Medical Records should be documented with complete and accurate information of patients along with correct administered medications. Tampering or altering medical records is illegal and is a crime punishable with fines and jail time. By doing such, can mislead and can cause harm to patients. But if you are dealing with such accusations or complaints, it is best to seek help from a nurse attorney.

At the time of the initial incident, the RN was employed as a Licensed Vocational Nurse at a hospital in Denton, Texas, and had been in that position for one (1) month.

An incident happened on or about April 19, 2019, through May 12, 2019, the RN failed to clarify an order for Clonidine on multiple occasions for the patient. Specifically, the order stated to administer Clonidine 0.1-milligram tablet every night at bedtime for agitation and inability to fall asleep. The RN held the regularly scheduled medication when the patient did not have trouble with agitation and sleep, without notifying the physician and requesting a change in the ordered daily dose. Additionally, the RN failed to adequately document holding Clonidine, including rationale and signs and symptoms the patient was exhibiting. The RN’s conduct resulted in an incomplete 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.

On or about May 12, 2019, the RN exceeded her scope of practice and inappropriately removed the peripherally inserted central catheter (PICC) line of the patient. The RN’s conduct unnecessarily exposed the patient to the risk of complications.

In response to the incident, the RN states that she attended Onboarding training, but that she did not receive any clinical training nor clinical policies. The RN states that after the incident, she completed the full onboarding training. She also states that the nurses and the patient’s mother called Thrive numerous times to have them contact the physician to change the order but it was not changed. She states that she was instructed to contact the agency instead of contacting the physician directly.

And also, the RN states that she attended PICC line training. She also states that no one at Thrive PICC line training instructed her that the PICC line can only be removed by a Registered Nurse (RN), and the employer policy was not provided to them. She states that she was not aware of the Texas Board of Nursing position statement regarding the removal of PICC lines. And that after the Thrive training she returned to the hospital and the hospital vascular nurses trained her on the PICC line. And states that she was trained on how to remove the PICC line, complications that could occur, and the RN was instructed that the order was for removal in ten days. Then she states that the physician’s order for the removal included the same information and did not state that an RN was required to remove the PICC line. The RN states that the Thrive RN assigned to the patient also assessed the client for resumption of home care and did not state that she would return to remove this line. And she added that when the antibiotics finished after ten days, the RN removed the PICC line during the night shift. And that the mistake was inadvertent and there was no patient harm. She states that she has learned for the incident.

As a conclusion to the behavior and actions made by the RN, the Board has come to the decision that the RN shall be subjected to discipline. The RN failed to hire a nurse lawyer to fully defend her case and had led in this decision of the Board.

Do you have questions about the Texas Board of Nursing disciplinary process? Contact The Law Office of  Attorney Yong J. An for a confidential consultation by calling or texting 24/7 at (832) 428-5679 and ask for attorney Yong.