cardiac studies was not authenticated by the practitioner until 8/19/11 at 8:55 AM.
? Telephone order dated 8/8/11 at 11:00 PM for medical restraint was not authenticated until 9/13/11 at 11:20 AM.
D. Record review of physician orders for Patient 26 revealed the following:
? Telephone order for behavioral restraint and medications dated 10/24/11 at 2:59 PM were not authenticated by the practitioner until 11/7/11 at 9:33 AM.
E. Record review of physician orders for Patient 27 revealed the following:
? Telephone order for behavioral restraint dated 10/7/11 at 11:30 PM was not authenticated by the practitioner until 10/13/11 at 9:14 AM.
F. Record review of physician orders for Patient 28 revealed the following:
? Telephone order taken by nursing for admission to Behavioral Services dated 10/6/11 at 2:10 PM was not authenticated by the practitioner until 10/10/11 at 11:48 AM.
G. Record review of physician orders for Patient 29 revealed the following:
? Order dated 9/11/11 at 8:00 PM for medical restraint from the physician as a verbal /telephone order failed to be authenticated by the physician until 10/1/11 at 9:35 AM.




12049


H. Record review of physician orders for Patient 5 on 12/5/2011 at 2:30 PM revealed:
? Verbal order written 12/3/2011 at 8:05 AM for Newman's Creme had not been authenticated by a physician.
? Orders for Inpatient Obstetrics admission given on 12/2/2011 at 8:45 AM had not been authenticated by the physician.
An interview with the Nursing Manager for Obstetrics during review of the patient's record confirmed the orders had not been authenticated and she provided copies of the orders.

I. Record review of physician orders for Patient 7 on 12/5/2011 at 3:30 PM revealed:
? Verbal orders written 12/3/2011 at 12:55 PM for Demerol 25 mg iIV [intravenous], Zofran 4 mg IV and sequential compression devices [SCD] per protocol were not authenticated by the physician within 48 hours.
? On 12/2/2011 at 0900 a verbal order for "Remote telemetry" had not been authenticated.
? On 12/2/2011 at 2:14 PM a telephone order for "Regular diet today, NPO at midnight, Type and crossmatch 2 more units of PRBC's [packed red blood cells] for a total of 4 units, give 1 unit of blood when blood becomes available, CBC in AM [complete blood count] had not been authenticated within 48 hours.
An interview with the Nursing Manager for 6 floor med/surg unit confirmed these orders had not been authenticated within the 48 hours during the review of the patient's record and she provided copies of the orders not authenticated.

J. Record review of physician orders for Patient 9 on 12/5/2011 at 1:45 PM revealed:
? Verbal orders given on 12/3/201 at 12:30 PM by anesthesia to obtain consent for anesthesia, and to apply SCD per protocol had not been authenticated within 48 hours.
An interview with the Nursing Manager for orthopedic unit confirmed the order for patient 9 had not been authenticated during the review of the patient's record and she provided a copy of the order.

K. Record review of the physician orders for Patient 15 in the NICU on 12/5/2011 at 10:30 AM revealed:
? A verbal order written 12/2/2011 at 10:35 PM for CBG @ 2300 [blood gases at 11:00 PM had not been authenticated.
? A telephone order given on 12/2/2011 at 11:45 PM for CBG @ 3:00 AM had not been authenticated by a physician.
? Another telephone order given on 12/2/2011 at 11:45 PM "Change vent settings - Rate increased to 28/min and pressure support increased to cmpfH2O.
? A telephone order was given on 12/3/2011 at 3:30 AM directing to "Obtain ordered labs at 0800 [8:00 AM] this am." The order had not been authenticated at the time of the review.

L. Record review of the physician orders for Patient 16 in the NICU on 12/5/2011 at 11:00 AM revealed:
? A telephone order was obtained on 11/26/2011 at 8:30 PM for Decrease rate 20, wean O2 as tolerate, CBG in AM with morning lab, chest x-ray in AM-1 view, decrease rate 15C 2:00 AM if stable. The order had not been authenticated.
? A telephone order was given on 11/29/2011 at 9:10 PM for "NCP in AM" and had not been authenticated.
An interview with the Nursing Manager of the NICU on 12/5/201 between 10 and 11:30 AM confirmed these orders had not been authenticated and provided copies of the unsigned orders for Patients 15 and 16.