State Findings:
Based on interviews and record review, the facility failed to provide services by qualified persons for two (#21 and #9) out of two residents reviewed out of 23 sample residents.
Specifically, the facility failed to ensure for Resident #21 and Resident #9:
–Staff who were licensed practical nurses (LPN) did not perform duties outside of their scope of practice including performing intravenous/peripherally inserted central catheter (IV/PICC) line flushes and procedures without qualifications or certification; and,
–LPN’s did not chart under the registered nurse (RN) designated orders on the medication and treatment administration record (MAR/TAR) and in the progress notes for a procedure that was to be completed by an RN.
Historical Note: Prior to January 1, 2006, Chapter IX rules required LPNs in Colorado to obtain separate IV certification, which was then attached to their licenses. LPNs were granted either an IV or IV-2 certification status after completion of a Board-approved IV course. IV-2 status included education in central line IV therapy. LPNs without IV-2 status, as of January 1, 2006, were ruled to no longer have IV certification. LPNs without IV-2 status, including any LPN/LVN endorsing into Colorado from another jurisdiction, must bear the responsibility, with their employer, of acquiring the necessary education, training and experience to safely perform within the IV scope of practice pursuant to section 3 of these rules. The approval process for IV Therapy and venous blood sampling authority contained in these rules replaces the previously applicable bi-level certification.
Review of the January 2023 CPO revealed the following order to be completed by an RN:
RN to flush PICC line with 10 cubic centimeters (cc) normal saline (NS) evert shift for IV therapy. PICC lumen flushes, positive blood return, dressing dry and intact, site without signs/symptoms of infection.
Discontinue this order when the PICC line is removed/discontinued. Start date 1/13/23.
Review of the January 2023 MAR/TAR revealed the following:
On 1/14/23 (day) LPN #2 documented the RN procedure was administered by her.
On 1/19/23 (evening) LPN #4 documented the procedure by signing his name and using code nine
(other/see progress notes), the corresponding progress note dated 1/19/23 at 9:17 p.m. revealed, completed by RN and signed by LPN #4.
-However, there was no signature and title of the person administering the treatment (beyond LPN #4) and no further progress notes on 1/19/23 for that treatment.
On 1/19/23 (night) LPN # 1 documented the procedure by signing her name and using code nine (other/see progress notes), the corresponding progress note dated 1/20/23 at 3:43 a.m. revealed, completed by RN and signed by LPN #1.
-However, there was no signature and title of the person administering the treatment (beyond LPN #1) and no further progress note documentation by an RN on 1/20/23 for that treatment.
On 1/23/23 (night) LPN # 4 documented the procedure by signing his name and using code nine (other/see progress notes), the corresponding progress note dated 1/24/23 at 2:35 a.m. revealed, to be completed by RN and signed by LPN #4.
-However, there was no signature and title of the person administering the treatment (beyond LPN #4) and no further progress note documentation by an RN on 1/24/23 for that treatment.
On 1/25/23 (day) LPN #2 documented the RN procedure was administered by her.
On 1/27/23 (day) LPN #2 documented the RN procedure was administered by her.
On 1/27/23 (evening) LPN #4 documented the procedure by signing his name and using code nine
(other/see progress notes), the corresponding progress note dated 1/27/23 at 9:05 p.m. revealed, completed by RN and signed by LPN #4.
-However, there was no signature and title of the person administering the treatment (beyond LPN #4) and no further progress note documentation by an RN on 1/27/23 for that treatment.
On 1/27/23 (night) LPN #4 documented the procedure by signing his name and using code nine (other/see progress notes), the corresponding progress note dated 1/28/23 at 3:14 a.m. revealed, to be completed by RN and signed by LPN #4.
-However, there was no signature and title of the person administering the treatment (beyond LPN #4) and no further progress note documentation by an RN on 1/28/23 for that treatment.
On 1/28/23 (day) LPN #2 documented the RN procedure was administered by her.
On 1/28/23 (evening) LPN #4 documented the procedure by signing his name and using code nine
(other/see progress notes), the corresponding progress note dated 1/28/23 at 9:02 p.m. revealed,
To be completed by RN and signed by LPN #4.
-However, there was no signature and title of the person administering the treatment (beyond LPN #4) and no further progress note documentation by an RN on 1/28/23 for that treatment.
Review of the February 2023 MAR/TAR revealed the following:
On 2/1/23 (night) LPN #1 documented the RN procedure was administered by her.
On 2/4/23 (evening) LPN #1 documented the procedure by signing her name and using code nine (other/see progress notes), the corresponding progress noted dated 2/4/23 at 7:54 p.m. revealed Completed by RN and signed by LPN #1.
-However, there was no signature and title of the person administering the treatment (beyond LPN #1) and no further progress note documentation by an RN on 2/4/23 for that treatment.
On 2/7/23 (evening) the documentation was blank, there was no documentation that the physician orders had been followed.
On 2/8/23 (night) LPN #1 documented the procedure by signing her name and using code nine (other/see progress notes), the corresponding progress noted dated 2/9/23 at 3:52 a.m. revealed completed by RN and signed by LPN #1.
-However, there was no signature and title of the person administering the treatment (beyond LPN #1) and no further progress note documentation by an RN on 2/9/23 for that treatment.
On 2/9/23 (evening) LPN #1 documented the procedure by signing her name and using code nine (other/see progress notes), the corresponding progress noted dated 2/9/23 at 9:36 p.m. revealed completed by RN and signed by LPN #1.
-However, there was no signature and title of the person administering the treatment (beyond LPN #1) and no further progress note documentation by an RN on 2/9/23 for that treatment.
On 2/12/23 (evening) the documentation was blank, there was no documentation that the physician orders had been followed.
On 2/15/23 (night) the documentation was blank, there was no documentation that the physician orders had been followed.
Review of the February 2023 CPO revealed the following order to be completed by an RN:
Obtain complete blood count (CBC), comprehensive metabolic panel (CMP) and C-reactive protein (CRP) (night shift nurse to have lab requisition completed) RN to draw via PICC every day shift, every Tuesday, for septic arthritis and bacteremia. Start date 1/17/23.
Review of the February 2023 MAR/TAR revealed the following:
On 2/7/23 (day) LPN # 2 documented the RN procedure was administered by her.
-LPN #1, LPN #2 and LPN #4 did not have intravenous certifications.
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