Accurate and comprehensive documentation is a cornerstone of nursing practice, essential for providing quality patient care, ensuring continuity of treatment, and maintaining transparency in healthcare records. Nurses are entrusted with the responsibility of meticulously recording vital signs, medication administration, and any verbal orders received from healthcare providers. However, there are unfortunate instances when deviations from these fundamental standards occur, raising serious concerns about patient safety and the nurse’s professionalism. In situations like these, nurses facing allegations or legal concerns related to documentation errors can greatly benefit from the expertise and support of a nurse attorney. Nurse attorneys are well-versed in the legal intricacies surrounding such incidents and can offer vital guidance in navigating the complexities.
At the time of the incident, he was employed as an LVN at a skilled nursing and rehabilitation facility in Lewisville, Texas, and had been in that position for one (1) month.
On or about November 16, 2021, while employed as an LVN at a skilled nursing and rehabilitation facility in Lewisville, Texas, LVN failed to completely and accurately document on the vital sign flow sheet and/or nursing notes heart rate and blood pressure readings, and the time said readings were obtained, for a patient. Further, LVN failed to completely and accurately document a verbal order received to administer Bactrim to the patient for cellulitis and failed to document administration of the Bactrim in the patient’s Medication Administration Record (MAR). LVN’s conduct created an incomplete and inaccurate medical record and was likely to injure the patient in that subsequent caregivers would not have accurate and complete information on which to base their care decisions.
In response to the above incident, LVN states the patient’s blood pressure was closely monitored. LVN also states the provider was contacted after a blister opened on the patient’s leg and the provider ordered Bactrim.
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)&(2) and 22 TEX. ADMIN. CODE §217.12 (1)(A),(1)(B),(1)(C)&(4).
A case was ultimately filed against him before the Texas Board of Nursing (BON). The said allegation was fatal to the LVN’s capability to perform the essential functions and duties. Sad to say, the nursing defense attorney who handled his case was not able to properly defend his interests and rights before the Board. The Texas Board of Nursing (BON) found him guilty of the offense alleged in the complaint and decided to place his RN license under disciplinary action.
If you also received a letter from the Texas Board of Nursing regarding a case or complaint filed against you, you should hire a nurse attorney immediately before it’s too late. 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. You may contact him 24/7 at (832) 428-5679 for more information or if you want to schedule a private consultation.