Failure to Verify RN License Status
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN), identified as Employee E4, held an active license in accordance with state laws. The RN was hired on November 4, 2024, but the facility did not verify his RN license until December 17, 2024, at which point it was discovered that his license had expired on October 31, 2024, and he was on probation. Despite this, RN Employee E4 worked 48 shifts from November 4, 2024, through January 5, 2025, as a medication passing nurse and RN supervisor. The facility's Human Resource employee, who was terminated on December 31, 2024, failed to ensure the RN's license was updated and active before his start date. The Regional Human Resource Employee E2 discovered the expired license during an audit on January 6, 2025, and informed the Nursing Home Administrator. The Director of Nursing confirmed that RN Employee E4 worked in his capacity without a valid license, and the Nursing Home Administrator acknowledged the facility's failure to comply with state licensing requirements.
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 for Background checks and RN job description 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.