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Based on policy review, clinical record review and interview, it was determined the Facility failed to ensure the safety of all patients on the Behavioral Health Unit was maintained during the admission of Patient #1 from 04/21/16 through 06/06/16 due to Patient #1 being on contact isolation but refusing to be compliant with isolation precautions. The failed practice did not ensure other patients on the Behavioral Health Unit were not exposed to infections and this failed practice had the likelihood to affect all patients on the Behavioral Health Unit at that time. Findings follow.

A. Review of policy titled "Isolation" stated under Contact Precautions "Limit the movement and transport of the patient from the room to essential purposes only. If transport or movement is necessary, minimize patient dispersal of droplets by masking the patient, if possible."
B. Patient #1 was admitted to the Behavioral Health Unit on 04/21/16. Review of microbiology reports revealed the following:
1) On 04/26/16, a urine test revealed ESBL (Extended Spectrum Beta-lactamase). Results stated "Contact Isolation is required".
2) On 05/18/16, a wound culture revealed MRSA (Methicillin Resistant Staph Aureus). Results stated "Contact Isolation is required".
C. Review of the clinical record of Patient #1 revealed she was combative, aggressive, demanding, and non-compliant with contact isolation procedures anf medications (to include the antibiotics prescribed for infections). She often refused to wear an isolation gown, refused hygiene care and was physically and verbally abusive toward staff. Staff documentation revealed the following:
1) Physician Progress Note written on 04/23/16 - The patient was kicking, threatening and aggressive toward anyone who came within 6 feet of her.
2) Nurse Note written on 04/27/16 at 0942 - Has been refusing hygiene care since admit. Pt is already on contact isolation for MRSA in wound of L (left) ankle and ESBL in urine. While education of importance of proper hygiene, pt became anxious, fidgeting in chair ...yelling out.
3) Nurse Note written on 04/28/16 at 0812 -She refuses to put on her gown for isolation, she is hitting and kicking staff.
4) Nurse Note written on 04/28/16 at 1635 - Patient is acting out and taking off her isolation gown, she is not redirecting she is not listening to staff. She started hitting staff. Patient would not leave gown on
5) Family Practice Consult written on 04/28/16 - Uncooperative, refused to use isolation gown.
6)Nurse Note written on 04/29/16 at 0958 - Patient is sitting in the dining room close to other patients...
7) Nurse's Note written on 04/30/16 at 1752 - Patient refuses numerous times today to let nurse change dressing to leg wound. Would not listen to reasoning for wound care. Patient intrusive when a peer had visitors. Staff attempted to move patient to dayroom and patient became physically aggressive hitting, scratching staff, yelling. Pt in the floor and would not get up. Took 3 staff members to get her in the wheelchair and away from patient and visitors.
8) Nurse's Note written on 04/30/16 at 2038 - Patient is contact isolation and will not wear a gown or gloves. Patient will not go to her room.
9) Family Practice Consult written on 05/01/16 - Uncooperative. Not wearing isolation gown.
10) Nurse's Note written on 05/10/16 at 1841 -Contact isolation for MRSA in wound ...Refuses to allow wound assessment and dressing change ... Refused dressing change x3 this shift.
11) Nurse's Note written on 05/16/16 at 1654 - Refusing to comply with contact isolation precautions despite repeated staff attempts to educate.
12) Nurse's Note written on 05/17/16 at 1631 - tried to explain to dtr (daughter) that patient will not allow a cleaning to wound and will not wipe herself well after voids ...Patient put her hands down her pants and then refused to wash her hands, asked patient politely to allow staff to wash her hands and patient hit staff, kicked staff.
13) Nurse's Note written on 06/03/16 at 1416 - She was physically abusive to the nurse this morning when the nurse let her speak to her sister when she called checking on her. After speaking to her sister and hanging up the phone rang again and she beat the nurse over to it on the wall and she answered it. She would not give the phone to the nurse and began hitting the nurse ...It took 2 other people to get the phone out of her hands.
14) Family Practice Consult 06/06/16 - Upset, yelling, attempting to hit staff, banging on table.
D. During an interview on 09/13/16 at 1430, when asked if isolation patients are treated differently than non-isolation patients, such as eating meals in their rooms, or having an individual therapy session in their rooms instead of going to Group, the Director of Behavioral Health stated no, other than isolation patients are to be gowned and gloved and they are to be at least three feet away from other patients at all times. She stated Group activity precautions were not relevant for Patient #1 because she always refused to go. Review of Patient Observation sheets revealed Patient #1 attended Group 56 times during her admission. The Director of Behavioral Health also stated all isolation patients eat their meals at a specific table in the day room and not in the dining room with other patients. Review of Patient Observation sheets, on which the location and activity of the patient is documented every 15 minutes, revealed Patient #1 was eating in the dining room with other patients 89 times throughout her stay.