Assessments Not Performed or Validated by RN
Penalty
Summary
The facility failed to ensure that assessments for two sampled residents were performed by a registered nurse (RN) as required by professional standards and the facility's comprehensive care plan. Specifically, review of the residents' records revealed that several SBAR Communication Forms, which are used to evaluate residents across ten body systems, were either unsigned or signed only by a licensed vocational nurse (LVN) rather than an RN. In some instances, the signature area was left blank, and in others, the forms were completed and signed solely by an LVN without RN validation or co-signature. The director of nursing (DON) and administrator confirmed that these forms are considered assessments and acknowledged that they were not completed or validated by an RN as required. The report references the Nursing Practice Act and the Scope of Vocational Nursing Practice, which clarify that while LVNs may contribute to data collection, only RNs are qualified to analyze, synthesize, and make clinical judgments necessary for comprehensive assessments. The failure to have RNs complete or validate these assessments means that the facility did not meet the professional standards of quality required for resident care planning and assessment. The DON and administrator acknowledged these findings during the surveyor's review.
Plan Of Correction
What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice On April 8, 2025, DON assessed resident #1 after notification by nurse that the X-ray result showed a closed nondisplaced fracture of the right ilium, unspecified fracture morphology. IDT reviewed the occurrence of injury of unknown source on April 8, 2025. On 2/11/2025, the IDT reviewed the fall occurrence of resident #2 the same day. Both residents did not sustain significant changes after occurrences. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken All residents had the potential to be affected by the deficient practice. What measures will be put into place or what systemic changes will be made to ensure that the deficient practice does not recur On April 17, 2025, DON initiated in-services for licensed nurses for completion and signing of the SBAR and Scope of Practice of LVNs. On May 21, 2025, DON initiated in-service for licensed nurses to write clinical notes or progress notes detailing observations after an incident of fall. The findings will be communicated with the physician. The DON also continued the discussion about the role of LVN and RN that was initiated on the April 17, 2025, in-service. How the corrective action(s) will be monitored to ensure the deficient practice will not recur; i.e., what quality assurance programs will be put into place DON or designee will review the fall incidents, including documentation, care plans, new interventions, and notifications. This review will take place during the daily Interdisciplinary Team (IDT) meetings, held on business days. Findings from weekly audits for 12 weeks will be presented by the DON to the QAPI committee monthly for 3 months. Date by which systemic corrections will be completed: May 31, 2025