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Based on the manner and degree of the standard level deficiency referenced to the Condition, it was determined the Condition of Participation §482.23 Nursing Services was out of compliance.

A-0395 (b)(3) - A registered nurse must supervise and evaluate the nursing care for each patient. Based on record review and interviews, the facility failed to ensure a registered nurse (RN) reviewed and evaluated nursing care provided by a licensed practical nurse (LPN) or a licensed vocational nurse (LVN) in three of five medical records reviewed. (Patients #1, #2, and #4)

Based on record review and interviews, the facility failed to ensure a registered nurse (RN) reviewed and evaluated nursing care provided by a licensed practical nurse (LPN) or a licensed vocational nurse (LVN) in three of five medical records reviewed. (Patients #1, #2, and #4)

Findings include:

Facility policies:

The Admission of a Patient policy read, the policy's purpose is to ensure admission practices are standardized and promote a safe environment. Under the procedure section, the policy read, upon the patient's arrival, the patient is greeted by the nursing personnel, escorted to the assigned room, assisted into bed if necessary, and instructed in the use of the call light, bed controls, room lights, and bathroom facilities. An RN will complete the Admission Assessment and initiate the Nursing Care Plan for the patient.

The Nursing Documentation policy read, the Admission Nursing Physical Assessment and individual plan of care will be completed by RN on admission. A patient focus assessment will be documented in the patient care record at least once per twenty-four (24) hour period by a Registered Nurse. The RN must sign and date the Admission Nursing Assessment and History. For Daily Nursing Assessments, an RN assessment will be completed on each patient every 24 hours. This is documented via the daily nursing assessment form and corresponding daily patient care record.

The NSG 14 Nursing Care Plan policy read, the patient care plan is initiated by a registered nurse (RN) upon admission.

References:

The facility's Position Description for a Registered Nurse read, the RN is responsible for utilizing the nursing process while delivering, directing and supervising the care of patients admitted to the nursing unit. The RN plans, coordinates, and provides patient care to include interdisciplinary planning, discharge planning, patient and family teaching for post-hospitalization, and accessing community resources. The Patient Care Essential Job Functions for the RN are: Monitors, records and reports symptoms and changes in a patient's condition. Modifies patient treatment plans as indicated by patients' responses and conditions. Consults and coordinates with healthcare team members to assess, plan, implement and evaluate patient care plans. Monitors all aspects of patient care. Directs and supervises LPNs, LVNs, Patient Care Techs (PCTs), Certified Nursing Assistants (CNAs) and Nursing Assistants (NAs). Demonstrates knowledge and skill in nursing processes/procedures, in accordance with policies and procedures

The facility's Position Description for an LVN/LPN nurse read, the LPN/LVN is responsible for providing appropriate nursing care, as directed by an RN on the nursing unit. Patient Care provided include: Under the direct supervision of an RN, assumes responsibility for the care of assigned patients on designated shifts. Monitors patients for changes in medical condition. Reporting and Documentation responsibilities include: Observing patient progress and reporting changes in patient status to the RN and physician. Assists the RN in obtaining physician orders to meet the medical and nursing needs of the patient.

Colorado Board of Nursing, Practice Act and Laws:

The Nurse Practice Act (2023), provided by the facility, defines the scope of practice of the LPN as that which is taught in schools of practical nursing in Colorado at this time. The LPN curriculum in Colorado focuses on the care of patients with predictable outcomes. The curriculum emphasizes the maintenance of those patients and the performance of nursing skills with a high degree of technical expertise. The practical nurse is taught to identify normal from abnormal in each of the body systems and to identify changes in the patient's condition, which are then reported to the RN or MD for further or a "full" assessment.

The Nurse Practice Act defines the scope of practice of the RN as the practice of professional nursing and includes the performance of both independent nursing functions and delegated medical functions. The Board of Nursing (BON) considers RNs to be independent practitioners.

1. The facility failed to ensure an RN reviewed and evaluated the nursing care provided by LPNs/LVNs. Specifically, without the direct supervision of an RN, LPNs/LVNs performed patient admission assessments, initiated patient care plans, provided patient education, and facilitated patient discharges.

A. Medical records reviews revealed from 11/15/22 to 3/23/23 Nursing Admission Assessments were performed by LPNs/LVNs. Additionally, daily nursing assessments and patient care plan updates performed by LPNs/LVNs lacked evidence of RN supervision and co-signatures. For example:

i. Patient #1's medical record review revealed Patient #1 was admitted on 3/17/23 with a diagnosis of cellulitis (a bacterial infection of the skin and tissues beneath the skin) and an abscess (a collection of infected fluid build-up). A review of the Nursing Admission Assessment for Patient #1 revealed the Nursing Admission Assessment and the Nursing Daily Plan of Care were performed and created by LPN #4 on 3/17/23 at 5:13 p.m. There was no evidence of supervision provided by an RN for this assessment.

On 3/18/23 at 3:20 a.m. and 11:10 a.m., and on 3/19/23 at 3:08 a.m. and 11:04 a.m., RN supervision and co-signatures were not documented for the daily nursing assessments performed by LPNs/LVNs.

According to Patient #1's medical record, Patient #1 was not assessed by an RN until 3/20/23 at 3:25 a.m., three days after Patient #1 was admitted to the facility.

ii. Medical record review revealed Patient #4 was admitted on 11/15/22 with a diagnosis of hemiplegia (paralysis affecting one side of the body) and hemiparesis (one-sided weakness or partial weakness on one side of the body) following cerebral infarction (damage to brain tissues from a loss of oxygen to the brain) affecting the left side of the body.

Further review of Patient #4's medical record revealed RN supervision and co-signatures were not documented for the daily nursing assessments performed by LPNs/LVNs on 11/25/22 at 9:49 p.m., on 11/26/22 at 2:03 p.m., and on 11/27/22 at 2:33 a.m.

iii. Medical record review for Patient #2 revealed Patient #2 was admitted on 1/15/23 with a diagnosis of hemiplegia and hemiparesis following cerebral infarction affecting the right side of the body.

According to Patient #2's medical record, the Nursing Admission Assessment and the Nursing Plan of Care were performed and documented by LVN #6 on 1/15/23 at 3:43 p.m. There was no evidence of supervision provided by an RN for this assessment.

Additional medical record review revealed on 1/22/2023 at 4:14 a.m. and 6:53 p.m., RN supervision and co-signatures were not documented for the daily nursing assessments performed by LPNs/LVNs.

These examples were in contrast with facility policies which stated a daily nursing assessment will be performed by an RN once every 24 hours. Additionally, an RN must perform, sign and date the admission nursing assessment and initiate the patient care plan for the patient.

B. Interviews with staff revealed RN supervision was expected to occur for all patient assessments, reassessments, and nursing care performed by LPNs/LVNs.

i. On 03/22/2023 at 9:55 a.m., an interview was conducted with LPN #2. LPN #2 stated she was not able to conduct the Nursing Admission Assessment. LPN #2 stated an RN was required to perform the admission assessment. LPN #2 stated LPNs were allowed to perform the daily nursing assessment, but an RN was required to review the assessment performed. LPN #2 stated if an RN had not performed an assessment on a patient within 24 hours of the LPN's assessment, the RN was required to physically co-sign the assessment performed by the LPN/LVN in the electronic medical record.

LPN #2 stated daily assessments were performed to monitor the patient to ensure they did not experience a change from the patient's baseline. LPN #2 stated a change in the patient's baseline was considered as a change in the patient's condition and indicated the patient's health was declining.

ii. On 3/22/23 at 10:24 a.m., an interview was conducted with LPN #4. LPN #4 stated an RN had to review and check the assessments performed by an LPN. LPN #4 stated RNs were required to co-sign and evaluate LPN assessments performed for patients who had not been assessed by an RN within a 24-hour period of when the LPN assessed the patient. LPN #4 stated RNs possessed more knowledge and education and were able to perform all nursing care functions for patients.

iii. On 03/22/2023 at 1:29 p.m., an interview was conducted with RN #1. RN #1 stated LPNs and LVNs had limitations to the scope of nursing care provided to the patient. RN #1 stated RNs were educated to identify changes in the patient's condition. RN #1 stated RNs were educated to identify and address patient health concerns and changes in patient conditions. RN #1 stated RNs were required to review the nursing assessments performed by LPNs and LVNs for accuracy and to ensure a change in the condition of the patient did not occur.

RN #1 stated the patient's safety was at risk when there was a lack of RN oversight. RN #1 stated LPNs and LVNs did not have the same knowledge, education, and experience as an RN.

iv. On 3/21/23 at 4:28 p.m., an interview with the corporate quality director (Director) #10 was conducted. Director #10 stated patient assessments performed by an LPN or LVN were required to have an RN co-sign. Director #10 stated facility policy required patient assessments performed by LPNs or LVNs to be co-signed by an RN within 24 hours of when the LPN or LVN performed the patient assessment.

Director #10 stated the Nurse Practice Act and the Position Description for an LVN and LPN outlined the nursing care and activities LPNs and LVNs were able to perform. Director #10 further stated the facility needed to re-educate nursing staff to ensure patient assessments performed by LPNs and LVNs were supervised and co-signed by an RN.