Unlicensed Staff Administered Controlled Substances as LVN
Penalty
Summary
The facility failed to ensure that Staff 1, who was hired as a Licensed Vocational Nurse (LVN), met the required qualifications and held a valid professional LVN license in accordance with state laws. Staff 1 was employed and functioned as an LVN for over a year and a half without proper documentation or verification of a valid LVN license. The personnel file for Staff 1 contained only a California ID and Social Security card, and a copy of an LVN license belonging to an unidentified individual, which did not match Staff 1’s identification. The Director of Staff Development confirmed that Staff 1 was hired using another individual's LVN license and that no verification was conducted through the California Board of Vocational Nursing and Psychiatric Technicians system. During the period under review, Staff 1 administered controlled substances, including Norco, Oxycodone, Percocet, and Tramadol, to multiple residents with serious medical conditions such as osteomyelitis, fractures, and paraplegia. Medication Administration Records showed that Staff 1 administered these medications on numerous occasions to at least four residents, as well as to six additional residents. The facility’s policy required employment background screening and license verification, and stated that employees without a valid license should not be employed. The Administrator acknowledged that the policy was not followed, resulting in the employment of an unlicensed and unqualified individual who provided direct care and administered controlled substances to residents.