Failure to Remove Impaired Nurse from Resident Care Duties
Penalty
Summary
The facility failed to ensure resident safety by allowing an LPN, who was observed by multiple staff members to be falling asleep and exhibiting abnormal behavior, to continue providing care throughout her scheduled shift. On the day in question, several staff—including CNAs, housekeeping, and dietary management—witnessed the LPN nodding off while standing, struggling to administer medications, and appearing disoriented while performing resident care tasks. These observations were reported to both the Administrator and the Director of Nursing (DON) early in the shift. Despite these reports, the Administrator and DON initially spoke with the LPN, who stated she was simply tired, and allowed her to return to work after providing her with coffee. Later, after continued staff concerns, the DON administered an over-the-counter urine drug test, which was reportedly negative, though neither the Administrator nor the DON could specify which substances were tested for or provide written documentation of the results. The LPN was permitted to complete her shift, and there was no evidence that she was removed from resident care duties at any point during the incident. The facility's own policy requires that staff conduct themselves in a manner that does not interfere with safe operation or bring discredit to the facility. However, the Administrator and DON did not follow this policy, as they did not remove the LPN from duty despite multiple, consistent reports of unsafe behavior. The LPN herself admitted to being excessively tired and acknowledged a history of substance abuse, though she denied current use. The Medical Director confirmed that any staff member appearing impaired should not be allowed to care for residents.