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Following a facility’s policy and procedures is very important as well as doing proper documentation. If not done properly and accurately, it can put a patient in harm. Therefore, every RN should practice keeping accurate and complete medical records for documentation purposes. Inaccurate documentation can lead to and can cause negative outcomes. If you are in such a situation, it is best to consult a nurse attorney to know what proper measures to take in facing cases.

At the time of the incident, an RN was employed as a Registered Nurse at a hospital in Pasadena, Texas, and had been in that position for eleven (11) months.

The incident happened on or about December 1, 2018, through December 2, 2018, while employed as a Registered Nurse, the RN failed to document in the Electronic Medical Record regarding the administration of two doses of intravenous antibiotics to the patient, including the name of the antibiotic, the patient’s response to the intravenous infusion, and infusion site assessments. The RN’s conduct resulted in an incomplete medical record, and exposed the patient to a risk of harm in that subsequent caregivers would not have accurate and complete information on which to base their care decisions.

In response to the incident, the RN states that on both December 1, 2018, and December 2, 2018, he administered Daptomycin intravenously to the patient based on the prescription order on the elastomeric device set for thirty (30) minutes. The RN states that after thirty (30) minutes he completed infusing the medication entirely. The RN states that on December 2, 201 8, he failed to clock into Homecare Home base in order to start the visit clock. The RN states that after the visits, he inaccurately corrected his visit time. Lastly, the RN reports that his visit times reflected on Homecare Home base are not indicative of his actual in-home time of forty (40) minutes.

As a result, the Texas Board of Nursing decided to place his nursing license under disciplinary action. It’s too bad that he failed to hire a nurse attorney for assistance, knowing that he had every reason to defend himself in the first place. His defense would have gotten better if he sought legal consultation from a Texas nurse attorney as well.

So, if you’re facing a complaint from the Board, it’s best to seek legal advice first. Texas Nurse Attorney Yong J. An is willing to assist every nurse in need of immediate help for nurse licensing cases. He is an experienced nurse attorney for various licensing cases for the past 16 years and represented over 200 nurses before the Texas BON. To contact him, please dial (832)-428-5679 for a confidential consultation or for more inquiries.