ALBANY, GA – PRUITTHEALTH PALMYRA

Based on record review, interviews, licensure review, personnel file review, and review of the facility policy titled, Non-Corporate New Hire Process the facility failed to ensure that a staff person hired as a licensed nurse had the required licensure to provide nursing care to residents on four of four wings of the facility (wings one through four). On January 30, 2020 a determination was made that a situation in which the facility’s noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment or death to residents. The facility’s Administrator, Director of Health Services, Corporate Nurse Consultant, and Clinical Competency Coordinator were informed of the Immediate Jeopardy on January 30, 2020 at 3:45 p.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on November 25, 2019.

Staff Person AA was hired on November 25, 2019 as a Licensed Practical Nurse (LPN). However, a review of her personnel file revealed that the practical nurse license contained within the file was for a single state, Florida nursing license. The non-Georgia license was not identified prior to hire by Human Resources (HR) staff. After surveyor inquiry on January 22, 2020, further investigation revealed that Staff Person AA did not have a valid nursing license to function as an LPN in any state and her identity was unknown. The Florida practical nurse license that Staff Person AA presented as her own, belonged to someone else.

Review of Staff Person AA’s work schedule and assignments revealed that she worked as an LPN on all wings of the facility from November 26, 2019 through January 21, 2020. Review of clinical records revealed that she provided nursing duties, that she was not licensed to provide, that included but were not limited to: medication administration via multiple routes, pain assessments, behavior monitoring, finger stick blood sugar checks, oxygen administration, indwelling urinary catheter care, [MEDICAL TREATMENT] assessments, change in condition assessments, peripherally inserted central catheter (PICC) line flushes, and gastrostomy tube care including administration of nutritional supplements, water flushes and medications through the gastrostomy tube.

Further review of clinical records and the nursing care that Staff Person AA provided revealed that she failed to ensure that a PICC line was flushed as ordered for Resident (R)#17, administered a dose of [MEDICATION NAME] medication three hours early for R#21, administered blood pressure medications outside of the Physician ordered parameters for R#22, failed to obtain a dressing change for a perma catheter for R#23, administered a dose of insulin two hours late for R#26, failed to follow up with the Physician or Nurse Practitioner for a high blood sugar reading for R#29, and failed to adequately assess a change in condition for R#34.

During a telephone interview on 1/23/2020 at 2:32 p.m., a search of the social security numbers by Regulatory Specialist EE with the Florida Department of Health, Division of Medical Quality Assurance, revealed that neither one of the social security numbers included in Staff Person AA’s personnel file matched the social security number associated with the practical nurse license she presented as her own.