Unlicensed Staff Member Provided Nursing Care and Demonstrated Incompetence
Penalty
Summary
The facility failed to ensure that nursing staff possessed the appropriate competencies and valid credentials to provide nursing services to all residents. An individual, identified as SM #1, was employed and worked as an LPN without holding a valid license, using false credentials that initially passed through the facility's background and license verification systems. During her employment, SM #1 demonstrated significant lapses in nursing skills, including improper handling of a resident's Foley catheter, which caused the resident pain, and multiple instances of incomplete documentation and medication errors. Staff interviews and disciplinary records revealed that SM #1 required extended orientation and frequent supervision due to her inability to complete competencies and perform basic nursing tasks independently. Further review showed that SM #1 was involved in several incidents, such as presenting a resident with unrecognized medications, attempting blood sugar checks on a non-diabetic resident, and being perceived as unskilled in IV administration. Other staff members reported that SM #1 often failed to perform her duties, required assistance from other nurses, and was frequently inattentive to resident care. Documentation issues, improper medication handling, and incomplete assessments were noted during her tenure. Staff expressed concerns about her proficiency and reported these issues to supervisors. The facility's investigation confirmed that SM #1 had worked for several months under false pretenses, and her lack of skills and credentials directly impacted the care provided to residents. The facility only discovered the falsification after multiple disciplinary actions and an incident involving improper Foley catheter care. SM #1 resigned when confronted with the investigation and refused to cooperate further.