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Based on record review, policy review and staff interview, the facility failed to ensure physician instructions for patient monitoring were followed. This affected seven (Patients #1, #2, #4, #6, #7, #8 and #9) of ten patients reviewed. The facility census was 21.

Findings include:

1. Review of the medical record for Patient #1 revealed he had been admitted on 06/16/20 for dementia with behavioral disturbance.

Review of nursing notes dated 06/21/20 and 06/22/20 revealed Patient #1 had increased anxiety and an elevated temperature, 100.8 degrees Fahrenheit (F) and 99.7 degrees F.

Review of a physician order dated 06/22/20 at 3:21 P.M. revealed vital signs were to be completed every four hours for closer monitoring of Patient #1's condition. Review of a physician order dated 06/23/20 revealed a chest X ray was ordered for a cough and anxiety.

Review of a nursing note dated 06/22/20 revealed , Patient #1's vitals were completed at 6:00 P.M., 7:00 P.M. and 9:00 P.M. Review of the night shift note for 06/22/20 and day shift on 06/23/20 revealed vitals were completed on 06/23/20 at 8:00 A.M., 9:20 A.M. and 2:00 P.M.

Patient #1 was discharged on 06/23/20 at 5:07 P.M. via emergency transport. A positive COVID test was noted post discharge as the swab test for the virus was performed on 06/23/20 prior to discharge.

2. Review of the medical record for Patient #2 revealed she had been admitted on 07/07/20 for confusion and combativeness.

Review of nursing notes for Patient #2 on 07/09/20 at 9:00 P.M. revealed Patient #2 had a temperature of 101.5 degrees F.

Physician orders on 07/09/20 included blood work, chest X ray and urinalysis. Review of orders dated 07/10/20 revealed and an antibiotic was prescribed for the fever and an infiltrate in the lungs. A swab for the COVID 19 virus was completed and a positive result was noted on 07/17/20.

There was a physician order dated 07/22/20 at 11:41 A.M. for vital signs every four hours for increased assessment, encouragement of face mask use and distancing in common areas.

Review of nursing data in nursing notes dated 07/22/20 revealed vitals were documented at 2:00 P.M. and 9:00 P.M.; on 07/23/20, vitals were recorded at 8:00 A.M., 12:00 P.M., 2:00 P.M. and 9:00 P.M.; on 07/24/20 and 07/25/20, vitals were documented at 8:00 A.M., 2:00 P.M. and 9:00 P.M.; on 07/26/20 vitals were documented at 8:00 A.M. The patient refused vitals at 1:00 P.M. and 2:00 P.M., then vitals were completed at 9:00 P.M. On 07/20/20, vitals were documented at 2:00 A.M., 8:00 A.M. and 2:00 P.M..

3. Review of the medical record for Patient #4 revealed he was admitted 11/16/20 and discharged 12/01/20 for treatment of dementia with behavioral disturbance.

Review of the medical record admission assessment revealed Patient #4 had diagnoses including insomnia, high blood pressure, diabetes, hypothyroidism and history of chest pain. Patient #4 was admitted at the Cincinnati location on 11/16/20 but was transferred to the Wilmington location after the hospital from which he was admitted reported he had tested positive for COVID 19 on 11/16/20.

Review of nursing notes dated 11/16/20 revealed Patient #4 was transferred to the Wilmington location at 3:30 P.M. Review of the physician orders revealed an order dated 11/16/20 at 4:10 P.M. for vital signs to be completed every four hours.

Review of nursing notes dated 11/16/20 revealed vital signs were documented at 9:00 P.M.; on 11/17/20 at 3:00 A.M., 8:00 A.M., 2:00 P.M. and 9:00 P.M.; on 11/18/20 vitals were documented at 8:00 A.M., 2:00 P.M. and 9:00 P.M.; on 11/19/20 vitals were documented at 3:00 A.M., 8:00 A.M., 2:00 P.M. and 9:00 P.M.; on 11/20/20 vitals were documented at 8:00 A.M., 2:00 P.M., and 9:00 P.M.; on 11/21/20 vitals were documented at 2:00 A.M., 8:00 A.M., 2:00 P.M., 6:00 P.M., and 9:00 P.M.; on 11/22/20 vitals were documented at 2:00 A.M., 8:00 A.M., 2:00 P.M., 9:00 P.M.; on 11/23/20 vitals were documented at 2:00 A.M., 8:00 A.M., 2:00 P.M., and 9:00 P.M.; on 11/24/20 vitals were documented at 1:55 A.M., 8:00 A.M., a blood pressure measurement only was completed at 1:00 P.M., vitals at 2:00 P.M. and 9:00 P.M.; on 11/25/20 vitals were documented at 8:00 A.M., 2:00 P.M., 9:00 P.M.; on 11/26/20 vitals were documented at 2:00 A.M., 8:00 A.M., 2:00 P.M., 9:00 P.M.; on 11/27/20 vitals were documented at 8:00 A.M., a blood pressure only at 9:00 A.M., vitals at 2:00 P.M. and 9:00 P.M.; on 11/28/20 vitals were documented at 8:00 A.M., 2:00 P.M., and 9:00 P.M.; on 11/29/20 vitals were documented at 8:00 A.M., 2:00 P.M. and 9:00 P.M.; and on 11/30/20 vitals were documented at 8:00 A.M., 2:00 P.M. and 9:00 P.M..

Review of the nursing notes revealed Patient #4 had a serum COVID test on 11/30/20, which was negative, and was discharged to an extended care facility on 12/01/20.

Interview with Staff A on 12/23/20 at 12:35 P.M. revealed the decision to transfer Patient #4 was made because the lower census at the Wilmington location allowed for better social distancing.

Interview with Staff B on 12/23/20 at 1:17 P.M. confirmed that Patient #4 was transferred to the Wilmington location because there was a lower census there, allowing for better social distancing and staffing there allowed for isolation protocol to be implemented.

4. Review of the medical record for Patient #6 revealed an admission date of 11/21/20 and a discharge date of 12/08/20, with diagnoses including dementia, high blood pressure and dementia with aggressive behavior.

Review of provider notes revealed on 12/06/20 a positive COVID test was reported for Patient #6.

Review of physician orders revealed on 12/06/20 a "bed block room" (isolation protocol), droplet isolation, encourage patient to wear a mask, and vital signs every six hours, with "COVID" written on the right margin of the order sheet at 11:04 A.M..

Review of the nursing notes for Patient #6 revealed vital signs were documented on 12/06/20 at 8:00 A.M., 2:00 P.M., 9:00 P.M.; on 12/07/20 at 6:30 A.M. and 9:00 P.M.; and on 12/08/20 at 8:00 A.M., 2:00 P.M. and 9:00 P.M..

5. Review of the medical record for Patient # 7 revealed an admission date of 12/16/20 related to dementia with behaviors.

Review of an intake assessment dated 12/16/20 revealed Patient #7 had a serology test positive for COVID 19 in his prior history, dated 12/08/20, among other diagnoses.

Review of physician orders dated 12/18/20 at 3:23 P.M. revealed an intravenous antibiotic, isolation protocol, a chest X ray and vital signs every six hours related to Patient #7's symptoms of wheezing, cough and malaise. The order for vital signs every six hours specifically listed times of 8:00 A.M., 2:00 P.M., 8:00 P.M. and 2:00 A.M..

Review of documentation dated 12/18/20 revealed vital signs were documented at 8:00 A.M., 2:00 P.M., 9:00 P.M.; on 12/19/20 vitals were documented at 6:00 A.M., 8:00 A.M., 2:00 P.M. and 9:00 P.M.; on 12/20/20 vital signs were documented at 8:00 A.M., 12:00 P.M., 4:00 P.M. and 9:00 P.M.. On 12/21/20 vital signs were documented at 8:00 A.M. and 1:30 P.M.. Patient #7 was out of the facility from 2:48 P.M. to 7:30 P.M. at a hospital. Patient #7 refused vitals at 8:00 P.M., then vitals were completed at 12:30 A.M.. Review of nursing notes dated 12/22/20 revealed vitals were documented at 8:00 A.M., refused at 2:00 P.M., completed at 9:00 P.M.. Review of nursing notes dated 12/23/20 revealed vitals were documented as refused at 2:00 A.M..

Review of physician orders revealed an order on 12/23/20 at 8:40 A.M. to send Patient #7 to the emergency room for evaluation of abnormal blood work. Patient #7 did not return to the facility.

6. Review of the medical record for Patient #8 revealed he was admitted on 12/21/20. Review of an admission assessment revealed diagnoses including chronic obstructive pulmonary disease, high blood pressure, history of a myocardial infarction and alcohol abuse, and dementia.

Review of physician orders revealed an order for a COVID 19 test due to malaise and fever and on 12/22/20 at 3:56 P.M. an order for vital signs every six hours was documented.

Review of nursing notes revealed vital signs were documented on 12/22/20 at 9:00 P.M.; on 12/23/20 at 8:00 A.M., 2:00 P.M. and 9:00 P.M.; on 12/24/20 at 8:00 A.M., 2:00 P.M., and 9:00 P.M.; on 12/25/20 at 8:00 A.M., 12:00 P.M., 8:00 P.M.; on 12/26/20 at 2:00 A.M., 8:00 A.M., 12:00 P.M., and 9:00 P.M.; on 12/27/20 at 8:00 A.M. and 2:00 P.M.; and on 12/28/20 at 8:00 A.M., 2:00 P.M. and 9:00 P.M..

7. Review of the medical record for Patient #9 revealed she was admitted 12/03/20 and discharged on 12/24/20.

Review of an admission assessment revealed Patient #9 had diagnoses including Alzheimer's dementia, depression, anxiety, high blood pressure, gastroesophageal reflux disease and arthritis.

Review of provider notes revealed the long term care facility contacted the psychiatric facility on 12/05/20 to report that a COVID 19 test completed on 12/01/20 had a positive result.

Review of physician orders dated 12/05/20 at 5:00 P.M. revealed an order for droplet precautions, encourage face mask use and vital signs every six hours.

Review of nursing notes revealed vital signs were completed on 12/05/20 at 9:00 P.M.; on 12/06/20 at 8:00 A.M., 2:00 P.M., and 9:00 P.M.; on 12/07/20 at 8:00 A.M., 2:00 P.M., and 9:00 P.M.; on 12/08/20 at 12:00 A.M., 6:30 A.M., 8:00 A.M., 2:00 P.M., and 9:00 P.M.; on 12/09/20 at 12:00 A.M., 6:30 A.M., 8:00 A.M., 2:00 P.M., and 9:00 P.M.; on 12/10/20 at 12:00 P.M. and 6:00 P.M.; and on 12/11/20 at 8:00 A.M., then an order to discontinue the six hour vitals was documented at 1:19 P.M..

During interview on 12/29/20 at 4:27 P.M., Staff A and Staff B stated there was no other documentation of the vital signs in the record for any of the above referenced patients.

An interview with Staff B on 12/29/20 at 12:39 P.M. revealed all orders will be followed as written unless contraindicated for patient safety. Staff B said nursing staff are expected to document data to reflect the completion of physician orders as dictated by nursing practice guidance and if the order cannot be completed that information should be documented and reported to the provider.

Interview with Staff C on 12/29/20 at 4:07 P.M. revealed orders for more frequent assessment of patient vitals were to monitor medical conditions and were not specific protocols for management of known or suspected COVID 19 infections. Staff C said vitals should be completed as ordered and documented in the patient's medical record in nursing notes throughout all shifts unless times specified otherwise. Staff C said vitals were completed twice per day at a minimum unless orders or circumstances dictated otherwise.

Review of the facility policy titled :Infection Control Policy no: IC-35", issued April 2020 and revised November 2020, revealed COVID positive patients will be separated from other patients, be encouraged to social distance and wear a mask, with provision of instructions and guidance for care and treatment measures by the team. to be followed.

Review of the facility policy titled "Nursing Care of Patients, Validating the Accuracy of Verbal or Telephone Orders, Policy no: NU 49", issue date May 2016, reviewed June 2020, revealed the facility process for transcribing and validating orders, but the act of following orders was not specifically described.