Avoiding Joint Commission Citations: LPN and RN Scope of Practice
In nursing care centers, the functions and responsibilities of the RN and LPN are often considered interchangeable. But, due to differences in the Nurse Practice Acts for Registered Nurses and Licensed Nurses (Practical (LPN)or Vocational (LVN)), there are circumstances in which their roles and responsibilities should be assessed differently.
Each state has their own Nurse Practice Acts for these two disciplines. There are some commonalities though, specifically as they relate to Joint Commission standards and surveys.
When Joint Commission issues recommendations related to nurses practicing outside of their scope, it can lead to re-surveys – a costly and burdensome process organizations want to avoid. There are two areas that arise most often during Joint Commission surveys in Nursing Care Centers- Comprehensive Assessments and IVs.
Can LPNs Perform Comprehensive Assessments?
The short answer is no. No U.S. state allows LPNs to perform comprehensive assessments independently.
While state practice acts vary in the exact terminology used to communicate this distinction, they generally indicate that LPNs are limited to conducting focused assessments and data collection. This data is then reviewed and compiled into the comprehensive assessment by an RN to develop the plan of care.
What does this mean in terms of day-to-day operations? First and foremost, each organization should start by understanding their state nurse practice acts for LPNs and RNs. Then, ensuring their policies and procedures are consistent with what is permitted under the practice acts. And finally, ensuring the day-to-day operations are consistent with those policies and procedures.
In the nursing care center setting, comprehensive assessments are most frequently completed upon resident admission, annually and with a significant change in resident condition.
Joint Commission will often cite instances of LPNs performing services outside of their scope of practice under human resources standards or one of the leadership standards. Examples of actual Joint Commission recommendations cited under one of these standards include:
“The LVN completed the admission assessment and initiated the baseline care plan without oversight or collaboration with an RN which is not in accordance with California law.”
“In resident records reviewed, admission data was collected by a licensed nurse who also established the interim plan of care without RN oversight or collaboration which is not in compliance with law and regulation in the state of Illinois.”
Based on each states Nurse Practice Act, and the organization’s policies and procedures, organization leaders may include steps such as having an RN conduct a documented review of the data collected by an LPN on admission to complete the comprehensive assessment and initiate the plan of care. Another option may be to have an LPN begin to collect data and have the RN join them at some point during the physical assessment. Some organizations may choose to have only RNs conduct admission assessments. These are just a few options that ensure nurses operate within the scope of practice set by the state, while ensuring residents are being comprehensively assessed in a timely manner.
Can LPNs Provide Care and Treatment of IVs?
The short answer is sometimes.
Once again, the Practice Acts vary from state to state regarding IVs. Most states require LPNs to complete a state approved certification program which would allow them to provide certain care and treatment of specified types of IVs.
It is imperative that organizations familiarize themselves with the IV certification options and requirements for LPNs specific to their State Practice Act. LPNs must practice due diligence when researching course options to ensure the certification class and curriculum meet state approval.
State Nurse Practice Acts have specific, varied, requirements for LPNs once IV certified. Requirements may include, but not be limited to, the type of IVs (e.g. peripheral lines vs central lines), type of fluids and medications that can be administered and the level of RN supervision required (e.g. onsite in some states, while others allow remote support). The majority of states allow certified LPNs to monitor IV sites and perform routine site care and dressing changes. Organizations must ensure their policies, procedures and practices for IV care and administration are consistent with the Practice Act.
Examples of IV related Joint Commission recommendations cited under the HR or Leadership standards (as cited above) include:
“LPNs administering IV antibiotics through the PICC line did not have the right certification, education or competency.”
“The LPN administered antibiotics through a central line which is not in compliance with the Illinois Administrative Code which only allows LPNs to administer medications through a peripheral line, resulting in staff performing duties outside their license and scope of practice.”
In just reviewing these two areas - Comprehensive Assessments and IVs, it is clear that challenges will arise if organization leaders are not familiar with the details of the Nurse Practice Acts in their state.
It is essential that these rules are taken into consideration in day-to-operations such as hiring needs, scheduling, and accepting new admissions to name a few to ensure the appropriate staff are available to provide care, treatment and services in accordance with licensure requirements, laws and regulations.
