Unlicensed LPN and Falsified Controlled Medication Documentation
Penalty
Summary
The deficiency involves the facility’s failure to ensure that nursing staff administering medications maintained current licensure and followed required procedures for controlled substances. A concern was raised when an oncoming medication nurse reported that a resident had not received a PRN medication for three months, which the nurse confirmed with the resident. In response, the facility reviewed all controlled medication logbooks and medication administration records and identified irregularities involving one LPN on two units and affecting ten residents. The irregularities included falsified sign-outs, forged staff signatures, altered dates, and removals of controlled medications without corresponding documentation on the medication administration records. During the facility’s investigation, it was discovered that the LPN suspected of these irregularities had been working with an expired state nursing license, despite being assigned to medication administration duties. Interviews with the Administrator and the former DON confirmed that the LPN did not hold a current state license required for the position and that the LPN had fraudulently removed controlled medications, including oxycodone, tramadol, morphine, Percocet, and butalbital/acetaminophen/caffeine, without following facility policies for administration and documentation. Facility policies required that a licensed nurse administer medications in compliance with state and federal laws, that controlled substances be counted and verified at shift change, and that documentation corrections be made properly by the original author, but these procedures were not followed by the LPN.
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