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Based on policy and procedure review and staff interview, the facility failed to ensure patient care policies met the annual review requirements. The annual reviews were lacking for 4 of 4 department policies reviewed (medical records, nursing services, dietary, and pharmacy). The findings were:

1. Review of the departmental policy and procedures for medical records, nursing services, dietary, and pharmacy showed they lacked evidence of annual review. Interview with the chief operations officer on 6/26/19 at 4:24 PM revealed the policy review committee reviewed policies quarterly. He further stated they started the process in January and the goal was to have all policies updated within one year. The review dates included:
a. Review of the Access to Medical Records policy had a review date of 4/26/11.
b. Review of the policies and procedures related to nursing services were titled Cardiac Arrest/Code Blue with a review date of 4/8/10, Admission to Niobrara Community Hospital with a review date of 8/31/16, Procedural Sedation and Analgesia with a review date of 8/31/16, Nursing Service Schedule with a review date of 8/17, Nursing Delegation with a review date of 8/17, Crash Cart Checklist with a review date of 8/17, Blood Transfusion Reaction with a review date of 10/15, Medication Safety Improvement Plan with a review date of 4/26/16, Discharge Plan with a review date of 9/16, and Organ/Tissue Donation with no review date.
c. Review of the policies and procedures related to dietary were titled Calorie Counts, Diet Consults, Diet Manual, Diet Orders, Diets, Equipment Operations, Evacuation, Unauthorized Persons in Kitchen, Food Preparation, Food Temperatures, Handling of Food, Leftovers, Meals for Patients, Meal Times, Menus, Nutritional Screens, Nutritional Supplements, Retention of Essential Records, Sanitary Practices, Emergency and Disaster Planning, Training, all with a review date of 7/11/11. Additional titles included Training/Orientation, Non-Routine Occurrences, Food Deliveries, and Collaboration with Other CAH Services with a review date of 12/20/11.
d. Review of the policies and procedures related to pharmacy were titled Narcotic Storage, Dispensing and Distribution with an approval date of 12/16, and Medication Management with a review date of 6/20/15.

Based on observation, staff interview, medical record review, and policies and procedures review, the facility failed to ensure staff developed and implemented appropriate care plans for 4 of 20 sample patients (#6, #7, #16, #17). The findings were:

1. Periodic observations on 6/24/19, 6/25/19, and 6/26/19 showed patient #6 wore a WanderGuard alarm, and wandered in the halls and into patient rooms. Further observation showed s/he resisted when staff tried to redirect him/her. Review of the 4/25/19 psychosocial well-being social services note showed the patient had dementia and 1 of the goals was "less wandering/less behaviors." Review of the April, May, and June 2019 Activities of Daily Living (ADL) tracking form showed the patient walked independently in his/her room and the corridors. Further review of the tracking forms showed the following documentation regarding the patient's behavior: On 12/25/18 "very confused"... tried to leave the facility. On 12/28/18 "confused, kept wandering in the halls" and going in other patient rooms. On 3/6/19 and 3/7/19 "wandering"... trying to go outside,... "difficult to redirect." On 3/10/19 "became agitated" with another patient, staff intervened when attempted to "strike" the other patient. On 3/11/19 "had a bowel movement" in another patient's closet and bathroom. On 3/12/19, 3/13/19, and 3/15/19 "wandered" into other patient rooms..."not easily redirected"... "aggressive"... "shoved" staff. On 3/25/19 "started to urinate in the corner" of the kitchenette area. On 3/28/19 was "not redirectable" and "kept getting into" other patient's food. Behaviors exhibited in April 2019 included pinched and punched staff, wandered into the radiology area of the hospital, combative, wandered in other patient rooms, and wore another patient's slippers. On 5/7/19 again "wandered" into the radiology area of the hospital and became "combative" when staff tried to redirect him/her. On 6/19/19 was "irritated"... would not cooperate in the dining room and was "spitting on the floor." On 6/21/19 "began digging" his/her nails into the staff's hands. Interview on 6/26/19 at 3:30 PM with certified nurse aide (CNA) #1 and CNA #2 revealed earlier that day the patient left the facility and staff had to "chase [him/her] down" to get him/her back inside the building.

Review of the March, April, May, and June 2019 medication administration records showed on 3/14/19, the physician increased the patient's daily doses of Risperdal (an antipsychotic medication). The medication was increased from 0.5 milligrams(mg) 2 times a day to 1 mg 2 times a day. Review of the care plan, revised on 5/7/19, showed identified problems included the patient was at risk for falls due to wandering, and interventions included WanderGuard on at all times, motion sensor alarms, and frequent checks on his/her whereabouts. Further review showed additional behaviors were not identified, and interventions for behaviors were lacking.

2. Review of the June 2019 ADL tracking form showed patient #7 required minimal assistance with transfers, personal hygiene and dressing. Further review showed s/he could propel his/her wheelchair without assistance. Review of the 6/13/19 psycho-social well-being note showed s/he had severe cognitive impairment. Review of the 9/1/18 physician's patient care summary showed the patient's diagnoses included senile dementia and debility. Review of the March 2019 to June 2019 medication administration record showed the patient started receiving Risperdal on 3/20/19. At that time the dosage was 0.5 mg twice a day. Further review showed a physician's order for Risperdal to be decreased to 0.25 mg once daily on 6/3/19 and "if behaviors worsen," call the physician. Review of the 6/28/18 extended care conference note showed the patient was having an increase in behaviors and was wheeling herself/himself into the wrong room. Review of the care plan, revised 6/17/19, showed identified problems included wandering and alteration in thought process related to increased dementia. Further review showed pharmacological interventions, monitoring, and goals were lacking.

3. Review of the 1/2/19 admission assessment showed patient #16 had dementia and was at risk for elopement. Review of the 2/28/19 nursing notes showed the patient was confused, argumentative and requesting to go home. Review of the 3/15/19 nursing notes showed at times the patient tried to leave the building. Review of 5/25/19 nursing assessment showed the patient was confused at time and wore a WanderGuard security bracelet. Review of the physician's orders showed Risperadal 0.25.mg with dinner was started on 2/28/19. Further review showed it was increased to 0.5 mg with dinner on 3/8/19 and remained unchanged. Review of the care plan, revised on 3/8/19, showed identified problems included elopement risk related to wandering. This review showed the interventions were frequent checks on patient's whereabouts and WanderGuard on patient's wrist. Further review showed the care plan did not include additional behaviors, monitoring, goals, and pharmacological interventions.

4. Review of the 2/19/19 nursing notes showed patient #17 was belligerent, obstinate, and non-compliant with care. Review of 6/9/19 nursing notes showed the patient slapped a CNA. Interview on 6/26/19 at 4:30 PM with CNA #3 and CNA #4 revealed the patient reacted differently to different staff. The stated they did not know why the patient became angry with some staff and not others. Review of the January 2019 to June 2019 medication administration record showed the physician ordered Lorazepam 0.5 mg as needed for agitation/anxiety at bedtime on 12/30/18. Review of the care plan, revised 3/29/19, showed the patient ambulated with a cane or walker and 1 of the assessed problems was wandering. This review also showed interventions included ensure the WanderGuard was functioning properly. Further review showed additional behaviors and interventions were not included in the care plan.

5. During an interview on 6/26/19 at 3:30 PM the director of nursing verified the care plans for the 4 patients did not include pharmacological and non-pharmacological interventions with individualized goals for all of the behaviors that were exhibited.

6. Review of the policy titled "Care Planning", dated April 2018, showed the facility's Care Planning/Interdisciplinary Team was responsible for the development of an individualized comprehensive care plan for each patient"..."Care plans will be reviewed at least monthly by nursing staff and quarterly by the Care Plan Team with changes made as necessary."