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F0836
E

Failure to Verify and Track Nursing License Expiration

Greensboro, North Carolina Survey Completed on 04-17-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to verify that one of its nurses, Nurse #4, maintained a valid, non-expired nursing license. Record review and staff interviews revealed that Nurse #4 was employed as an LPN and continued to work at the facility after her license had expired. Nurse #4 was unaware of her license expiration until she received a letter from the state Board of Nursing. She reported that she had not worked for a period due to surgery and chemotherapy and did not recall receiving any renewal reminders from the facility or the Board of Nursing. The facility did not notify her of the license expiration, and she confirmed she had not worked since discovering her license was expired. Interviews with facility leadership indicated inconsistencies in the tracking and notification process for nursing licensure. The DON stated that the facility was responsible for tracking licenses and notifying staff 30 days prior to expiration, with the human resources department handling notifications. However, the Human Resource Director described a system in place since 2021 that should have sent automatic reminders to the employee and relevant staff, but could not explain why Nurse #4's case was missed. The Administrator stated that the facility did not keep track of nursing licensures and considered it the employee's responsibility to maintain current licensure.

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