Failure to Ensure Nursing Staff Competency in Following Physician Orders for BP Assessment
Summary
The facility failed to ensure that nursing staff, specifically an LVN and RNs, demonstrated the necessary competencies and skills to follow physician orders for blood pressure assessment for a resident. The resident in question was admitted with diagnoses including toxic encephalopathy and depression, and was determined by a physician to lack capacity for decision-making, though the Minimum Data Set indicated cognitive intactness. The resident's care plan did not address the diagnosis of hypotension, despite a physician order to monitor for orthostatic hypotension once weekly. Review of the Medication Administration Record showed that the required monitoring for orthostatic hypotension was not documented on the specified date. During interviews, it was confirmed that the LVN did not follow the facility's job description, which requires accurate and timely documentation of resident assessments and care. The absence of documentation was interpreted by staff as evidence that the assessment was not performed. Further interviews with the DON and review of job descriptions for both LVNs and RNs revealed that the nursing staff did not fulfill their responsibilities for documentation and implementation of physician orders. The DON acknowledged that the RNs did not complete the required documentation or provide the ordered care, and stated that additional training was needed for the involved staff.
Plan Of Correction
F 726 Competent Nursing Staff Corrective Action: LVN 4 is no longer employed at facility. Other Residents Affected Identification: There are no other residents affected by this deficient practice. Measures and Systemic Change: DON/Designee initiated skills competency (on 05/02/25) regarding accurate blood pressure monitoring for all Licensed Nurses on 05/02/2025. DSD to ensure all new hires have a skills competency prior to starting. Monitor Performance: The DON/Designee will present the results to the QA Committee for monthly review for the next 3 months and quarterly thereafter or until substantial compliance is achieved.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
An LPN whose license had been suspended for narcotic diversion was hired and allowed to work full-time night shifts on two units for about a month, completing all nursing duties including medication administration, because the facility did not perform required ongoing licensure verification. The DON and HR each believed the other was responsible for checking licenses, and there was no evidence that licenses were being verified on hire, quarterly, and annually as required. The issue came to light only after an anonymous report, at which point it was confirmed that the LPN had worked multiple shifts while unlicensed, potentially affecting all residents in the facility.
The facility failed to ensure adequate RN or RT coverage for two ventilator-dependent residents whose care plans and orders required frequent ventilator checks, trach care, suctioning, HME and circuit changes, and close monitoring of respiratory status. On at least one night shift, only LPNs were on duty with no RN or RT present, despite these residents’ dependence on mechanical ventilation and tracheostomies. The DON acknowledged there was no RN or RT on that shift, believed prior daytime RN presence met requirements, allowed LPNs to perform ventilator care without certification or documented competency, and was unsure whether such care was within LPN scope of practice. Cited literature from the National Library of Medicine noted that mechanical ventilators are complex, require specific training, and are best managed by RTs, with improper management linked to poor outcomes.
A resident with a PICC line for IV cefepime therapy and multiple comorbidities received IV medication from an LPN who attached IV tubing directly to the open end of the PICC line without a needleless connector, after cleaning only the open hub. The LPN stated that PICC lines do not have valves, despite reporting prior IV therapy training. Facility leadership and HR reported they did not maintain competency or training records for agency staff, and one agency only verified licensure while another provided a self-assessment showing the LPN rated IV skills as limited and requiring supervision, even though the facility’s contract assigned responsibility for orientation, education, and competency of agency staff to the facility.
A staff member was hired and worked in the capacity of a CNA for an extended period without ever obtaining CNA certification or being listed on the Nurse Aide Registry. HR records and interviews showed that the individual completed two Nurse Aide Training classes and repeatedly failed the written competency test, yet was still permitted to perform CNA duties and provide direct care to residents. The personnel file contained only training completion certificates and no verification of an active CNA certification or registry check, affecting care provided to all residents in the facility.
A CNA transferred a resident with cognitive and physical impairments using a mechanical lift without a second staff member present and without having received proper training on the equipment, in violation of facility policy requiring two trained staff for such transfers.
A resident with complex medical needs did not receive prescribed IV vancomycin through a PICC line because no RN was available to administer the medication. The medication was delivered, but scheduled doses were missed due to the absence of qualified staff, despite facility policy requiring timely administration of medications.
Unlicensed LPN Worked Multiple Shifts Due to Failure in Ongoing Licensure Verification
Penalty
Summary
The facility failed to ensure that all nursing staff were competent and legally licensed to provide nursing care and services to residents, affecting its entire census of 67 residents. An Ohio Board of Nursing order showed that an LPN’s professional license had been suspended due to narcotic diversion, yet review of the LPN’s personnel file revealed no evidence that the facility had completed required quarterly licensure verification. The LPN had been hired and continued to be employed without the facility identifying the suspension through its own processes. A confidential interview raised concerns that the LPN, whose license was suspended for issues involving narcotics, continued to work as a nurse and provide care to residents. Interviews with the DON and the Administrator confirmed that the LPN worked full-time night shifts on two units and completed all nursing duties, including passing medications, for approximately one month after the license suspension. The DON verified that the LPN worked 13 shifts with a suspended license. The Administrator reported learning of the licensure issue only after receiving an anonymous phone call and then discovering during the subsequent inquiry that nursing licenses were supposed to be checked and verified as active on hire, quarterly, and annually, but this was not being done. The DON and Human Resources Supervisor each believed the other was responsible for checking licenses, and there was no evidence of a systematic process to ensure ongoing licensure verification for nursing staff.
Insufficient Qualified Nursing and Respiratory Staff for Ventilator-Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure sufficient qualified RNs or RTs were available to care for residents requiring ventilator support. Resident #1 was admitted with sepsis, pneumonia, and acute and chronic respiratory failure with hypoxia and had physician orders for ventilator checks every four hours and as needed, tracheostomy care every shift and as needed, suctioning via trach as needed, and daily HME changes. Care plans for Resident #1 documented dependence on a ventilator and tracheostomy, with goals to maintain adequate oxygenation and be free from respiratory distress, and interventions including monitoring lung sounds and oxygen levels, providing respiratory treatments and oxygen as ordered, and ensuring ventilator settings were correct. Resident #2 was admitted with anemia, ventilator dependence, and functional quadriplegia, and had care plans indicating alteration in respiratory function related to respiratory failure, tracheostomy, ventilator use, and a history of aspiration pneumonia and mucus plugging. The care plans for Resident #2 included goals to remain free from respiratory distress and maintain oxygen levels at provider-set targets. Interventions required included ventilator checks every four hours, AVAP per physician order, tracheostomy tube changes every 30–45 days by an RT, regular changes of ventilator circuits, HMEs, inner cannulas, trach ties, and nebulizer setups, as well as suctioning, CPT, aerosol treatments, and close monitoring of lung sounds, oxygen levels, and signs of dyspnea. Review of staffing schedules for a specified week showed that on one night shift there were three LPNs on duty and no RTs or RNs present, despite the presence of two ventilator-dependent residents. In an interview, the DON confirmed that there was no RN or RT on that night shift and stated he believed that having an RN in the building earlier in the day met requirements and that LPNs could care for ventilator residents based on education and observation, even though they had no certification or documented return demonstration. The DON also stated he was unsure whether ventilator care was within the LPN scope of practice. Literature from the National Library of Medicine cited in the report emphasized that mechanical ventilators are sophisticated devices requiring specific training, that inappropriate management can result in poor patient outcomes, and that RTs are best suited to manage and adjust ventilators, underscoring the need for appropriately trained personnel.
Failure to Ensure Competent IV Therapy Administration by Agency LPN
Penalty
Summary
The deficiency involves the facility’s failure to ensure that an IV medication was administered by a competent licensed nurse and to verify and document IV therapy competencies for an agency LPN. A resident was admitted with a postoperative wound infection, a PICC line placed in the right upper arm for long-term IV antibiotic therapy, and multiple comorbidities including diabetes, liver disease, hypertension, anemia, depression, and a history of stroke. The resident had an order for IV cefepime 2 g in 100 ml normal saline to be given three times daily via the PICC line. On observation, the PICC line had a flesh-colored bandage wrapped around the base, obscuring the insertion site, and the external catheter had a purple open-ended hub labeled “5 ml” with no needleless connector/valve attached. During administration of IV cefepime, the LPN cleaned the open end of the external PICC with an alcohol swab, flushed with normal saline, and then attached the IV tubing directly to the open end of the PICC line without a needleless connector device. When questioned, the LPN stated that PICC lines she worked with never had valves and that this was how PICC lines are, despite reporting that she had IV therapy training and certification. Licensure review showed the LPN had been licensed less than a year and, per the Ohio Board of Nursing, IV certification is no longer listed on LPN licenses for those licensed after a certain date, making IV training and competency verification the employer’s responsibility. The Human Resource Director reported she did not maintain personnel files, licensure checks, or competency records for agency staff, and the interim DON reported having no education or competency documentation for the LPN other than IV training provided after the issue was identified, stating that the agency would have competency records. The Administrator reported that one staffing agency only verified licensure and did not check competencies, and that another agency provided only a self-assessment skills checklist on which the LPN rated her IV therapy skills as limited and requiring supervision. The facility’s contract with that agency specified that the facility was responsible for orientation, education, training, and competency of agency staff.
Uncertified Staff Member Allowed to Perform CNA Duties
Penalty
Summary
The facility failed to ensure that a staff member working as a CNA met state and federal requirements before providing direct resident care. Human Resources records and interviews showed that this individual was hired as a CNA and provided care to residents for approximately 17 months without ever obtaining CNA certification or being listed on the Nurse Aide Registry. The HR Director reported that the staff member completed an initial Nurse Aide Training class and repeatedly attempted the CNA test but failed the written portion multiple times, then missed a subsequent test and was required to retake the entire training. After completing a second Nurse Aide Training class, the staff member again failed the written test and never achieved certification. Despite this, the facility allowed the individual to continue performing CNA duties and providing care to residents throughout the facility. Review of the personnel file confirmed only certificates of completion for two Nurse Aide Training classes and no documentation of a Nurse Aide Registry check or active certification. This deficiency was identified through personnel record review and staff interviews and was associated with complaint investigations, with the facility census noted as 60 residents at the time of the survey. The report states that this failure had the potential to affect all residents residing in the facility.
Failure to Train Staff on Mechanical Lift Use and Adherence to Transfer Protocols
Penalty
Summary
The facility failed to ensure that staff were properly trained and demonstrated competency in the use of mechanical lifts, as required by facility policy. Observation revealed that a Certified Nursing Assistant (CNA) attempted to transfer a resident with dementia, muscle weakness, and impaired balance from bed to wheelchair by pulling the resident to a standing position multiple times before resorting to a mechanical lift. The CNA then used the mechanical lift to transfer the resident without the assistance of a second staff member, contrary to the facility's policy that mandates at least two staff for such transfers. Interviews with the CNA and the Administrator confirmed that the CNA had not received training on the use of mechanical lifts upon hire and that two staff should be present during mechanical lift transfers. The facility's policy also requires staff to be trained and demonstrate competency with the specific equipment used. The deficiency was identified during a review of residents dependent on mechanical lifts, affecting one resident directly observed and potentially impacting others.
Failure to Provide Qualified Staff for IV Medication Administration via PICC Line
Penalty
Summary
The facility failed to ensure that qualified staff were available to administer intravenous (IV) medication through a Peripherally Inserted Central Catheter (PICC) line for a resident who required this level of care. The resident, who had diagnoses including multiple sclerosis, neuromuscular dysfunction of the bladder, and Crohn's disease, was admitted and later readmitted to the facility. Following a hospital visit for a urinary tract infection, the resident was discharged with a new order for vancomycin IV to be administered every twelve hours via a PICC line. The medication was delivered to the facility, but was not administered as ordered. Documentation and staff interviews revealed that the doses of vancomycin scheduled for administration were missed because there was no Registered Nurse (RN) available to initiate the medication through the PICC line. The Director of Nursing (DON) confirmed that she was the only RN on staff and was not present to administer the medication, and the Assistant Director of Nursing (ADON) was no longer employed at the facility. Facility policy required that medication be administered without unnecessary interruptions and in accordance with prescriber orders, but this was not followed due to the lack of qualified staff.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
