Unlicensed Nurse Provided Care and Administered Medications
Penalty
Summary
The facility failed to ensure that all nursing staff maintained appropriate and current licensure while working, resulting in an unlicensed individual performing duties as a nurse. Specifically, an LPN's license expired, and she continued to work as a nurse for a period of time without a valid license. The Director of Nursing (DON) and other staff confirmed that the lapse in licensure was not identified until after the LPN had already worked several shifts in the nursing role. The DON admitted that the LPN was a transfer from another facility and her license status was not checked upon transfer. Once the expired license was discovered, the LPN was removed from nursing duties and reassigned as a CNA while she worked to renew her license. During the period when the LPN's license was expired, she administered medications and provided nursing care to multiple residents with complex medical conditions, including Alzheimer's disease, bipolar disorder, chronic kidney disease, and various mental health disorders. Medication administration records confirmed that the unlicensed LPN dispensed a range of medications to several residents during this time. The facility census indicated that 52 residents could have been affected by this lapse in licensure oversight.