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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 hospital in Garland, Texas, and had been in that position for two (2) years and one (1) month.

On or about June 10, 2020, while employed as an RN at a hospital in Garland, Texas, RN documented the patient was checked every fifteen (15) minutes, but RN was not seen in the video at the patient’s room during each documented check and failed to complete the “interventions” section of the observation form. In addition, RN failed to reassess the patient and/or properly document the reassessment after a suicide attempt causing the patient to be moved to a room for involuntary admissions. RN’s conduct could have resulted in an inaccurate medical record and could have created an unsafe environment for the patient.

In response, RN states she and staff did the patient’s assessments and documented the fifteen (15) minute checks, but the nurses were unused to the form since it was typically completed by the nurse aides and she admits she failed to document interventions. RN and a witness state RN completed an online incident report, received a confirmation email, but for an unknown reason the report was no longer in the records along with her documentation towards the end of her shift. RN states when she was told her documentation was missing, she immediately returned to the hospital approximately an hour after leaving and completed late entries for the missing notes. 

The above action constitutes grounds for disciplinary action in accordance with Section 301.452(b)(10)&(13), Texas Occupations Code, and is a violation of 22 TEX. ADMIN. CODE §217.11(1)(A),(1)(B)(1)(D)&(1)(M) and 22 TEX. ADMIN. CODE §217.12.(1)(A),(1)(B)&(4).

A case was ultimately filed against her before the Texas Board of Nursing (BON). The said allegation was fatal to the RN’s capability to perform the essential functions and duties. Sad to say, the nursing defense attorney who handled her case was not able to properly defend her interests and rights before the Board. The Texas Board of Nursing (BON) found her guilty of the offense alleged in the complaint and decided to place her RN license under disciplinary action.

If you also received a letter from the Texas Board of Nursing regarding a case or complaint filed against you, you should hire a nurse attorney immediately before it’s too late. Texas Nurse Attorney Yong J. An is one of those dedicated nurse attorneys who helped represent more than 300 nurse cases for the past 16 years. You may contact him 24/7 at (832) 428-5679 for more information or if you want to schedule a private consultation.