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Based on record review and interviews, the facility failed to ensure that the face-to-face within one-hour after the initiation of a restraint was documented by a registered nurse who had been trained to complete the assessment. Failure to do so resulted in 1 of 1 patient (Patient #4) having a face-to-face assessment documented in part by an LVN.

Findings included:

Record review of policy 200.40, "Restraint/Seclusion," reviewed 1/15/2019, showed:
"E. Face-to-Face Evaluation by the Physician or Trained RN: Within one hour of the initiation of restraint/seclusion, the patient shall be evaluated in person by a physician or trained Registered Nurse."

Record review of the "Emergency Administration of Psychotropic Medication - One Hour Face to Face Follow-up," dated 10/2/2019 at 4:05pm for Patient #4 showed two different handwriting. The first handwriting sections included date, time, patient's immediate situation, patient's reaction to intervention, and current physical and medical status. The second handwriting sections included current psychological status, current behavior, and "are there any factors contributing to the patient's behavior."

In an interview with Staff EE (LVN) on 10/24/2019 at 12:00pm, she stated she completed the first portion of the "One Hour Face to Face Follow-up" and Staff II (RN) completed the second portion, as denoted by the change in handwriting.

Based on record review and interviews, the facility failed to ensure that there was a delineation of responsibilities for patient care. Failure to do so resulted in 15 of 15 patients (Patients #1-15) with Daily Nursing Assessments (the reassessment) being conducted by an LVN instead of an RN.

Findings included:

Record review of the Texas Board of Nursing Position Statement 15.27 The Licensed Vocational Nurse Scope of Practice showed:
"The LVN assists in determining the physical and mental health status, needs, and preferences of culturally, ethnically, and socially diverse patients and their families based on interpretation of health-related data. The LVN collects data and information, recognizes changes in conditions and reports this to the RN supervisor or another appropriate clinical supervisor to assist in the identification of problems and formulation of goals, outcomes and patient-centered plans of care that are developed in collaboration with patients, their families, and the interdisciplinary health care team. The LVN cannot perform independent assessments as the LVN has a directed scope of practice under supervision. The LVN participates in the nursing process by appraising the individual patient's status or situation at hand. Also known as a focused assessment, this appraisal may be considered a component of a more comprehensive assessment performed by a RN or another appropriate clinical supervisor. For example, a RN may utilize the data and information collected and reported by the LVN in the formation of the nursing plan of care; however, the RN's comprehensive assessment lays the foundation for the nursing process."

See: https://www.bon.texas.gov/practice_bon_position_statements_content.asp#15.27

Record review of Houston Behavioral Healthcare Hospital policy 200.01, "Plan for the Provision of Nursing Care," reviewed 3/1/2017, showed:
" IV. PURPOSE: ... B. ... [R]egistered nurses shall use the assessment skills initially and on an ongoing basis to determine the level of care ...
D. Nursing care needs are identified for all patient populations based on the specialized knowledge of registered nurses. The psychiatric nurse will assess nursing care needs based on the understanding of family dynamics, pharmacology, physiology, effectiveness of coping skills, availability of support systems, and progression through the adult developmental continuum ...
H. ...[A] competent registered nurse is expected to demonstrate the ability to transfer scientific knowledge from social, biological, and physical sciences in applying the nursing process, as follows: ...
4. Delegate tasks to subordinates based upon the legal scope and practice of the subordinate ... All nursing care is planned, prescribed, coordinated, and monitored by registered nurses ... "

In an interview with the CNO (Staff D) on 10/24/2019 at 1:00pm, he stated the "Daily Nursing Assessment" is a reassessment conducted on each patient every 12 hours. He also stated the facility allows this reassessment to be conducted by the LVN.

In an interview with Staff EE (LVN) on 10/24/2019 at 12:00pm, she stated she sometimes works with one RN and MHTs. The RN will assign half of the patients to her. She completes the "Daily Nursing Assessment" on her assigned patients. She also stated that the "Daily Nursing Assessment" is a comprehensive assessment.

In an interview with Staff II (RN) on 10/24/2019 at 11:20am, she stated she assigns completion of the "Daily Nursing Assessment" to LVNs.

Record review of Daily Nursing Assignment Sheet dated 10/2/2019, 7am - 7pm, showed Staff II (RN) as the "Charge Nurse." Seven patients had been assigned to Staff II (RN) and eight patients assigned to Staff EE (LVN). There were no other licensed staff listed on the assignment sheet. Two MHTs were documented (Staff SS and Staff TT).

Record review of Daily Nursing Assessments for Patients #1-15 show the following elements:
a) Type of precautions and observation level
b) Risk assessment - suicidality, homicidality, and fall
c) Detox protocol
d) Physical assessment with vulnerability and pain
e) Affect and mood, level of consciousness, orientation, and appearance
f) Thought process, content, and speech

Patient #1.
Daily Nursing Assessment, dated 10/22/2019 at 10:40am, completed by Staff EE (LVN)

Patient #2.
Daily Nursing Assessment, dated 10/24/2019 at 9:00pm, completed by Staff OO (LVN)

Patient #3.
Daily Nursing Assessment, dated 10/9/2019 at 9:00pm, completed by Staff OO (LVN)

Patient #4.
Daily Nursing Assessment, dated 10/2/2019 at 9:58am, completed by Staff EE (LVN)

Patient #5.
Daily Nursing Assessment, dated 10/24/2019 at 5:43pm, completed by Staff PP (LVN)

Patient #6.
Daily Nursing Assessment, dated 10/23/2019 at 9:00pm, completed by Staff OO (LVN)

Patient #7.
Daily Nursing Assessment, dated 10/24/2019 at 9:01am, completed by Staff PP (LVN)

Patient #8.
Daily Nursing Assessment, dated 10/23/2019 at 9:00pm, completed by Staff OO (LVN)

Patient #9.
Daily Nursing Assessment, dated 10/22/2019 at 9:20pm, completed by Staff G (LVN)

Patient #10.
Daily Nursing Assessment, dated 10/24/2019 at 9:13am, completed by Staff PP (LVN)

Patient #11.
Daily Nursing Assessment, dated 9/27/2019 at 10:00am, completed by Staff QQ (LVN)

Patient #12.
Daily Nursing Assessment, dated 10/24/2019 at 9:00pm, completed by Staff OO (LVN)

Patient #13.
Daily Nursing Assessment, 10/20/2019 at 7:30pm, completed by Staff RR (LVN)

Patient #14.
Daily Nursing Assessment, dated 10/24/2019 at 9:07 am, completed by Staff PP (LVN)

Patient #15.
Daily Nursing Assessment, dated 10/24/2019 at 9:00pm, completed by Staff OO (LVN)