Uncertified Staff Administered Medications Without Proper Credentials
Penalty
Summary
The facility failed to ensure that nursing staff possessed the appropriate competencies and valid certifications required to provide care and administer medications to residents. Specifically, Staff Member A worked a total of 88 shifts administering medications and performing duties as a Medication Aide (MA) without holding a valid MA certificate or CNA certification during the period in question. Staff Member A was listed incorrectly as an LVN on the staff roster, and her Graduate Vocational Nurse (GVN) permit had expired. Despite this, she continued to work under the supervision of an RN, and her credentials were not properly verified or maintained by the facility's Human Resources Director (HRD) or Director of Nursing (DON). The facility's own policy required verification of licensure and certification, but this was not followed, and Staff Member A was allowed to work without the necessary credentials. Record reviews confirmed that Staff Member A signed as a CMA on facility training and administered medications to residents, although there were no documented hospitalizations, harm, or negative outcomes related to her actions. Interviews with the DON, HRD, and Administrator revealed a lack of awareness and oversight regarding Staff Member A's expired or missing certifications. The DON acknowledged that Staff Member A was not an MA and had not taken the MA test, and the HRD confirmed that Staff Member A's GVN was expired upon hire. The Administrator was unaware of the lack of a current MA certificate. The facility's failure to ensure proper licensure and certification for staff directly led to this deficiency.