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.
One such incident occurred to an RN in Brownsville. On or about June 14, 2019, while employed as a Staff Nurse in a local hospital in Brownsville, Texas, RN failed to accurately document a skin assessment on the medical record of a patient. RN documented a skin assessment as “Within Normal Limits,” when this patient was admitted with a left toe amputation. RN’s conduct resulted in an inaccurate medical record and was likely to injure the patient in that subsequent caregivers would not have complete information on which to base their care decisions.
On or about June 15, 2019, while employed as a Staff Nurse in a local hospital in Brownsville, Texas, RN failed to complete and/or document an intake/output assessment to include intake and output, and an incentive spirometry assessment in the medical record of Patient B, prior to leaving his work shift. RN’s conduct resulted in an inaccurate medical record and was likely to injure the patient in that subsequent caregivers would not have complete information on which to base their care decisions.
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) and 22 TEX. ADMIN. CODE §217.12(1)(A),(1)(B),(1)(C)&(4).
As a result, the Texas Board of Nursing decided to place his RN license under disciplinary action. It’s too bad that he failed to hire a nurse attorney for assistance, knowing that he had every reason to defend herself in the first place. His defense would have gotten better if she actually sought legal consultation from a Texas nurse attorney as well.
So, if you’re facing a complaint from the Board, it’s best to seek legal advice first. 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 16 years and represented over 200 nurse BON license cases before the Texas BON. To contact him, please dial (832)-428-5679 for a confidential consultation or for more inquiries.