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NORTH DAKOTA STATE HOSPITAL
NURSING CARE PLAN
Tag No.: A0396
THIS IS A REPEAT DEFICIENCY FROM THE SURVEY COMPLETED ON 06/05/13.
Based on observation, record review, review of facility policy, and staff interview, the Hospital failed to develop a nursing plan of care and/or recovery plan (a type of interdisciplinary care plan) for 1 of 1 active patient record (Patient #5) observed in a onesie (a one piece garment that zips up the back). Failure to develop Patient #5's plan of care to include the onesie limits the staff's ability to monitor and evaluate the effectiveness of this intervention.
Findings include:
Review of the Hospital policy "Section Two Plan of Nursing Care (NCP)" occurred on 08/14/13. The policy, revised November 2012, stated, "Purpose: The plan of nursing care is a professional tool utilized throughout the individual's hospital stay which provides a guide to maximize the individual's level of health. . . . The RN [Registered Nurse] utilizes the nursing process, incorporating assessment, nursing diagnosis, individual oriented goals, nursing interventions (action), and evaluation into the plan of care for each individual. . . . Formal Nursing Care Plans shall be written for: 1. Newly identified medical problems or medical problems that need further nursing interventions than those identified by the goal on the RECOVERY PLAN. . . ."
On 08/14/13 at 2:15 p.m., two certified nursing assistants (CNAs) (#1 and #2) assisted Patient #5 to the bathroom. Observation showed Patient #5 wore a onesie which zipped up the back. The CNA (#1) stated the patient cannot unzip the onesie and Hospital staff dressed the patient in it to prevent her from disrobing and removing her incontinence brief.
Patient #5's record, reviewed on 08/14/13, identified diagnoses including schizoaffective disorder, bipolar type, rapid cycling. The patient's plan of care failed to include her behavior of disrobing and the use of the onesie.
During an interview on the afternoon of 08/14/13, an administrative nurse (#3) agreed the onesie should be included in Patient #5's plan of care.