F0659

D

Unlicensed LPN Worked Multiple Shifts and Administered Medications

Burlington, Vermont Survey Completed on 01-14-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure that nursing care was provided by a nurse holding an active state license as required for the position. Review of credentials for an LPN under investigation for misappropriation of medications showed that the nurse’s multistate compact license, which had permitted practice in the survey state, had expired on a specified date. A nursys.com search confirmed that the LPN then only held an active single-state license in North Carolina, which was not valid for practice in the survey state. Despite this, the LPN continued to be scheduled and worked 11 shifts after the compact license expiration, including 6 shifts in which medications were administered in the role of an LPN Team Leader, a position whose job description requires a current state LPN license in good standing for the state of employment and includes administering medications and treatments as an essential function.

Interviews and record review further showed that the Administrator was aware that the LPN’s license status had changed and stated that the LPN had selected the wrong option during renewal, resulting in a single-state license rather than a multistate compact license that included the survey state. The Administrator also reported that the Human Resources position was vacant and that the spreadsheet used to track staff license expiration dates had not been updated. The former DON stated that during a review of the LPN’s personnel file, it was identified that the LPN’s state nursing license needed for the position had expired, and that the Administrator had taken on the task of researching the expired license. Despite the facility’s stated expectation that staff must have an active license in the state to work, the LPN continued to work multiple shifts without a valid license for that state.