LVN Worked Multiple Shifts with Inactive License Due to Lapse in Verification
Penalty
Summary
The facility failed to ensure that one of its Licensed Vocational Nurses (LVN) maintained an active license in accordance with state law. Review of records showed that the LVN worked a total of 61 shifts over a period of several months while her license was inactive due to failure to renew. The issue was discovered when the Director of Nursing (DON) was notified by the state licensing board that the LVN's license was inactive. The LVN had mistakenly selected the inactive option instead of renewal during the online renewal process and did not verify the status of her license, assuming it was renewed because her payment was processed. The facility's policy required Human Resources (HR) to verify employee licenses upon hiring and monthly thereafter, and to notify the facility of any approaching expiration dates or inactive licenses. However, the HR department did not identify that the LVN's license had become inactive, and the LVN continued to be scheduled and worked multiple shifts without a valid license. The deficiency was identified through interviews and review of timecards, licensing records, and facility policies.
Plan Of Correction
Corrective Action LVN 2: LVN license was updated to active on 05/08/2025. Identification of Others at Risk All residents of this facility have the potential to be affected by this deficiency. A review of 25 RN and LVN licenses status has been done by the DON on 05/06/2025. All licenses were active. Process to Prevent Recurrence The DON has inserviced the licensed nurses between 05/7/2025 and 5/10/2025 on the importance of keeping their nursing license active. The DON/designee will check the status of the licensed nurses' licenses monthly X3 months and annually thereafter. Results of monthly review will be reported to QA&A committee. Monitoring Process The DON will report the results of the nursing license reviews to the QA&A committee monthly. The Quality Assessment & Assurance and Continuous Quality Improvement Committee will monitor compliance by review of findings and actions/resolutions taken during the monthly meeting x3 months. Complete Date: 06/11/2025