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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. This is why every RN should practice keeping accurate and complete medical records for documentation purposes. Inaccurate documentation can lead and can cause a negative outcome. 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, the RN was employed as a Registered Nurse at a hospital in Bryan, Texas, and had been in that position for one (1) year and four (4) months.

The incident happened on or about June 5, 2018, the RN discontinued a Patient-Controlled Analgesia (PCA) containing Fentanyl for a patient, but failed to follow the facility’s policy and procedures for wastage of the unused portion of the medication. The RN’s conduct left medications unaccounted for and placed the pharmacy in violation of Chapter 481 (Controlled Substances Act) of the Texas Health and Safety Code.

And on the same day, the RN misappropriated Fentanyl belonging to the facility or patients thereof or failed to take precautions to prevent such misappropriation. The RN’s conduct was likely to defraud the facility and patients of the cost of the medications.

Another incident happened on or about November 11, 2018, the RN failed to document a physician’s verbal order to decrease the rate of a continuous sodium chloride infusion to a patient and also failed to accurately and completely document the adjusted rate for the infusion throughout the shift, Additionally, the RN failed to administer scheduled Tylenol to the patient as per physician orders. The RN’s conduct created an inaccurate medical record and exposed the patient to a risk of harm in that failure to administer medications as ordered by the physician could have resulted in the non-efficacious treatment of the patient’s condition.

In response, the RN states that he forgot to dispose of the medications prior to the end of the shift. In addition, he states that the IV fluid rate was changed as per his conversation with the physician. And also states that he did not document appropriately the patient’s refusal of the Tylenol.

Due to the professional misconduct of the RN, the evidence received by the Board is sufficient to prove that the RN committed the violation(s) which is cause pursuant to Section 301.452(b)(10)&(13), Texas Occupations Code, to take disciplinary action against the RN.

 If only the RN had hired and consulted a nurse attorney, the case could have a positive outcome. Hiring a nurse attorney can be an RN’s best line of defense against accusation or complaint cases.

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.