Ensuring the thorough and accurate assessment of patients’ conditions is a fundamental aspect of nursing practice, especially when it comes to recognizing critical changes that may impact a patient’s care and well-being. Nurses are entrusted with the responsibility of promptly assessing and documenting patients’ clinical status, particularly when signs of deterioration are evident. Deviations from these critical standards can have serious consequences for patients and raise concerns about the nurse’s competence and adherence to established protocols. In situations like these, nurses facing allegations or legal concerns related to patient assessment and documentation can significantly benefit from the support and expertise of a nurse attorney. By offering guidance and support, nurse attorneys contribute to accountability within the healthcare profession while safeguarding the nurse’s rights and professional reputation.
At the time of the initial incident, he was employed as an RN at a medical facility in Laredo, Texas, and had been in that position for five (5) months.
On or about November 27, 2021, while employed as an RN at a medical facility in Laredo, Texas, RN failed to complete the National Institute of Health Stroke Score (NIHSS) for a patient, after RN informed the charge nurse that the patient was having difficulty communicating and appeared weaker than the day before. Additionally, RN falsely documented that he performed the NIHSS at 0830, when RN had not yet completed the assessment. RN’s conduct resulted in an inaccurate medical record and was likely to injure the patient from possibly undetected changes of condition.
In response, RN states that the patient seemed to be confused and was talking nonsense. RN states that when the patient was asked questions to assess his orientation, the patient answered all questions appropriately. RN states that he mentioned to the manager and charge nurse that something just didn’t seem right with this patient. RN states that the patient seemed to be having increased difficulty with verbal communication and seemed weaker in his motor skills assessment. RN states that the nurse manager asked him to complete a National Institute of Stroke Scale (NIHSS) on the patient. RN states that the stroke scale has eleven (11) items on it; he reports that nine (9) of these were performed around 0830. RN states that the patient showed no deficits in these nine (9) items. RN states that the other two items needed flashcards, and that the flash cards were not available on the unit he was assigned to. RN states that the clinical educator brought the flash cards up to the unit around 1330, after the nurse manager asked him about the NIHSS scale. RN states that after speaking to the manager, he went into the electronic medical record and documented the stroke scale as being done at 0830.
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)(C),(1)(D),(1)(M)&(3)(A) and 22 TEX. ADMIN. CODE §217.12 (1)(A),(1)(B),(1)(C),(6)(A)&(6)(H).
The Texas Board of Nursing then subjected the RN and his license into disciplinary action. The accusation would have been defended by an experienced and skilled Texas Nurse Attorney, had the RN hired one. Hiring a Texas Nurse Attorney for defense is applicable for any kind of accusation laid against an RN or LVN.
For more details and to schedule a confidential consultation, you must approach one of the most experienced Texas Nurse Attorneys, Yong J. An. He is an experienced nurse attorney who represented more than 500 nurse cases for RNs and LVNs for the past 17 years. You can call him at (832) 428-5679 to get started or to inquire for more information regarding nursing license case defenses.