Expired RN License Leads to Deficiency
Penalty
Summary
The facility failed to ensure that nursing staff possessed the required skills to properly care for residents' needs, as evidenced by the case of RN Employee E4. The personnel records review revealed that RN Employee E4 was hired on November 4, 2024, but their RN license had expired on October 31, 2024. Despite this, RN Employee E4 continued to work as a licensed professional RN, performing duties such as passing medications, documenting in medical records, and sometimes acting as an RN supervisor. These responsibilities require a current and active RN license, which RN Employee E4 did not possess at the time. Interviews with the Director of Nursing and the Nursing Home Administrator confirmed that the facility did not ensure that RN Employee E4 had the necessary valid license to perform their duties. This oversight was identified during a review of personnel files, facility documentation, and policy review, highlighting a failure in the facility's processes to verify and maintain up-to-date licensure for their nursing staff. The deficiency was noted for one out of five personnel files reviewed, indicating a lapse in compliance with the regulatory requirements for nursing services.
Plan Of Correction
1. Registered Nurse Employee E4 no longer works at the facility. 2. The Human Resource Director/designee will audit current licensed staff to ensure licenses are active and in good standing. 3. The Human Resource Director will be re-educated on facility policies by the Nursing Home Administrator/designee. 4. The Nursing Home Administrator/designee will audit new hires weekly for four weeks and monthly for three months to ensure licensed staff licenses are in good standing. Outcomes will be reported to the Quality Assurance Performance Improvement Committee for review and recommendations.