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Accurate and comprehensive documentation lies at the core of nursing practice, ensuring the continuity and quality of patient care. However, there are instances when lapses in documenting critical assessments and care can lead to serious repercussions, both for the patients involved and the RN responsible for their well-being. During times of distress stemming from allegations related to inadequate documentation and patient care, a nurse attorney can offer invaluable support to RNs.

At the time of the initial incident, she was employed as an RN at a hospital in Fort Worth, Texas, and had been in that position for one (1) year and eight (8) months.

On or about June 3, 2021, through June 26, 2021, while employed as an RN at a hospital in Fort Worth, Texas, RN was accused of the following:

  1. RN failed to document in the medical record completion of assessments and/or reassessments and/or care provided to nine different patients. RN’s conduct resulted in incomplete medical records and was likely to injure the patients in that subsequent care givers did not have accurate and complete information on which to base their decisions for further care.
  2. RN failed to address the elevated blood pressure readings of a patient by either administering an as needed dose of Hydralazine as ordered or contacting the physician. RN’s conduct was likely to injure the patient in that failure to treat the patient’s elevated blood pressure could have resulted in adverse consequences.

In response, RN states that she can only be accountable for the omissions found in her charting. She is very aware of the statement regarding the nursing profession that “if it’s not charted it’s not done.” However, RN is confident that she took care of her patients even though there is missing documentation on different days. With respect to the omissions in her charting, RN states that it does not reflect the manner in which she cared for her patients. RN states that the unit in which she worked was a very fast paced unit and that she felt bullied by some staff at times. RN states that the environment did have a negative impact on her nursing documentation due to the pressure of not being allowed to overlook her charting. RN states that she stands strong in saying that she has never placed a patient in harm’s way in her thirty years of nursing experience.

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),(1)(M),(1)(P)&(3)(A) and 22 TEX. ADMIN. CODE §217.12(1)(A)&(1)(B).

However, without valid evidence to defend her side of the story, the RN lost the case. Furthermore, the RN failed to hire a Texas nurse attorney to help her with her case. Because of this, the Texas Board of Nursing disciplined the RN’s license.

Do not be stressed or anxious if you find yourself in a similar situation as that of the RN mentioned above. All you need to do is to find the right RN/LVN license attorney who can help you in the case. Equip yourself with the knowledge and expertise you need for a successful outcome by consulting a knowledgeable and experienced Texas RN/LVN license attorney. Texas Nurse Attorney Yong J. An is an experienced nurse attorney for various licensing cases for the past 16 years and represented over 300 nurses before the Texas BON. Contact the Law Office of Yong J. An 24/7 through text or call at (832) 428-5679.