Failure to Verify Nursing Licensure for LPN
Penalty
Summary
The facility failed to ensure that nursing staff were properly licensed to practice in the state of Missouri. An LPN, who had obtained a nursing license in Illinois, was employed and worked as a GPN and later as an LPN in the facility without holding a Missouri nursing license. Review of records showed that the LPN had completed a practical nursing program and began working as a GPN, but after passing the licensure examination, continued to work as an LPN without Missouri licensure. The LPN provided direct care, including medication administration, wound care, and care for residents with tracheostomies and tube feedings, often without direct supervision or pairing with an experienced nurse. Interviews with facility staff revealed that there was an expectation for GPNs to work under the oversight of a licensed nurse and for HR to verify and track licensure status, including the 90-day limit for GPNs to obtain licensure. However, HR did not verify that the LPN was licensed in Missouri, and neither the new DON nor the Administrator were aware of the situation until it was brought to their attention by the state surveyor. The LPN resigned after the issue was discovered. The failure to verify and ensure proper licensure had the potential to affect all residents in the facility.