Unlicensed DON Provided Nursing Oversight and Direct Care
Penalty
Summary
The deficiency involves the facility’s failure to ensure that nursing services were provided by a licensed nurse when the Director of Nursing (DON1) worked while her nursing license was under temporary suspension. A document from the South Carolina Department of Labor Licensing and Regulation dated June 18, 2025, stated that DON1’s license to practice nursing in the state was temporarily suspended effective immediately, until further order of the Board. Despite this suspension, DON1 continued to work at the facility on June 18, 2025, and June 23, 2025, performing DON duties and providing nursing leadership oversight without a valid nursing license. The facility’s own job description for the Director of Nursing, signed by DON1, specified that the DON must be a registered nurse in good standing with the State Board of Nursing and responsible for overall management of the nursing department, staffing levels, resident safety, and direct resident care as needed. During the period of suspension, DON1 provided direct care and clinical oversight for at least two residents. For one resident (R4), the electronic medical record for June 2025 documented that on June 23, 2025, the resident approached DON1 to assess a large erythematous and ulcerated rash under the right pectoral area. The note indicated that the nurse practitioner and physician were made aware and examined the area, and that DON1 contacted the wound provider and obtained orders for Mycolog II cream twice daily for 14 days, Diflucan 100 mg by mouth daily for 5 days, Keflex 500 mg by mouth twice daily for 10 days, and Interdry application several hours after the cream. The documentation further showed that at 2:33 PM that same day, DON1 entered medication orders for Diflucan and Cephalexin for erythrasma, and later documented extensive interaction with the resident regarding showering and timing of leg wraps, including multiple reminders and an explanation of her need to leave the facility for an appointment. For another resident (R5), the electronic medical record for June 2025 showed that DON1 completed a weekly summary note and signed an interdisciplinary team (IDT) conference assessment on June 18, 2025, the same date her license suspension became effective. These entries indicated that DON1 was performing clinical assessment and documentation functions for this resident while not legally authorized to practice as a nurse. Human Resources staff later stated that they were unaware of the suspension at the time and that DON1, a salaried exempt employee who did not clock in and out, continued to perform typical DON duties during this period. The survey agency determined that the facility’s noncompliance with nursing services requirements, specifically allowing an unlicensed individual to function as the DON and provide direct resident care, constituted Immediate Jeopardy related to 42 CFR §483.35(c)(3) Nursing Services.
Removal Plan
- Notify the Medical Director of the Immediate Jeopardy and complete any additional required external notifications if applicable.
- Initiate a primary source audit of all currently employed licensed nursing staff to confirm active licensure and good standing; print/electronically save verification evidence and place it in personnel files.
- Complete a look-back investigation for all shifts worked by the ex-employee; assess/interview identified residents.
- Provide mandatory re-education to licensed nursing staff on the requirement to immediately notify the Administrator and/or DON of any license investigation, consent order, suspension, restriction, expiration, or other status change.
- Monitor compliance through QAPI; report results monthly for three months and quarterly for three additional quarters; QAPI Committee to re-evaluate need for further monitoring; Human Resource Director responsible for monitoring and follow-up.
- Upload current active nursing licenses for all licensed nursing staff into the facility’s human resources system to centralize and improve access to credential verification.
- Re-educate the Human Resources Director on the licensure certification and registration of personnel policy.
- Implement a process requiring all newly hired employees to sign an attestation that they must inform the Administrator/DON/HR Director of any licensure investigation, consent order, or change in licensure status; failure to report may result in discipline up to termination.
- Initiate an attestation for all currently employed licensed personnel regarding responsibility to report any licensure investigation, consent order, or change in licensure status; failure to report may result in discipline up to termination.
- Complete all attestations for licensed personnel; employees will not work until the attestation is completed.
- Implement a standardized license verification form and a central licensure tracking log with verification and expiration dates.
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