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Documentations have been a signature specialty of a nurse attorney when handling cases for some nurses. However, some nurses tend to forget this fact because they really felt like they should be responsible even if they never intended to commit such an error.

On or about May 8, 2020, through May 30, 2020, while employed as an RN with a home healthcare provider in Frisco, Texas, RN failed to accurately and completely document that she performed integumentary assessments on a patient, in that she documented that the patient had no changes to her integumentary status, when the patient had a worsening shoulder wound related to prior surgery. RN’s conduct placed the patient at risk for complications such as infection, sepsis, and osteomyelitis from an untreated surgical wound, and resulted in an incomplete medical record that was likely to injure the patient in that subsequent caregivers would not have complete information on which to base their decisions for further care.

In response to the incident, RN states that she was first notified of the patient’s wound on June 3, 2020. LVN states that she reviewed the patient’s files, plan of care, recent notes, and orders prior to caring for the patient. RN states that there was no mention of a shoulder wound or injury in the patient’s file. RN states that her last visit with the patient occurred on May 30, 2020. RN states that her focused assessments and skilled visits were performed within her scope of practice.

The above actions constitute 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)&(2)(A) and 22 TEX. ADMIN. CODE §217.12(1)(B).

However, without enough evidence to prove she’s not guilty, the RN lost the case. This is the reason why the Texas Board of Nursing placed her RN license under disciplinary action.

If you ever undergo cases such as this, it’s best to seek the assistance of a good nurse attorney as it could make the case better in your favor. Be sure to find a nurse attorney who is experienced and knowledgeable in several nurse cases to ensure the best assistance possible. If you also received a letter from the Texas Board of Nursing regarding a case or complaint filed on you, you should hire a nurse attorney immediately before it’s too late. 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 300 nurses before the Texas BON. To contact him, please dial (832) 428-5679 for a confidential consultation or for more inquiries.