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Ensuring thorough and accurate documentation, patient education, and diligent follow-up are vital aspects of a nurse’s responsibilities. However, there are instances when deviations from these standards can have serious implications for both the patient and the nurse’s professional conduct. In situations like these, nurses who find themselves facing allegations or legal concerns can greatly benefit from the support and guidance of a nurse attorney. A nurse attorney can advocate for the nurse’s rights, ensuring they receive fair treatment throughout the investigation and any legal proceedings that may follow.

At the time of the initial incident, RN was employed as a Women’s Health Nurse Practitioner at a healthcare facility in Corpus Christi, Texas, and had been in that position for twenty (20) years.

On or about August 10, 2020, RN failed to document accurately and completely, a physical exam and patient teaching about ordered diagnostic mammogram and ordered prolactin serum level, and/or follow up instructions with a patient, who was experiencing breast tenderness and producing breast milk not associated with childbirth. RN’s conduct created inaccurate and/or incomplete medical records and placed the patient at risk for harm in that subsequent caregivers could rely on her documentation to provide further care.

On or about August 10, 2020, through February 3, 2021, when no diagnostic mammogram and prolactin serum level results for the patient were received due to the patient’s failure to go for ordered testing although the patient was not contacted by RN to remind or educate the patient on the importance of getting the ordered testing, RN failed to provide appropriate follow up after ordering a diagnostic mammogram and prolactin serum level for the patient who was experiencing breast tenderness and producing breast milk not associated with childbirth. Subsequently, the patient was diagnosed with invasive ductal breast cancer involving one (1) lymph node in February 2021. RN’s conduct could have deprived or delayed the patient of timely referral for specialized care.

In response, RN states she performed a physical exam on August 10, 2020, but did not document the physical exam in the patient’s medical record. RN states she ordered a diagnostic mammogram and prolactin level for further evaluation. RN documented in the August 10, 2021, Assessment/P1an “. . .MAMMO, DIAGNOSTIC, DIGITAL, BILATERAL, PROLACTIN SERUM.”. The facility’s medical record of the patient documents fax on August 10, 2021, to an outpatient surgery center for the patient to have a diagnostic bilateral mammogram and documents an email of orders to a laboratory in Corpus Christi for prolactin level. RN states she discussed with the patient the importance of these diagnostic tests, told the patient not to delay obtaining the tests, gave copies of the orders to the patient, explained where to go for testing, and told the patient to return after the tests were done, but RN did not specifically record this discussion in the medical record. In addition, RN states the practice in place at the time to remind the patient to complete the tests did not work as anticipated in this instance, and the patient did not schedule her mammogram until six (6) months later. 

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)&(4)(A) and 22 TEX. ADMIN. CODE §217.12 (1)(A),(1)(B)&(4).

Because of this, the RN was summoned by the Texas Board of Nursing to defend her side, but the RN failed to hire a nurse attorney to help her with her case and without proper defense, the Texas Board of Nursing then 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 on you, you should hire a nurse attorney immediately before it’s too late. Equip yourself with the knowledge and expertise you need for a successful outcome by consulting a knowledgeable and experienced Texas nurse attorney. Texas Nurse Attorney Yong J. An is one of those dedicated nurse attorneys who helped represent more than 500 nurse cases for the past 17 years. Contact the Law Office of Yong J. An 24/7 through text or call at (832) 428-5679 for a confidential consultation regarding any accusations from the Texas BON.