F0726

D

Unlicensed GPN Functioned as LPN After Failing NCLEX

Biloxi, Mississippi Survey Completed on 02-24-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure that nursing services were provided by qualified and appropriately licensed personnel, as required by facility policy and state regulations. The facility’s policy on Compliance and Ethics – Risk Areas for Fraud and Abuse states that sufficient staffing must include staff with appropriate clinical training, licensure, and/or expertise to meet residents’ needs. A graduate practical nurse (GPN) was issued a temporary LPN permit with a defined expiration date and later took the NCLEX-PN exam. The NCLEX candidate report showed that the GPN did not pass the exam, and the state Board of Nursing’s published guidance states that if a new graduate fails the NCLEX, the temporary permit becomes invalid and the individual may no longer work under that permit.

Despite receiving notification of failing the NCLEX, the GPN continued to work in the capacity of a licensed nurse for approximately five and one-half days, as confirmed by time cards, staffing schedules, and assignment sheets. During this period, she was assigned a full resident assignment and continued to administer medications, perform treatments, and document in residents’ medical records. The GPN acknowledged she did not verify the status of her permit with the Board of Nursing and did not inform facility administration of her failed exam. The DON confirmed she was unaware of the failed exam, believed the temporary permit remained valid until its printed expiration date, and that the facility had no system to verify exam results with the Board of Nursing, instead relying on self-reporting by the nurse. As a result, nursing care was provided by an individual who did not hold a valid license or permit during the identified timeframe.