Just curious. Work as LTC Weekend Supervisor. Have LVN who works the floor, but also takes call for a physician who has several patients in the facility. The LVN scope of practice prohibits independent nursing judgment and limits them to focus assessments. There by limiting their ability to evaluate an acute change in condition, take action to repair the condition by executing orders for medication, labs or tests without directly consulting the APN, PA or MD. So, when the MD is called, the service directs me to the LVN standing next to me. (Yes, she is taking call while she is working the floor!! Huge conflict). Then she actually gives me an order, based on her interpretation of labs or other vital signs, for additional labs, x-rays to confirm her suspected diagnosis, antiemetics, antipyretics, PPI's etc. All without checking a chart for possible drug interactions (like she would recognize one) or allergies to medications!!. The DON and ADM are fully aware of this "Practice of medicine" and I am curious, should I notify the BON, on both LVN and DON, the Dept of Age/Dis to intervene for potential immediate harm to a patient, and the Board of Med for delegation violations on the MD's part? I know I hold responsibility for direct report for practice violations on the LVN's part at least to cover my license as a mandated reporter!! Just curious. Have my NPA, Occ Codes and all the necessary doc's to move forward, just don't want to destroy any careers. But, she is obviously in over her head, but orders with complete disregard to patient safety. Thanks
You are doing what you feel is right... and there is nothing wrong with that! :)
The only way we know what is right or wrong is to ask the people who made up the laws to begin with. I must admit the LPN role confuses me. I have seen some great LPNs; however, I don't think the role is defined well enough... at least not in my state. I can ask 5 nurses what a LPN can do and I can pretty much guarantee you that I will get 5 different answers.
There is a huge disconnect up in my area between what they do vs. what they should do. It is not unusual to see LPNs practice professional nursing.
Specializes in Gerontology, Med surg, Home Health.
Let me get this straight. The LPN works as a staff nurse in your facility. She also works for an MD who gives her permission(for lack of a better word) to give orders for his patients. Speaking for myself (and for my staff since I am the DNS), this practice would not be tolerated in my building. We take orders from MDs, nurse practitioners, and Physicians' Assistants. Never would I take an order from an LPN or a regular old RN for that matter.
So what you're really angry about is that this LVN is charge off-hours. She's taking orders from legitimately licensed personnel and then passing them on as per protocol. And about this you're going to call the BON.
Nope...
As I understand the OP...
She (the LPN) IS NOT even calling/communicating with the "legitimately licensed personnel"...
This LPN can/will just scream patient orders off the top of her head (without consulting a properly trained and licensed RN/APN/PA/MD/DO) while walking down the hall... (am I correct...??)
As a former LPN...and current APN... I KNOW s/he is not adequately trained to do so...
It sounds like this LPN is "practicing medicine" without a license...
It IS your duty to report this to the BON and seek clarification.
If one of these patients have a poor outcome... YOU WILL be held liable... simply because YOU followed the "orders" of a person YOU knew was NOT authorized to "Practice Medicine."
NO ONE will protect your license as well as you will...
I think this person has 2 jobs. While working at the LTC facility, patients from her other job are calling her and that she is taking phone calls for the doctor. If I understand (which is a BIG if)... she is traiging for a doctor while working at the LTC facility.
The doctor that she is taking calls for also has priviledges at this LTC facility and therefore she is acting in a dual role.
Specializes in Acute/ICU/LTC/Advocate/Hospice/HH/.
ok everyone, just in from the texas bon, and it is cut and paste, her actual text, not rewritten or altered in any form. will file the official concern in the morning with the bon's reply attached to cover me re: my duty to report. thanks for all the opinions, but knew it had to be spelled out in b&w somewhere. cool topic though huh?
board staff suggest you again review the board's faq on lvn's being on-call/performing telephonic nursing/triage, along with position statement 15.5 re: nurses carrying out standing orders. we also suggest review of npa section 301.002(2) and (5) (definitions of professional and vocational nursing). both definitions in statute preclude a lvn or rn from engaging in "aspects of medical diagnosis or prescription of therapeutic or corrective measures." this includes delegation of "medical assessment" which would be the practice of medicine, not the practice of nursing, as it requires independent medical judgement.
the faq on lvns being "on-call" explains the position of the bon (which was also the position of the bvne before the board's combined in 2004) that telephonic nursing, being on-call, and performing triage are all outside of the lvns scope of practice---including that no amount of "ojt" or "continuing education" would provide a lvn with the minimum knowledge necessary to carry out such tasks. the only exception is in a controlled/structured setting, such as a poison control center or a md office where the md is present and the lvn is dealing strictly w/pts in the office setting (and can physically summon the md to come). poison control centers work off of approved computerized medical flowsheets that do the decision-making for the nurse, who simply enters the data and the system tells him/her what question to ask next. there is no independent thinking or judgement in this example.
rule 217.11 standards of nursing practice is the main rule applied to nursing practice in any setting. standard (1)(b) requires a nurse to always advocate for client safety. standard (1)(n) requires a nurse to clarify any order or treatment that the nurse believes could be inaccurate, non-efficacious, or contraindicated. this would also apply if you do not believe it to be a valid order authorized by a physician's standing order. even if the lvn is using standing orders, to have the lvn making the determination telephonically of which standing order is appropriate, including verbally relaying drug, dose, route, frequency, is not only performing telephonic nursing/independnet nursing judgment of a patient situation that is not stable and predictable, but is also not in alignment with recommended "best practices" with regard to minimizing verbal order use (joint commission national patient safety goals and the institute of safe medication practices http://www.ismp.org.)
there is a pharmacy board regulation that provides that even an unlicensed person functioning in a physician's office setting and communicating directly with the md can relay orders as the physician's "designated agent." the law regarding verbal orders through another party relayed from the physician is under their jurisdiction. please see their web site at http://www.tsbp.state.tx.us or contact them at (512) 305-8000. the statute in the pharmacy act (tx occ. code, subtitle j, section 551.003(14) defines who can be a "designated agent" for relaying orders from the md. this law does states under (a) that the designated agent is "an individual" designated by the md---ie, in a physician's office it does not have to be a licensed person who relays orders from the md. in a facility, the designated agent definition includes: "(b) a licensed nurse, physician assistant, or pharmacist employed in a health care facility to whom the practitioner communicates a prescription drug order;"
pharmacy board rule 291.34(b)(4)(a) and (b) further establishes requirements for verbal or electronic submission of orders, including orders communicated by a designated agent. bon staff cannot speak as experts on laws outside of the bon's jurisdiction, so staff again recommend you call the pharmacy board should you have additional questions about the statute or rules listed above.
Specializes in UR/PA, Hematology/Oncology, Med Surg, Psych.
So is the BON pursuing this?
Correct me if I'm wrong, but you're saying that the Dr. doesn't want bothered after hours by being on-call, so he hired this LPN to do it for him? Instead of having another Dr. take his patient calls, he has the LPN take them and give orders, etc. without her consulting another Dr., NP, etc? So she isn't getting orders from someone to pass along, she's giving them all on her own?
Wow! Not safe, legal, or ethical. How can she or the Dr. think that this is o.k.
Hopefully the BON will get involved which would lead to the BOM getting involved. This practitioner is allowing this and therefore shares the accountability.
Wow, I don't know how that was allowed to go on for so long. There is no way I would take an order from an LPN or anyone for that matter that was not a PA, NP, or MD. If there was no support from the facility, I would quit before it threatened my license. That is unbelievable! You would think after a MD had worked so hard for his degree that he would guard it a little more closely:bugeyes:
So, is the BON going to follow up, I could not tell from their response?
PsychNurseWannaBe, BSN, RN
747 Posts
You are doing what you feel is right... and there is nothing wrong with that! :)
The only way we know what is right or wrong is to ask the people who made up the laws to begin with. I must admit the LPN role confuses me. I have seen some great LPNs; however, I don't think the role is defined well enough... at least not in my state. I can ask 5 nurses what a LPN can do and I can pretty much guarantee you that I will get 5 different answers.
There is a huge disconnect up in my area between what they do vs. what they should do. It is not unusual to see LPNs practice professional nursing.
Let us know what you find out.
:typing