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Failure in documenting a complete assessment of a patient could become a problem to the patient’s treatment and a problem also for the RN’s part, as this could be the reason for her/his being put into disciplinary action. But always remember that a nurse attorney can help you go through accusation and complaint cases.

At the time of the initial incident, the RN was employed as a Travel Nurse at a hospital in Tyler, Texas, and had been in that position for four (4) months.

It was on or about January 27, 2020, while employed as a Travel Nurse and was on assignment for caring for a laboring patient, the RN failed to completely document in the patient’s medics record, including failure to document fetal heart tone assessments, verbal orders to re-start the Pitocin after fetal heart decelerations occurred, stopping the Pitocin infusion a second time, verbal orders received for the amnioinfusion rate, administration of the amnioinfusion, administration of oxygen to the patient in response to fetal heart decelerations, and contact with the physician and other interventions in response to continued fetal heart decelerations. The RN’s conduct resulted in an incomplete medical record and exposed the patient to a risk of harm in that subsequent caregivers would not have accurate and complete information on which to base their care decisions.

In response to the incident, the RN states that she received a verbal order from the physician to place an intrauterine pressure catheter (IUPC) and fetal scalp electrode (FSE), as well as an order for an amnioinfusion. The RN states that she had not confirmed the rate with the doctor, but she started the fluid around 50 ml/hr. and then immediately called him to confirm the rate, the RN states that after the patient’s cesarean section, she went to the nurse manager’s office, where she was told that her contract was being terminated. The RN states that she informed them at that time that she had not completed her charting, but she was not allowed to finish it and was told not to worry about it. The RN adds that she had made some notations on a paper monitoring strip when she did not have time to chart.

Due to the RN’s action, based on the evidence received, the Texas Board of Nursing has sanctioned and put the LVN into disciplinary action. But she failed to hire a nurse attorney to fully defend her case which leads to this decision of the Texas Board of Nursing. Hiring a nurse attorney could have changed the outcome of the case.

If you have questions regarding the Texas Board of Nursing disciplinary process, you may contact the Law Office of Nurse Attorney Yong J. An for a confidential consultation by calling or texting 24/7 at (832) 428-5679 and ask for attorney Yong.