Every medication administered to a patient should be accurately and completely documented on a patient’s medical record. It is one of the nurse’s roles to ensure that a patient’s medical record is correct. If an RN does incorrect and inaccurate documentation there’s a tendency of harming the patient. The RN who is assigned to do that can be sued by the patient or by the family and can lead to license suspension or revocation. This can be avoided or prevented if the RN involve is ready to face the Board together with a nurse attorney.
At the time of the incidents, the RN was employed as an ICU Staff Nurse at a hospital in Pharr, Texas, and had been in that position for five (5) years and five (5) months.
The incident happened on or about April 3, 2019, while employed as an ICU Staff Nurse, the RN failed to accurately and completely document the administration of propofol to a patient’s medical record. As a result of the administration of propofol, the patient experienced an adverse reaction. The RN failed to document the administration of normal saline and epinephrine, as well as citing the protocol/standing order for its use. The RN’s conduct resulted in an inaccurate and incomplete medical record. In addition, the RN failed to clarify physician orders for propofol for the patient.
In response to the incident, the RN states that the physician ordered the administration of propofol, and the patient’s primary nurse entered the order. The RN states that the patient’s primary nurse was an agency nurse with limited intensive care unit experience and the RN offered to assist her during the shift. The RN states that the patient’s primary nurse welcomed the assistance. She states that once the patient was intubated, the patient started to wake up so she offered to administer the propofol while the primary nurse entered the orders into the computer. She also states that she started the propofol drip with the medication pump and denies administering the medication as an intravenous push. Rather, the RN states she used a syringe to clear the line and discard the waste.
The RN states that she started the drip with the medication pump and set the drip to administer the medication over the course of thirty minutes. She monitored the patient to ensure the patient exhibited stable vital signs before returning to her patients. She states that she did administer the epinephrine; however, she believes she acted appropriately and under the protocols established by the hospital. The RN also states that between fifteen minutes to thirty minutes after the administration of the propofol, the RN and the primary nurse noticed a significant drop in the patient’s blood pressure and heart rate. As the primary nurse did not know the hospital protocol, the RN states she led the care for the patient. The RN states she started a bolus of normal saline. The blood pressure and heart rate continued to drop, so the RN took epinephrine from the crash cart and administered the medication. The RN states that thereafter, the patient’s blood pressure and heart rate stabilized. The RN states that she acted appropriately in an emergent situation and she appropriately used epinephrine to resolve this emergency. The RN notes that the primary nurse documented the administration of medication, but noted the medication as atropine. The RN states that she believed the primary nurse would specifically document the record. The RN states that in retrospect she should have double-checked the record or just documented it herself and rather than stepping in, the RN should have allowed the charge nurse to step in.
As a result, the Board has put the RN into disciplinary action as per a violation of 22 TEXAS ADMINISTRATION CODE §217.11 (1)(B),(1)(C), C.)&(D) and is pursuant to Section 301.452(b)(10)&(13), Texas Occupations Code.
If only the RN could have hired a nurse attorney for the defense, everything could have been different. Hiring a nurse attorney should be an RN’s sole priority in dealing with such cases. A right nurse attorney with years of experience in handling nurse cases is the best fit to hire.
Do you have questions about the Texas Board of Nursing disciplinary process? Contact The Law Office of RN License Attorney Yong J. An for a confidential consultation by calling or texting 24/7 at (832) 428-5679 and ask for attorney Yong.