It is understandable that there is confusion about which members of nursing services have sufficient authority and education to assess residents in California nursing homes (NHs). The confusion is a consequence of issues related to the discipline of nursing itself, California RN and LVN scopes of practice, the nature of the nursing skill mix used in NHs, and language used in the October 2024 (version 1.19.1) Resident Assessment Instrument/Minimum Data Set guidelines.¹

The discipline of nursing is an applied science that has evolved in the United States based on family and community caregiving practices, in addition to caregiving shortages associated with the Civil War, WWI, and WWII. It includes technical, cognitive, people skills and manual labor. In the late 1940s, educators identified the university setting as providing the proper educational preparation for the professional nurse. The nursing process (assessment, planning, implementing, and evaluating), otherwise known as problem-solving or critical thinking, and the care plan document, were identified as the unique domains of RNs.²

The reality is that many people, regardless of educational preparation, make assessments and problem-solve in their daily lives. However, to perform these skills in the clinical domain, California has defined the RN’s and LVN’s authority, or scope of practice, in regulations. See (https://www.rn.ca.gov). In fact, the authority to make clinical assessments of residents overlaps between the RN and the LVN. The RN is to perform the nursing process, which includes a clinical assessment. Similarly, the LVN has the authority to conduct basic patient assessments. The limitation is that, in California, the LVN is not allowed to conduct “comprehensive” health assessments.³ The responsibility of developing care plans is the responsibility of the RN and physicians.

In fact, we know that most licensed nurses practicing in California NHs are LVNs. They do, in fact, make assessments, and develop care plans. While researchers have reported that LVNs and LPNs commonly practice outside of their scope of practice, the NH industry uses LVNs because their wages are lower than that of an RN. The economic term for this practice is that the LVN is a perfect substitute for the RN. That is the LVN costs less but provides the same value to the consumer. Researchers have reported evidence that suggests that the LVN is not a perfect substitute for the RN. Better quality outcomes have been achieved when NHs have a higher ratio of RNs to LVNs. That is, there is value-added by RN practice that is associated with better resident outcomes. ⁴

As a practical matter, the RN working in a NH needs to recognize two things about their practice in relation to LVN co-workers. Most important is the relationship between the LVN and RN as it relates to assessments associated with completion of the RAI/MDS. CMS states in the RAI/MDS manual that “the MDS does not constitute a comprehensive assessment. It is a preliminary assessment to identify potential resident problems, strengths, and preferences.” ¹ This suggests that, in having an LVN practicing in the state of California, they are not technically practicing beyond their scope of practice. The RN MDS Coordinator, to the extent that they are coordinating the completion of the MDS, are not attesting to its accuracy, only to the completion of the document. Because LVNs in California and other states are developing care plans, whether the RN realizes it or not, they are delegating RN practices to the LVN and need to understand this as such.³

Given these factors, effective use of the nursing skill mix used to provide care to NH residents needs greater study and understanding. Specifically, LVNs and RNs need to better understand their practice relationships as team members and collaborators with nursing assistants and other members of the interdisciplinary team. With the promise of having more RNs working in NHs, it is essential that they learn how to use the nursing skill mix members effectively. RNs need to better educate one another, other providers, family members, and advocates about how the diverse members of nursing services contribute to quality care in the NH.

1. Centers for Medicare and Medicaid Services. RAI Version 3.0 Manual. Chapter 4: Care area assessment (CAA) process and care planning. Version 1.19.1 October 2024.
2. Nursing Clinics (https://www.nursing.theclinics.com) Transforming the Work Environment in Nursing Homes, 2022.
3. California Board of Registered Nursing (https://www.rn.ca.gov)
4. Kolanowski A, Cortes TA, Mueller C., et al. (2021). A call to the CMS: mandate adequate professional nurse staffing in nursing homes. AJN, 121:3.