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Conducting incomplete and inaccurate documentation could cause RNs to lose their hard-earned license. Such conduct could contribute to inaccurate and poor-quality care to patients. If an RN is in such trouble, ask a nurse attorney to help you fight against allegation cases.

At the time of the incident, she was employed as an RN at a hospital in Plano, Texas, and had been in that position for two (2) years and eight (8) months.

On or about March 2, 2020, while employed as an RN at a hospital in Plano, Texas, RN failed to completely and accurately document in the nursing notes events during the postoperative phase for a patient, including pain levels, administration of Phenergan, all administrations of Dilaudid, the efficacy of administered pain medications, and communications with provider. RN also failed to assess the patient’s vital signs the last hour the patient was in the post-anesthesia unit. Approximately two hours after RN was instructed to leave the facility and the patient was transported to the floor, rapid response was initiated; the patient required intubation and additional surgery for abdominal hemorrhage. RN’s conduct created an incomplete medical record and exposed the patient to risk of harm from undetected and untreated changes in blood pressure.

In response, RN states she appropriately intervened to make the patient more comfortable, and states she assessed the patient’s pain level and notified the physician the patient was bleeding. RN established her compliance with Hospital Policies in effect at the time regarding the timing of vital signs and the charting of patient response to medications using the RASS system per hospital policies. The PACU was closed at 1700 and RN was the only nurse assigned to the Unit. RN states she expected the patient to be transferred to a room when she removed the vital sign monitors at approximately 1745 and states the patient remained in the PACU awaiting an available bed on the admitting floor. RN also states she was then instructed by her nurse manager to depart the PACU; that her nurse manager took over the care of the patient and she had no further involvement with the patient. RN was instrumental in creating new procedures for charting and assessment of patients in the PACU to be followed in the PACU and an additional RN position was created for this unit.

The above action constitutes 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)&(3)(A) and 22 TEX. ADMIN. CODE §217.12.(1)(A),(1)(B),(1)(C)&(4).

However, without valid evidence to defend her side of the story, the RN lost the case. Furthermore, the RN failed to hire a Texas BON attorney to help her with her case. Because of this, the Texas Board of Nursing disciplined the LVN’s license.

Do not be stressed or anxious if you find yourself in a similar situation as that of the RN mentioned above. All you need to do is to find the right RN/LVN license attorney who can help you in the case. Equip yourself with the knowledge and expertise you need for a successful outcome by consulting a knowledgeable and experienced Texas RN/LVN license attorney. Texas Nurse Attorney Yong J. An is an experienced nurse attorney for various licensing cases for the past 16 years and represented over 300 nurses before the Texas BON. Contact the Law Office of Yong J. An 24/7 through text or call at (832) 428-5679.