HospitalInspections.org

Based on review of the facility policy, Nursing Scope of practice rules, review of daily nursing assessments from May 2023 to June 2023, and confirmed in interview, the facility failed to ensure an RN (registered nurse) performed the reassessment for six of fourteen charts reviewed per standards of nursing practices .

Findings included:

Review of the facility policy Provision of Care - Nursing (POC N127, revised 12/2022) under Daily Resassment had no documentation of who will perform the assessment, only that "an assessment completed and documented every shift."

According to Texas Board of Nursing online reference site

" ...The LVN performs focused assessments and contributes to care planning, interventions, and evaluations. The RN is responsible for the overall coordination of care and performs comprehensive assessments, initiates the nursing care plan, implements and evaluates care of the client or patient."

Evaluation and Re-assessment:
"A critical and fourth step in the nursing process is evaluation. The RN evaluates and reports patient outcomes and responses to therapeutic interventions in comparison to benchmarks from evidence-based practice and research findings and plans any follow-up care and referrals to appropriate resources that may be needed. The evaluation phase is one of the times when the RN reassesses patient conditions and determines if interventions were effective and if any modifications to the plan of care are necessary."


Random review of patient charts revealed the following two of fourteen charts with an LVN (Personnel # E) who performed the re-assessment.

Patient #1: 06/15/2023, 06/19/2023
Patient #2: 06/14/2023; 06/15/2023; 06/19/2023

Random review of patient charts revealed the following four of fourteen charts with an LVN (Personnel #D) who performed the re-assessment.

Patient #5: 06/15/2023; 06/24/2023
Patient #6: 06/24/2023
Patient #7: 05/22/2023; 05/23/2023
Patient #8: 06/15/2023

Random review of patient charts revealed the following two of fourteen charts with no documentation of who performed the re-assesment

Patient #1: 06/18/2023
Patient #2: 06/20/2023

An interview with the CNO (Personnel #C) on 6/30/2023 at 1320 in the conference room confirmed the above findings. She was unaware an LVN could not perform the shift reassessments and she acknowledged the nurse should have signed the shift assessment.