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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 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, she was employed as an RN at a medical facility in Pharr, Texas, and had been in that position for thirteen (13) years and three (3) months.

On or about February 5, 2019, while employed as an RN at a medical facility in Pharr, Texas, and caring for a PACU patient, RN failed to completely document an assessment including pulse check and movement of extremities of the patient post vascular procedure and failed to document physician notification and communication regarding the patient’s continued need for airway management including jaw thrust and trumpet, and oxygen at ten (10) liters per minute via mask to keep oxygen saturation above ninety-five (95) percent. RN’s conduct resulted in an incomplete medical record and could have injured the patient from subsequent care decisions made without the benefit of accurate and reliable information.

In response, RN states that she does admit to her inadequate documentation. RN reports that the patient’s bedside was busy, and she was unable to always reach the computer to document due to an ongoing in-service which blocked her access to the computer. RN states that she intended to complete the documentation after the patient was transferred.

The above actions constitute grounds for disciplinary action in accordance with Section 301.452(b)(10)&(13), Texas Occupations Code, and a violation of 22 TEX. ADMIN. CODE §217.11(1)(A),(1)(B),(1)(D)&(3)(A) and 22 TEX. ADMIN. CODE §217.12(1)(A)&(1)(B).

The evidence against the RN was strong. At the same time, she was not able to properly defend her case in court. As a result, her nursing license was placed under disciplinary action by the Texas Board of Nursing.

Avoid a similar thing from happening on your end. Make sure to find the right defense lawyer in case a complaint will be filed against you before the Texas Board of Nursing (BON). For more details or for a confidential consultation regarding accusations, it’s best to contact an experienced Texas nurse attorney. Texas Nurse Attorney Yong J. An is an experienced nurse attorney who represented more than 150 nurse cases for RNs and LVNs for the past 16 years. You can call him at (832)-428-5679 to get started or to inquire for more information regarding nursing license case defenses.