LPNs working unsupervised in nursing homes

whipping girl in 07, RN · Aug 5, 2009

Depends on the SBONs rules, which may vary from state to state. You just have to check with the board.

It may be legal, but it doesn't necessarily make it right.

Sensoria17 · Aug 5, 2009

I know in CA it depends on the size of the facility.

lisamc1RN, LPN · Aug 6, 2009

It's legal in Ohio. We have to have 8 hours of RN coverage per day and after that, we don't have to, and often don't have an RN in the building. This isn't to say that we don't have access to our RN's. We do. We have an RN on call every day of the week.

Thornbird · Aug 6, 2009

It is legal in many states for LPN's to work in a nursing home without an RN present. Actually, I believe the majority of states allow for 11-7 to be staffed without an RN. Even in states, like CT, where it is equired that an RN be present, the facility may get a waiver for night shift if there is no RN available and the level of care doesn't warrant it.

Why exactly would an RN be necessary on night shift in an average nursing home? The nature of the facilities is that patients are generally stable and if something acute happens, the patient is usually sent to an ED anyways since covering docs, for the most part, don't want to give orders on patients they don't know.

Depending on scope of practice in a particular state, there is often little to no difference in what LPN can actually DO when dealing with non-critical patients. Including updating care plans, writing orders even initiating IV's.

catlynLPN · Aug 6, 2009

It's legal in my state. That's what LTC's are mostly staffed with.

We also work on my state job without an RN in the building.

But we have RNs on call.....we can reach them at any time for any reason, also have a doctor on call, and my facility is very good about accepting the LPNs judgement on sending someone to the ED and if it is really urgent we don't even have to call the doctor or RN first before sending someone out.

southernbeegirl, BSN, RN · Aug 6, 2009

if a facility has 99 beds or less they are required to have 8 consecutive RN hours/day. if 100or more beds then they have to have RNs 24/7

nerdtonurse?, BSN, RN · Aug 6, 2009

It's legal in mine. After 11p, LPNs are the only ones on most night shifts at the NHs I call when we get an admission. They always have an RN on call; on the rare occasion I talk to an RN, she's inevitably a newhire (they don't want to pay RNs nightshift differentials is the complaint I've heard, at least from the NHs around here). Just comes down to plain old money.

While some of the folks are pretty fragile, it's not like it's a hospital, either. If they're so sick that the LPN who's looked after them for 6 hours when the RN's there suddenly can't handle it when the RN drives home, the resident needs to be in a hospital, not a NH. Or you need a different LPN.

SlightlyMental_RN · Aug 6, 2009

Why exactly would an RN be necessary on night shift in an average nursing home? The nature of the facilities is that patients are generally stable and if something acute happens, the patient is usually sent to an ED anyways since covering docs, for the most part, don't want to give orders on patients they don't know.
Depending on scope of practice in a particular state, there is often little to no difference in what LPN can actually DO when dealing with non-critical patients. Including updating care plans, writing orders even initiating IV's.

Would you feel comfortable with the assessment and knowledge level of a LPN to determine if something is serious or manageable until morning? Patients tend to be much more ill in nursing homes and requiring much more in-depth skilled nursing care.

These all happened over 2 noc shifts:

One patient who had repeated non-responsive episodes--had to do repeated in-depth neuro assessments on him.

Had one patient fall twice. 3 other patients fell as well throughout the facility during the shift. All had to be evaluated in order to be determined if they needed to be sent out for further evaluation. One patient did, and had to obtain bed hold for Medicare and print out all the paper work. Had to also give report to the EMT's when they arrived.

Patient's meds have been changed, and need family notification. Had to call family and do drug-teaching/explanation...very in-depth.

Had another patient have a hypoglycemic episode--she needed to be thoroughly assessed.

Another patient was having terrible stomach pain, but she has drug-seeking behaviors.

Patient with terminal cancer is having uncontrolled pain. Track down hospice.

Another patient was having multiple episodes of diarrhea, showing s/s of dehydration.

Another patient was complaining of SOB and chest pain. Had to assess if MI and get orders from MD (for nitro admin., increased 02, etc.).

In my experience, you do not send out to the ER unless absolutely necessary--most acute problems are handled by the RN on staff and a phone call to the MD on call.

AllSmiles225 · Aug 6, 2009

My building is staffed primarily by LPNs on the night shift. I think that LPNs are just as capable of "assessing" a patients need for a visit to the ER and if the situation is not that serious..I also think they are capable of making a phone call to the MD.

SlightlyMental_RN · Aug 6, 2009

My building is staffed primarily by LPNs on the night shift. I think that LPNs are just as capable of "assessing" a patients need for a visit to the ER and if the situation is not that serious..I also think they are capable of making a phone call to the MD.

Believe me, I think that LPN's are very capable and can have great assessment skill, too. In my state, however, the LPN's scope of practice does not include performing assessments. They can collect data, but they are not supposed to be doing in-depth assessments. I'm sure that other states have different views. My concern is whether the LPN wants the same level of responsibility (in the legal-sense) that comes with the further education and certification of having a RN.

Thornbird · Aug 9, 2009

Would you feel comfortable with the assessment and knowledge level of a LPN to determine if something is serious or manageable until morning? Patients tend to be much more ill in nursing homes and requiring much more in-depth skilled nursing care.
These all happened over 2 noc shifts:
One patient who had repeated non-responsive episodes--had to do repeated in-depth neuro assessments on him.
Had one patient fall twice. 3 other patients fell as well throughout the facility during the shift. All had to be evaluated in order to be determined if they needed to be sent out for further evaluation. One patient did, and had to obtain bed hold for Medicare and print out all the paper work. Had to also give report to the EMT's when they arrived.
Patient's meds have been changed, and need family notification. Had to call family and do drug-teaching/explanation...very in-depth.
Had another patient have a hypoglycemic episode--she needed to be thoroughly assessed.
Another patient was having terrible stomach pain, but she has drug-seeking behaviors.
Patient with terminal cancer is having uncontrolled pain. Track down hospice.
Another patient was having multiple episodes of diarrhea, showing s/s of dehydration.
Another patient was complaining of SOB and chest pain. Had to assess if MI and get orders from MD (for nitro admin., increased 02, etc.).
In my experience, you do not send out to the ER unless absolutely necessary--most acute problems are handled by the RN on staff and a phone call to the MD on call.

Nothing on this list is outside of what night shift LPN's are doing all across the country and more. First, some states allow LPN's to perform "basic assessments". Second whatever semantics are used, LPN's are doing assessments every day all over the country, even if in the end it is "cosigned by RN". An LPN is fully capable of "collecting data", informing the MD and proceeding from there. Patient/family teaching re: meds is definitely within LPN scope. Printing paperwork and obtaining bed holds - not so difficult. Recognize S/Sx dehydration - very basic. "Assess hypoglycemia" - use glucometer & follow orders. And how exactly does anyone "assess if MI" without a 12 lead EKG? Why would anyone not seek further treatment for someone having "repeated unresponsive epiodes"? And if these episodes are anticipated, as in near-death, then the plan and oredrs are in place and repeated in-depth assessment not needed. There is no point to Assessment, no matter how "in-depth", if not followed by Planning and Interventions.

No, you don't send SNF patients out unless necessary and if it's not necessary, an LPN should be able to handle the care, if it's so necessary it needs to happen in the middle of the night it's usually obvious even to the CNA's.