Health inspection·December 11, 2024

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm Based on record review and interview, the facility failed to ensure Resident 1's assessments were performed by a registered nurse (RN) to meet professional scope of practice and standards of practice. Residents Affected - Few This facility failure had the potential to place Resident 1 at risk of not being assessed appropriately and potentially resulting in harm to resident. Findings: 1.According to the Nursing Practice Act, Business & Professions Code, Chapter 6, Nursing Section 2725 indicates, .(b) The practice of nursing within the meaning of this chapter means those functions, including basic health care, that help people cope with difficulties in daily living that are associated with their actual or potential health or illness problems or the treatment thereof, and that require a substantial amount of scientific knowledge or technical skill . RN is accountable for an ongoing comprehensive assessment that includes data collection (LVN data collection contribution), analysis, and drawing conclusions/making judgments in order to: formulate diagnoses and update diagnoses, formulate or change the plan of care, decide on specific activities to implement the plan of care, prioritize and coordinate delivery of care, delegate to nursing care competent staff to deliver required care . RN uses scientific knowledge and experience to make clinical judgments/assessments about observed abnormalities and changes based on a series of complex, independent and collaborative decision-making activities Set priorities for implementation of nursing care, priorities regarding urgency of patient concerns . LVN is not prepared by formal education to make RN level nursing judgments/assessments that include independent analysis, synthesis, and decision-making. RN is responsible for collecting (LVN data collection), analyzing, and collaborating with all information sources to ensure a comprehensive written plan of care that is based on current standards of safe practice. According to the Scope of Vocational Nursing Practice, section 518.5 indicates, The licensed vocational nurse performs services requiring technical and manual skills which include the following: (a) Uses and practices basic assessment (data collection), participates in planning, executes interventions in accordance with the care plan or treatment plan, and contributes to evaluation of individualized interventions related to the care plan or treatment plan. The data collection performed by the LVN is integrated to the data collection the RN collects to analyzed, synthesized, and make decisions regarding patient/residents' care as outlined above. During a concurrent interview and record review on 12/10/24 at 10:30 a.m. with the director of nursing (DON), Resident 1's documents titled, SBAR/COC, dated 11/8/24 at 2:29 p.m., was reviewed and indicated, Resident 1 had a change of condition (COC) due to weight loss of 7.8 pounds in one week. SBAR/COC, dated 11/18/24 at 8:25 p.m., indicated, Resident 1 developed a skin discoloration on left Page 1 of 2 055957 055957 12/11/2024 Santa Paula Post Acute Center 250 March Street Santa Paula, CA 93060

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few lateral leg. SBAR/COC, dated 12/9/24 at 1:45 a.m., indicated, Resident 1 had lower abdominal distention/more pronounced on right side. SBAR/COC, dated 12/10/24 at 7 a.m., indicated Resident 1 developed a dry scab on top of right eyebrow. The SBAR/COC document consisted of Resident 1's assessment of all the body systems. The DON confirmed the SBAR/COC documents are Resident 1's assessments and were conducted by LVNs. Communicated to the DON Resident 1's assessments were conducted by an LVN without having an RN validate the assessments and/or cosign the assessments. It is not within the LVN scope of practice to perform assessments independently. The DON acknowledged this and stated, I understand. I will check with information technology IT to see if we can add on the document the RN's signature who is validating the assessment . 055957 Page 2 of 2