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Based on record review and interview the facility failed to ensure appropriate measures were in place in 1 of 1 (ID#2) patient to ensure safety.

Findings Include:

Record review of the facility policy "Responsibilities in Event Reporting" release date 06/2020, stated Hospital personnel are responsible for reporting in a timely and efficient manner, patient and visitor events through the Event Reporting system.
Procedure: Take any necessary steps to ensure the patient's safety.

Record view revealed on 08/03/2021@ 1045, patient (ID#2) was admitted with a diagnosis of hemipegia on left nondominate side. He (ID#2) was found on the floor by the occupational therapist (ID#67). When she finished her session, OT (ID#67) left the patient (ID#2) in the bathroom. Patient (ID#2) fell forward after trying wipe himself after a bowel movement, small redness on right side of forehead no bleeding, alert and oriented.

Interview with Director of Quality Management (ID# 51) at 1046 on 06/15/2022, who stated "there is no documentation in the system regarding the fall and I am glad it was documented in the medical record so this could be validated".

Interview 06/15/2022 at 1050 with both the Quality Director (ID# 51) and Program Director of the Acute Rehab Unit, (ID#61), concluded that the incident report should have been reported and doucmented by the (ID#67) occupational therapist.

Based on observation, record review and interview the facility failed to promote infection prevention and control to include surveillance to avoid sources and transmission of infection.

Findings Include:
Record review of the facility policy, "Hand Hygiene" released 06/2021, original date 09/1997 stated, all staff and persons will perform hand hygiene before entering and when leaving the patient's room every time.

Observation on 06/14/2022 of staff on the afternoon of 06/14/2022 at 1335 the interdisciplinary team were observed meeting outside of patient rooms, with the various disciplines discussing patient needs and care. Several team members were noted to enter room 501 (ID#7) and exited the room at 1340 without gelling in and out or washing their hands.

The staff included the Director of Rehabilitation (staff ID#55), a physician (staff ID#57) and Case Manager RN (staff ID#59) who all entered and exited room 501 (patient ID#7) without gelling in and out or washing their hands.

Observation on 06/14/2022 at 1345 a patients family member (patient ID# 13) was noted to be in the patients (ID#13) room 509 without a gown, feeding the patient. Patient (patient ID#13) had a sign on the door (room 509) for contact isolation.

Interview with (staff D#51) Quality Director, stated the patient (ID#13) had C-Diff. The infection control practitioner was notified to educate the family member in room 509.

Observation at 1347 on 06/14/2022, nurse (staff D#60) was noted to be in and out of patient's (ID#12) room 510 without washing or gelling her hands.

Interview on 06/14/2022 at 1350 with (staff ID #51) the quality manager, who stated the facility had been without a infection control (ID) practitioner for a few months and the new ID practitioner was an epidemiologist and just started at the facility.