RNs Tops at Preventing Costly Medicine Problems in SNFs

Registered nurses (RNs) are better equipped than licensed practical nurses (LPNs) to identify medication order discrepancies that could lead to major problems, according to a new study from the University of Missouri.

“If we’re not managing these medications appropriately and not identifying what the potential problems are, these residents may end up back in the hospital,” lead researcher Dr. Amy Vogelsmeier told Skilled Nursing News. “It’s costly in terms of time and it’s unnecessary. It’s something that could have been avoidable.”

The study, which was published in BMC Health Services Research, examined how RNs and LPNs described their part in the practice of medication reconciliation, which identifies medication order discrepancies when patients transfer from hospitals to nursing homes, as well as their rationale for identifying medication order discrepancies.


It included 13 RNs and 13 LPNs working in 12 different nursing homes in the Midwest. The researchers used four resident transfer scenarios, with embedded medication order discrepancies, and interviewed the nurse participants about whether or not they perceived such discrepancies.

RNs ask more questions

They found that RNs were far more likely to identify discrepancies, which meant they questioned things more, Vogelsmeier said.


RNs would talk about how they wanted to know a patient’s clinical history and the medical appropriateness of a prescription; they would also be more likely to want to communicate with a physician about those questions, the study found.

LPNs, by contrast, were much more likely to assume orders were correct, even if discrepancies existed between the order and a patient’s medication.

“They made assumptions about the resident’s background or history, even if they didn’t have that in front of them,” Vogelsmeier said.

She noted that LPNs are much more focused on the tasks of their work, due to concerns about time and competing demands on their work.

“So they’re thinking: ‘I’ve got to get this medication paperwork completed, I’ve got to get the resident in the bed,’” she explained. “It’s a checklist on the list of things they have to get done.”

What SNFs can learn

The study should not be seen as pitting RNs against LPNs, but rather as recognizing the differences in the training and scope of their respective tasks, Vogelsmeier stressed. Yet in many nursing homes, RNs and LPNs are assigned to the same tasks and given the same roles, she noted.

“There’s a difference in their level of education and there’s a difference in their legal scope of practice,” she said.

Though nursing home residents are now much more ill and frail coming out of the hospital than in years past, nursing homes have not adjusted staffing to account for the difference, Vogelsmeier said. Regulations have also not adjusted. And though cost is a factor, as LPNs are less expensive than RNs in terms of staff salaries, Vogelsmeier believes the other element is lack of recognition for RNs’ different contributions.

Recognizing potential areas of improvement in care coordination has become a major issue in the skilled space, especially as SNFs look to reduce readmissions and participate in bundled payment models, which place a financial premium on working together across the care spectrum.

“RNs have a more expanded understanding of clinical conditions, understanding of how to assess a resident or condition change, how to identify potential problems,” she explained. “There’s the potential that those types of things may go undetected when RNs aren’t at the front line doing that or overseeing that kind of work.”

Written by Maggie Flynn

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