Hartland Park Rehab: Unlicensed Nurse Worked 82 Shifts - KY

The nurse, identified as LPN8 in inspection records, continued providing resident care from the date her license was suspended until she was terminated months later. The Kentucky Board of Nursing had suspended her license for at least two years and warned that continued practice would violate state law and be "punishable by criminal sanctions."

The facility's own employee handbook required licensed staff to provide proof of current registration and warned that employees who failed to renew their licenses "will not be allowed to work until the expired license or certification is current." The handbook stated violations could result in disciplinary action up to termination.

LPN8 had signed acknowledgment of receiving the employee handbook, according to facility records reviewed by inspectors.

The nursing board's certified letter to LPN8 stated she was "prohibited from engaging in the practice of nursing within the Commonwealth of Kentucky." The letter noted the suspension would be public information that could be shared according to state regulations and federal law.

Despite these warnings, facility nursing schedules showed LPN8 worked continuously from the suspension date through her eventual termination.

The facility administrator told inspectors the facility had no policy regarding staff licensure verification. When asked about the importance of maintaining active licenses, she said it was crucial because staff "were responsible for taking care of residents and care being provided needed to be in accordance of regulation and to ensure residents safety."

The Director of Nursing said valid licenses were important "to ensure the staff was in compliance and to ensure staff members were up-to-date with education hours."

The Assistant Administrator confirmed LPN8 had worked as a nurse with a suspended license and was terminated only after the facility discovered the suspension.

Pain Medication Delays

In a separate violation, inspectors found a resident with broken legs in both femurs received inadequate pain management during his March readmission to the facility.

Resident 124, who was cognitively intact according to facility assessments, consistently reported pain scores of 5 to 8 on a 10-point scale during his first two days back at the facility. Despite having orders for both scheduled and as-needed pain medication, he did not receive the as-needed doses when his pain was highest.

On March 1 at 3:10 PM, the resident reported pain at 5 out of 10 but received no as-needed medication. The next day, his pain spiked to 8 out of 10 at 9:49 AM and again at 1:24 PM, but he received no additional pain relief beyond his scheduled doses.

Medication records showed he received his scheduled 15 mg Oxycodone doses at noon and 6:00 PM on March 2, plus a 5 mg as-needed dose at 9:15 PM. However, the as-needed medication was not given during the hours when his pain was most severe.

The resident's care plan addressed his risk for pain but only included the intervention to "administer medications per orders" without addressing the pattern of undertreated breakthrough pain.

Family Brings Prohibited Food

Inspectors also found care plan failures involving a resident with swallowing difficulties whose family regularly brought foods that violated her prescribed pureed diet.

Resident 36, who had dysphagia and was cognitively intact, was ordered to receive pureed texture foods after failing a swallowing evaluation at the hospital. However, inspectors observed potato chip bags and opened saltine crackers on her bedside table during their visit.

The resident told inspectors she had "no coughing or choking on regular food" but acknowledged she "did not pass the swallowing test at the hospital." She said her family brought her food.

Her daughter confirmed the family brought food, saying the facility told them "it was okay to bring in food" and that they monitored her mother. The daughter said her mother's spouse, who also lived at the facility, brought her regular-texture foods.

Staff interviews revealed the family had brought fried chicken, green beans, and mashed potatoes for the resident's birthday celebration. The speech therapist said she had educated the family about the texture diet, but the resident had told her during a July reassessment that she wanted to remain on pureed foods because "some foods were hard to swallow."

The unit manager acknowledged the resident's care plan should address "the diet texture, the resident's non-compliance, and the family's non-compliance with bringing regular-texture food."

However, the resident's care plan focused only on dental problems and oral care, with no interventions addressing the ongoing diet violations or family education needs.

Medication Security Lapses

On the facility's memory care unit, inspectors observed a medication cart left unlocked and unattended, creating potential access for confused residents.

A unit manager walking past the cart noticed it was unlocked and secured it. The nurse assigned to the cart told inspectors she was unaware she had walked away without locking it.

"It was important to always keep the medication cart locked so residents, visitors, and other staff did not have access to medications that could cause harm if taken," the nurse said.

Another nurse on the unit emphasized that ensuring carts were locked "should be done every single time before you walked away," particularly important because confused residents "did not open drawers and take medications that could cause harm."

Inspectors also found expired eye drops being used for a resident with pre-glaucoma. The latanoprost drops for Resident 132 were marked as opened on June 20, 2024, but the pharmacy label indicated they expired after 42 days. The resident continued receiving the drops through early August, well past their expiration date.

The medication container itself had a blank space where the opened date should have been written, despite facility policy requiring such labeling. The pharmacist told inspectors that while expired latanoprost doesn't cause adverse effects, "the potency of the medication decreased the further out from the expiration date" and "was not as beneficial."

Infection Control Failures

Staff failed to follow infection control precautions for three residents on enhanced barrier protocols, potentially spreading infectious organisms throughout the facility.

In one incident, a Social Service Assistant in a resident's room on contact precautions picked up a clipboard, placed it on the sink, removed her gloves, then picked up the clipboard again and left without washing her hands or cleaning the clipboard.

"It was a mistake she did not wash her hands and clean the clipboard before leaving the room," she told inspectors afterward.

A wound care nurse providing dressing changes to another resident on precautions properly wore protective equipment during the procedure but then placed her used eye shield on top of her treatment cart outside the room. She cleaned the eye shield but failed to disinfect the cart surface.

"She should have disinfected the top of the treatment cart because there could have been infectious organism on the cart from the eye shield," she acknowledged.

A registered nurse administering medications to a third resident on enhanced barrier precautions handled medications and entered the room without wearing required gloves.

The nurse said she was "nervous" and admitted "infectious organisms could have potentially been on her hands and transferred to the resident from not wearing gloves."

The Director of Nursing told inspectors that staff discussed residents on enhanced precautions daily in morning meetings and said they had not identified any issues with staff compliance.

Blocked Hallways

Inspectors found hallways crowded with equipment that could impede emergency evacuations.

One hallway had four folded wheelchairs lined against the handrail opposite a linen cart, creating a narrow passage for residents and staff.

A registered nurse said hallways were "frequently crowded with linen carts, medication carts, meal tray carts, and extra resident equipment" which "created a safety issue for residents trying to maneuver the hallway, especially in an emergency."

The unit manager explained the wheelchairs had been washed but lacked name tags, so staff didn't know which rooms they belonged in. She said her expectation was for wheelchairs to be stored folded in residents' rooms or shower rooms when not in use.

The Administrator said she expected hallways to "remain free from excess equipment for resident safety in case of an emergency."

Full Inspection Report

The details above represent a summary of key findings. View the complete inspection report for Hartland Park Health & Rehabilitation from 2024-08-16 including all violations, facility responses, and corrective action plans.

Additional Resources

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