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Providing thorough and accurate patient assessments, especially when it concerns skin integrity and wound care, is an indispensable aspect of nursing practice. Nurses are entrusted with the responsibility to recognize and document any changes in a patient’s condition, particularly in vulnerable areas such as skin health. However, there are occasions when these fundamental responsibilities may not be met, raising concerns about patient care and professional conduct. In situations where nurses encounter allegations or legal concerns related to patient care and documentation, a nurse attorney can provide invaluable support and expertise. Nurse attorneys can advocate for the nurse’s rights throughout the investigation and any ensuing legal proceedings, ensuring the nurse is treated fairly and effectively represented.

At the time of the initial incident, she was employed as an LVN at a health care facility in Galveston, Texas, and had been in that position for one (1) year and one (1) month.

On or about May 24, 2021, while employed as an LVN at a health care facility in Galveston, Texas, and providing care for a patient, LVN failed to adequately assess the patient’s skin and/or recognize a change in skin condition and documented that the patient’s bilateral heels were intact with blanchable redness. Subsequently, the Wound and Ostomy Care Nurse assessed the patient and found that the patient’s right heel had a 3.5 by 3.5cm deep tissue injury with brown, dark purple, and black discoloration. After notification of this finding from the nursing supervisor, LVN reassessed the patient and changed her documentation to incorrectly reflect that the patient’s bilateral heels were intact with purple discoloration. LVN’s conduct resulted in an inaccurate medical record and was likely to injure the patient from clinical care decisions based upon incomplete assessment information.

In response, LVN states that she did her skin assessment that morning and did not note any skin discoloration. When it was brought to her attention that the wound care nurse found discoloration, LVN immediately went to assess the patient. LVN states that when she reassessed the patient, she almost missed the skin discoloration on the patient’s right heel that was found by the wound care nurse. At that time, LVN states that she went back and updated her documentation about the findings. LVN states that she also notified the floor supervisor who had made her aware of the wound nurse’s findings and told her that she had updated her assessment. LVN also advised her that she had updated her assessment finding. LVN adds that this experience has taught her the importance of documenting as she assesses or completes a task.

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)&(2)(A) and 22 TEX. ADMIN. CODE §217.12 (1)(A),(1)(B)&(1)(C).

However, without enough evidence to prove she’s not guilty, the LVN lost the case. This is the reason why the Texas Board of Nursing placed her LVN 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. 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 17 years and represented over 500 nurses before the Texas BON. To contact him, please dial (832) 428-5679 for a confidential consultation or for more inquiries.