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Based on observation, staff interviews, and review of maintenance records between April 23 and April 24, 2018, the facility failed to construct, install and maintain the building systems to ensure life safety to patients.

42 CFR 482.41 Condition of Participation: Physical Environment is NOT met

Findings include:

The facility was found to contain the following deficiencies.

K 351 Sprinkler System - Installation
K 353 Sprinklers Systems- Testing and Maintenance
K 918 Essential Electrical Systems - Other

Refer to the full description at the cited K tags.

The cumulative effect of environment deficiencies result in the Hospital's inability to ensure a safe environment for the patients.

Based on record review and interview, facility staff failed to document reappointment and privileging approval decisions for 5 of 9 providers reviewed (Physician T, Physician W, Physician Y, Physician Z, Physician Assistant AA).

Findings include:

Review of the facility's Medical Staff Bylaws, dated 9/20/2017, revealed "Appointment Process: 7. ...the Board of Managers shall make a decision either to appoint the practitioner to the staff or to reject them for staff membership. All decisions to appoint shall include a delineation of the clinical privileges which the practitioner may exercise. 8. When the Board of Managers decision is final, it shall send notice of such decision through the CEO to the Chairman of the Executive Committee and by certified mail, return receipt requested, to the practitioner."

Per record review, Physician T's credentialing file included an application for re-appointment and privileging dated 8/13/2016. A letter from the facility's Chief Executive Officer, dated 10/16/2016, revealed Physician T was reappointed to the facility's medical staff. The letter did not include the privileges for which Physician T had been approved.

Per record review, Physician Y's credentialing file included an application for re-appointment and privileging dated 8/22/2017. A letter from the facility's Chief Executive Officer, dated 12/15/2017, revealed Physician T was reappointed to the facility's medical staff. The letter did not include the privileges for which Physician T had been approved.

Per record review, Physician Z's credentialing file included an application for re-appointment and privileging dated 8/2/2016. There was no letter or documentation that Physician Z had been reappointed to the medical staff or for which services Physician Z was privileged to provide.

Per record review, Physician Assistant AA's credentialing file included an application for re-appointment and privileging dated 8/3/2016. There was no letter or documentation that Physician Assistant AA's application had been approved by the Board of Managers or for which services Physician Assistant AA was approved to provide.

Per record review, Physician W's credentialing file included an application for re-appointment and privileging dated 8/26/2016. There was no letter or documentation that Physician Z had been reappointed to the medical staff or for which services Physician Z was privileged to provide.

During an interview on 4/24/2018 at 11:05 AM, Health Information Management Director X stated "the letters are missing." Per X, the facility maintains a contracted service to perform credentialing of staff and "MEC [Medical Executive Committee] approves, then they go to the Board [of Managers] for approval." Director X stated "after the Board approves them, the executive assistant always sent an approval letter but [executive assistant] is no longer here."

Based on record review and interview, facility staff failed to develop care plans relevant to active patient problems in 4 of 16 inpatient care plans reviewed (Patient #24, Patient #2, Patient #4, Patient #23).

Findings include:

Review of facility policy "Plan of Care - Individualized and Interdisciplinary" dated 3/18/2018 revealed "Each patient's individualized and interdisciplinary plan of care is appropriate to the patient's individualized assessed needs, strength, limitations and goals. ...3. B. Modifications are made to the plan of care and resource allocations are made based on reassessment of the patient at specific intervals and related to the following elements: 1. Progress toward goals. 2. Failure to make progress. 3. Unusual response to treatment. 4. Failure to participate. 5. Other significant data. 6. Emergent issues."

Per medical record review, Patient #24 was admitted to the facility on 4/20/2018 for rehabilitation services. Patient #24's admission history and physical, dated 4/20/2018, includes a review of systems that documented "Psych/Cognitive: + [positive] depression and anxiety" and an active problem list of "Anxiety and depression -Consult health psych -Continue home fluoxetine [antidepressant], lorazepam [sedative/antianxiety medication]." Review of a consult note from the discharging facility's health psychology provider, dated 4/20/2018, revealed "patient endorsed feeling depressed and indicated frustration following impaired mobility.." and included recommendations for Patient #24 to manage depressive symptoms and recommendation of a psychology consult at the admitting facility. Review of physician progress note dated 4/21/2018 revealed "Patient denies any new concerns... is looking forward to working in therapies today, anxious to get going." Review of nursing progress note dated 4/23/2018 at 12:04 AM revealed "Alert, irritable, impulsive...patient being obsessed about discharging home and [#24's] decreased physical abilities." On 4/23/2018 at 10:56 AM, physician progress notes "Patient ...isn't feeling well this morning. Voices frustration about not receiving a lot of therapies this weekend. ...voicing active suicidal ideation with OT including a plan both at home and here at [facility]. Patient's wife concerned..." Suicide precautions of 1:1 monitoring were implemented on 4/23/2018. On 4/24/2018 at 9:09 AM: "This morning patient states ...will be leaving AMA [against medical advice]. ...[Patient #24] is confused, actively suicidal. ...We will call the police, recommend transport to the ED for inpatient psychiatry evaluation."

Review of Patient #24's care plan did not include any problems, goals or interventions related to coping, depression or suicidal ideation. During an interview on 4/24/2018 at 2:40 PM, Nurse Manager E stated "I would expect to see something about this in the care plan."


09948


Patient #2 was admitted on 4/5/18 with Guillain-Barré syndrome (GBS). Review of the MAR (medication administration record) on 4/24/18 revealed medical orders for Oxycontin (narcotic) 5-10 mg. as needed for pain control. Review of the interdisciplinary care plan on 4/24/18 revealed no care plan for pain control with patient's pain goal preference.

Patient #4 was admitted with Rhabdomyolysis and Acute Kidney Injury on 4/15/18. Review of the 4/15/18 physician's History and Physical revealed Patient #4 suffered from dysphasia (trouble swallowing) and was on aspiration precautions. Review of the interdisciplinary care plan on 4/24/18 revealed no care plan for oral intake/nutrition precautions.

During interview and record review with Nurse Manager Q on 4/24/18 from 1:00 PM through 2:55 PM, Q stated "there is no care plan for this" for Patients #2 and #4.


37420


Patient #23's medical record was reviewed on 4/24/18 at 7:30 AM. Per medical record review Patient #23 was admitted on 4/17/18 for physical and occupational therapy after having aortic valve replacement surgery on 4/11/18. Admission history and physical documented "wound vac to sternal surgical incision wound change every 5 days." Review of Patient #23's care plan identified problems for Activities of Daily Living, Case Management, Circulatory/Cardiovascular, Function/Mobility/Neurological, Pulmonary/Respiratory, and Safety. There is no documented care plan problem for the sternal surgical incision wound.

An interview was conducted with Nurse Manager E on 4/24/18 at 9:45 AM who stated "there should be a wound problem on the care plan."

Based on record review and interview the facility failed to ensure that pain reassessments were completed 60 minutes after oral analgesic administration per facility policy in 8 of 16 inpatient medical records reviewed (Patients #14, #15, #17, #18, #19, #20, #21 and #22).

Findings include:

The facility policy titled "Provision of Care" Policy #: POC 7.56 last reviewed on 2/16/18 was reviewed on 4/23/18 at 12"30 PM. This document revealed on page 3 under "C. Ongoing Assessments/Reassessments by licensed nursing staff: i. Pain is assessed at least every shift during regular shift assessments, with patient complaint of pain, as needed related to patient's treatment(s)/patient condition, after analgesic administration and other pain interventions. ii. Reassessment of pain is conducted through: 1) Evaluation and documentation of response to pain interventions. " Documented continued under "iv. Reassessment of pain relief interventions vary according to patient level of pain and patient status, pain relief interventions performed by the nurse and/or pharmacological agent administered and route of administration, nursing judgment and according to physician orders if present. 1) Recommended time frames for reassessment of effectiveness of pain relief may include: b) 1 hour reassessment - oral medication and non-pharmacological interventions."

Per review of Patient #14's medical record on 4/23/18 at 11:00 AM revealed that Patient #14 on 4/19/18 at 3:59 PM was given an oral medication for pain and no reassessment of pain was documented until 8:10 PM, on 4/19/18 at 8:10 PM was given an oral medication for pain and no reassessment of pain was documented until 8:37 PM, on 4/19/18 at 8:37 PM was given an oral medication for pain and no reassessment of pain was documented until 4/20/18 at 6:20 AM, on 4/22/18 at 8:37 PM was given an oral medication for pain and no reassessment of pain was documented until 9:26 PM, and on 4/23/18 at 5:18 PM was given an oral medication for pain and no reassessment of pain was documented until 8:16 PM, and on 4/24/18 at 11:19 AM was given an oral medication for pain and no reassessment of pain was documented until 11:19 AM. All of the above were time periods greater than the one hour reassessment of pain after oral medication given.

Per review of Patient #15's medical record on 4/23/18 at 11:40 AM revealed that Patient #15 on 4/18/18 at 12:00 AM was given an oral medication for pain and no reassessment of pain was documented until 4:00 AM, and on 4/23/18 at 9:30 AM was given an oral medication for pain and no reassessment of pain was documented until 12:00 PM. All of the above were time periods greater than the one hour reassessment of pain after oral medication given.

Per review of Patient #17's medical record on 4/23/18 at 12:10 PM revealed that Patient #17 on 4/7/18 at 8:18 PM was given oral pain medication and no reassessment of pain relief was documented until 4/8/18 at 7:37 AM, on 4/8/18 at 8:30 PM was given an oral pain medication and no reassessment of pain relief was documented until 4/9/18 at 5:35 AM, on 4/10/18 at 4:38 PM was given an oral pain medication and no reassessment of pain relief was documented until 7:55 PM, on 4/10/18 was given an oral pain medication at 7:55 PM and no reassessment of pain was documented until 9:00 AM, on 4/13/18 at 8:24 PM, on 4/14/18 at 9:20 AM was given oral pain medication and no reassessment of pain was documented until 12:00 PM, on 4/14/18 at 5:20 PM was given oral pain medication and no reassessment of pain was documented until 9:15 PM, on 4/15/18 at 1:41 PM an oral pain medication was administered and no reassessment of pain was documented until 5:28 PM, and on 4/21/18 at 1:18 PM was given an oral medication for pain and no reassessment of pain relief was documented until 8:23 PM. All of the above were time periods greater than the one hour reassessment of pain after oral medication given.

Per review of Patient #18's medical record on 4/23/18 at 1:55 PM revealed that Patient #18 on 4/23/18 at 11:54 AM was given oral pain medication and no reassessment of pain relief was documented until 9:00 PM. All of the above were time periods greater than the one hour reassessment of pain after oral medication given.

Per review of Patient #19's medical record on 4/23/18 at 2:10 PM revealed that Patient #19 on 4/13/18 at 10:00 PM was given oral pain medication and no reassessment of pain relief was documented until 4/14/18 at 4:04 AM, on 4/14/18 at 9:00 PM was given oral pain medication and no reassessment of pain relief was documented until 4/15/18 at 2:00 AM, on 4/16/18 at 7:47 AM was given oral pain medication and no reassessment of pain relief was documented until 12:11 PM, on 4/16/18 at 5:50 PM was given oral pain medication and no reassessment of pain relief was documented until 11:10 PM, on 4/18/18 at 7:28 AM was given oral pain medication and no reassessment of pain relief was documented until 12:00 PM, on 4/18/18 at 9:08 PM oral pain medication was given and no reassessment of pain relief was documented until 4/19/18 at 1:00 AM, on 4/20/18 at 2:22 PM was given oral pain medication and no reassessment of pain relief was charted until 7:00 PM, on 4/22/18 at 4:00 PM was given an oral medication for pain and no reassessment of pain was documented until 7:58 PM, on 4/22/18 at 9:39 AM an oral medication was given for pain and no reassessment of pain was documented until 1:39 PM, on 4/22/18 at 1:39 PM an oral pain medication was given and no reassessment of pain was documented until 7:58 PM, and on 4/23/18 at 10:18 PM oral pain medication was given and no reassessment of pain relief was documented until 3:00 AM. All of the above were time periods greater than the one hour reassessment of pain after oral medication given.

Per review of Patient #20's medical record on 4/23/18 at 3:20 PM revealed that Patient #20 on 4/21/18 at 3:45 PM was given an oral medication for pain and no reassessment of pain was documented until 5:00 PM, and on 4/22/18 at 8:45 PM was given an oral medication for pain and no reassessment of pain was documented until 4/23/18 at 3:00 AM. All of the above were time periods greater than the one hour reassessment of pain after oral medication given.

Per review of Patient # 21's medical record on 4/23/18 at 3:35 PM revealed that Patient #21 on 4/10/18 at 6:00 PM was given oral pain medication and no reassessment of pain relief was charted until 8:30 PM, on 4/12/18 at 1:15 PM received oral pain medication and no reassessment of pain relief was documented until 4:00 PM, on 4/16/18 at 8:34 AM was given oral pain medication and no reassessment of pain relief was documented until 9:00 PM, on 4/19/18 at 6:40 PM was give oral pain medication and no reassessment of pain relief was documented until 10:00 PM, and on 4/20/18 at 10:35 AM oral pain medication was given and no reassessment of pain relief was documented until 4:15 PM. All of the above were time periods greater than the one hour reassessment of pain after oral medication given.

Per review of Patient # 22's medical record on 4/24/18 at 7:15 AM revealed that Patient #22 on 4/19/18 at 9:24 AM was given an oral medication for pain and no reassessment of pain was documented until 4/20/18 at 8:02 AM, on 4/22/18 at 9:04 PM was given an oral medication for pain and no reassessment of pain was documented until 4/23/18 at 5:10 AM, and on 4/24/18 at 7:35 AM was given an oral medication for pain and no reassessment of pain was documented until 9:57 AM. All of the above were time periods greater than the one hour reassessment of pain after oral medication given.

The above deficiencies were confirmed in interview with Nurse Manager E on 4/23/18 at 11:00 AM that the facility expectation is that staff will complete a reassessment of pain relief/management 60 minutes after analgesic is administered.

Based on record review and interview, the hospital pharmacist failed to ensure that nursing staff reconciled narcotic counts per hospital policy, in order to promptly report, investigate and trend pharmaceutical narcotic discrepancies and potential diversions, in 3 of 3 months reviewed (2/1/2018 through 4/22/2018), and 4 of 4 nursing units reviewed (1 and 2 East, 1 and 2 West).

Findings include:

Review of hospital pharmacy policy "250-Medication Management Plan, revised 1/2/2018" revealed "Audits of schedule II controlled substances control systems are performed on an ongoing basis with results forwarded and reviewed by an appropriate manager."

Review of hospital pharmacy policy "375-Controlled substances -Record keeping, effective date 8/17/2015" revealed "B.2. Periodic audits shall be performed to prevent diversion or where diversion is suspected."

Review of hospital pharmacy policy "395- NarcStation Operations, effective date 8/17/2015" revealed "N. Acudose cabinet discrepancy resolution, 1. Nursing staff are responsible for resolving discrepancies created related to the use of Acudose cabinets for patient care activities. 2. Pharmacy staff is responsible for resolving discrepancies created related to incorrect stocking of Acudose cabinets... 2.b. (Pharmacy) staff will investigate the situation and if a stocking error was made will resolve the discrepancy."

Review of the facility's "Monthly Narcotic Count Record" revealed the following directions "narcotic counts must be at change of shift (within 1 hour). Narcotic counts must be fully viewed by both staff members performing the count. The count must be completed and accurate prior to staff leaving duty. As part of end of shift count, verify that all tamper-evident seals are intact. If not, immediately notify Pharmacy will collect. For dates the area (nursing unit) is closed, write closed in the signature columns." This form contains monthly dates, the time that counts were completed, 7:00 AM to 7:00 PM RN (registered nurse) counting and RN verifying columns, and 7:00 PM to 7:00 AM RN counting and RN verifying columns. Review of the these 2018 forms revealed the following:

1) For the 1 EAST nursing unit, Narcotic counts were NOT conducted on the first shift (7:00 AM to 7:00 PM) on the following calendar days: February 1, 2, 4 through 15, 17 through 23, 25 through 28;
March 5, 9, 23 and 31; and April 11, 13, and 21.

For the 1 EAST nursing unit, Narcotic counts were NOT conducted on the second shift (7:00 PM to 7:00 AM) on the following calendar days: February 15, 16 and 28.

2) For the 2 EAST nursing unit, Narcotic counts were NOT conducted on the first shift (7:00 AM to 7:00 PM) on the following calendar days: February 1, 2, 4 through 12, 15, 17, 18, 20 through 23, 26 through 28; March 9, 10, 18, 20, 23 and 31; and April 5, 12 and 16.

For the 2 EAST nursing unit, Narcotic counts were NOT conducted on the second shift (7:00 PM to 7:00 AM) on the following calendar days: February 14 and 28.

3) For the 1 WEST nursing unit, Narcotic counts were NOT conducted on the first shift (7:00 AM to 7:00 PM) on the following calendar days: February 2, 4 through 15, 17 through 23, 25 through 28; March 9 and 31; and April 4, 11, 13, 14, and 16.

For the 1 WEST nursing unit, Narcotic counts were NOT conducted on the second shift (7:00 PM to 7:00 AM) on the following calendar days: February 10, 15, 16 and 28.

4) For the 2 WEST nursing unit, Narcotic counts were NOT conducted on the first shift (7:00 AM to 7:00 PM) on the following calendar days: February 1, 2, 5 through 12, 14 through 18, 21 through 23, 25, 27 and 28; March 5, 9, 25, 26 and 31; and April 7, 8, 11, 12 and 22.

For the 2 WEST nursing unit, Narcotic counts were NOT conducted on the second shift (7:00 PM to 7:00 AM) on the following calendar days: February 1, 9, 10, 16 and 28; and April 6 and 21.

During interview with hospital Pharmacist M on 4/23/2018 at 3:30 PM and, M stated "I was aware there were problems with nursing narcotic counts but the nursing department handles that." When asked how the pharmacy validates that discrepancies or how diversions are caught in a timely manner, M stated "that is a nursing responsibility." On 4/24/2018 at 11:30 AM, Pharmacist M stated that M does "not routinely" run narcotic count accuracy reports from the automated dispensing units of the nursing floors to verify that all narcotic discrepancies are captured by the nursing staff. M stated "I review the discrepancy reports when they are given to me by nursing." There was no documented evidence that this hospital's pharmacy department is providing oversight to the nursing department in order to ensure the proper reporting of narcotic discrepancies/diversions or proper evaluation and trending of narcotic discrepancies/diversions to improve narcotic medication delivery.

Based on observation, record review and interview the facility failed to ensure equipment is inspected and maintained per manufacturer instructions in 1 of 2 patient care areas observed (Rehabilitation/Physical Therapy).

Findings include:

The facility policy titled "Medical Equipment Management Plan" Policy #: EOC 2.17, last revision date of 12/21/2017, revealed under "SCOPE The Medical Equipment Management Program is designed to assure proper selection, of the appropriate medical equipment to support a safe patient care and treatment environment. The Program will assure effective preparation of staff responsible for the use, maintenance, and repair of the equipment, and manage risks associated with the use of medical equipment technology. Finally, the Program is designed to assure continual availability of safe, effective equipment through a program of planned maintenance, timely repair,ongoing education and training, and evaluation of all events that could have an adverse impact on the safety of patients or staff as applied to the building and services provided at the Hospital." Under "FUNDAMENTALS" item C. "Medical equipment may injure patients or adversely affect care decisions if not properly maintained." Document continued on under "OBJECTIVES The Objectives for this Plan are: Assure all hospital equipment is inspected annually or more often, as necessary to assure proper operation." Under "ORGANIZATION AND RESPONSIBILITY" item D. "The Safety Officer/Plant Operations Manager implements a medical equipment maintenance program and tracks maintenance provided by original equipment manufacturers, and other contractors who provide maintenance and repair services for specific items of equipment." And under "PERFORMANCE ACTIVITIES" second paragraph "The performance measurers for the Medical Equipment Program are: Assure annual and semi-annual preventative maintenance inspections are conducted based on risk assessment."

On 4/24/2018 at 12:40 PM observed in "Therapy Department" a "Biodex Balance System SD" with an electrical sticker dated for 2016. An interview was conducted with Plant Manager A on 4/24/2018 at 1:30 PM. When asked about preventative maintenance schedule for therapy equipment, Plant Manager A accessed computer spreadsheet with dates of preventative maintenance listed for facility equipment. Therapy department equipment did not have dates entered. Plant Manager A provided a list of Therapy Equipment make/model/description and last pm (preventative maintenance). "Hand Bike, Tilt Table/stand assist, Recumbent Stepper, Recumbent Lower Body Ergometer, Treadmill and Partial weight bearing gait therapy device" have no dates entered under "Last PM." Mat Table last PM documented 2016 (Electrical inspection only), Car Transfer simulator 2015 (Electrical inspection only), Parallel Bars 2015 (Electrical inspection only), Balance 2016 (Electrical inspection only), and hydrocollator 2016 (Electrical inspection only). Plant Manager A stated "UW was supposed to be doing these and clearly they weren't."

Based on observation, staff interviews, and review of maintenance records between April 23 and April 24, 2018, the facility failed to construct, install and maintain the building systems to ensure life safety to patients.

42 CFR 482.41(b) Standard: Life Safety from fire is NOT met.

Findings include:

The facility was found to contain the following deficiencies.


K 351 Sprinkler System - Installation
K 353 Sprinklers Systems- Testing and Maintenance
K 918 Essential Electrical Systems - Other

Refer to the full description at the cited K tags.

The cumulative effect of environment deficiencies result in the Hospital's inability to ensure a safe environment for the patients.

Based on observation and interview, staff failed to use aseptic technique in medication administration in 1 of 1 injectable medication observations (Patient #1).

Findings include:

Observations in public corridor/hallway adjacent to Room 214 and in Room 214 on 4/23/2018 at 1:20 p.m. revealed the following:
RN (registered nurse) U removed the COW (computer on wheels) from the wall plug in the public access corridor adjacent to Room 214, and rolled it into Room 214 (Patient #1). RN U laid the pre-prepared insulin syringe and alcohol pad down on top of the COW's shelf. RN U did not disinfect the shelf of this COW, that had been exposed to potential pathogens from the public access corridor, before placing this clean injectable medication (insulin) on its surface. RN U washed hands and put on clean gloves, then picked up the COW's medication scanner to scan Patient #1's identification bracelet. RN U did not ensure that this scanning device had been disinfected before using clean gloved hands to pick it up. RN U then used these potentially contaminated gloves to administer a subcutaneous insulin injection into Patient #1's left lower abdomen. RN U then moved the COW from Room 214 into the hallway without wiping or disinfecting the COW.

During an interview on 4/24/2018 at 3:45 PM Infection Preventionist P stated the facility does not have a policy, the only expectation is that the COW is not touched with dirty gloves. Per P, there is no expectation that the COW should be wiped because "they don't come in contact with anything in the room."

Based on record review and interview, facility staff failed to ensure timely referral to the Organ Procurement Organization (OPO) for 1 of 1 patient deaths reviewed (Patient #13).

Findings include:

Review of the facility's OPO contract, dated 9/12/2015, revealed "Hospital shall notify [OPO] by telephone of any individual whose death is imminent or who has died at the hospital... Timely notification or 'timely referral' is defined as calling [OPO] within one (1) hour of a patient meeting the clinical criteria described..."

Review of facility policy "Organ and Tissue Donation" dated 12/27/2017 revealed "When a patient's clinical status is consistent with the definition of imminent death, a member of the healthcare team shall call the OPO... Timely notification is made to preserve the option of donation for the patient and family. ...Documentation of the notification phone call to OPO and donor suitability determination will be documented in a progress note in the electronic medical record..."

Per medical record review, Patient #13 expired at the facility on 3/26/2018 at 10:14 AM. The facility's expiration checklist instructs "Call must be placed to OPO within 1 hour of the patient's death." Per Patient #13's expiration checklist, the notification call was made to the OPO on 3/26/2018 at 12:00 PM, more than 1 hour after Patient #13's death.

During an interview on 4/24/2018 at 9:50 AM, Chief Clinical Officer C stated "the OPO was notified in the appropriate time, but [staff] documented the time the OPO returned the call." Per C, staff should be documenting the time the call was made, not returned.

Based on record review and interview the facility failed to ensure that infection control surveillance of employee handwashing was being completed in a manner to implement corrective action plans and/or education to the departments with identified handwashing issues in 1 of 1 infection prevention program (Infection Control).

Findings include:

An interview was conducted with Infection Preventionist P on 4/24/18 at 11:00 AM. Infection Preventionist P stated that there was no policy on hand washing surveillance "I randomly pick staff monthly and email them the audit tool. If I haven't received any back and it's getting close to the end of the month I contact their supervisors and tell them I am still waiting for them to do their audits." Infection Preventionist P stated "there is no way to track what departments have non-compliance from audit forms that are returned" and that "there is no follow up teaching to the departments with identified non compliance." Documentation was provided that revealed the "% performed" of hand hygiene audits for 2016, 2017 and 2018. March, April of 2017 and January 2018 had no documented percentage of hand hygiene audits completed. There was no documentation of the results of audits and/or departments and staff who were noted to be non compliant with hand hygiene and further education or action plans.