Medical Records should be documented with complete and accurate information of patients along with correct administered medications. Tampering or altering medical records is illegal and is a crime punishable with fines and jail time. By doing such, it can mislead and can cause harm to patients. However, if you are dealing with such accusations or complaints, it is best to seek help from a nurse attorney.
At the time of the initial incident, he was employed as an RN at a hospital in Richardson, Texas, and had been in that position for three (3) years and five (5) months.
On or about April 18, 2020, and April 19, 2020, while employed as an RN at a hospital in Richardson, Texas, RN did the following:
- RN failed to document pre-treatment vitals in the medical record of a patient, before administering breathing treatments to the patient. 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.
- RN failed to document the breath sounds of another patient after administering a nebulizer treatment, when the patient was found short of breath with an oxygen saturation of 68%. 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, RN states that he administered the treatments as ordered. Furthermore, RN states that he assessed the breath sounds before and after administering the nebulizer treatment, noting that lung sounds were assessed at 1740, prior to the nebulizer treatment at 1755; then emergency medical services personnel assumed care of the patient.
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) and 22 TEX. ADMIN. CODE §217.12(1)(A),(1)(B),(1)(C)&(4).
As a result, the Texas Board of Nursing decided to place his RN license under disciplinary action. It’s too bad that he failed to hire a nurse attorney for assistance, knowing that he had every reason to defend himself in the first place. His defense would have gotten better if he sought legal consultation from a Texas nurse attorney as well.
So, if you’re facing a complaint from the Board, it’s best to seek legal advice first. 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 16 years and represented over 300 nurses before the Texas BON. To contact him, please dial (832)-428-5679 for a confidential consultation or for more inquiries.