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Accurate documentation has a huge impact on a patient’s improvement in health recovery. Doing accurate and clear documentation is essential in nursing care. It is also in the clinical guidelines of nursing and is one of many responsibilities of nurses. Some nurses tend to disregard the guidelines of appropriate documentation and then later, regret it. So, if the Board summoned you, hire a nurse attorney for help in facing the Board.

At the time of the initial incident, she was employed as an RN at a medical facility in San Antonio, Texas, and had been in that position for one (1) year.

On or about May 18, 2020, while employed as an RN at a medical facility in San Antonio, Texas, RN withdrew medications for multiple patients but failed to accurately document the administration of the medication in the patients’ Medication Administration Record (MAR). Furthermore, RN documented the administration of medications in the MAR when there was no corresponding medication withdrawal from the medication dispensing system associated with the time and date of administration. Finally, RN failed to follow the facility’s policy and procedures for wastage of the unused portions of several medications. RN’s conduct created an inaccurate medical record and could have left medications unaccounted for.

In response to the above incidents, RN states she may have failed to document some administrations due to computer issues and heavy demands of her assigned patients. RN states she normally worked the Progressive Care Unit but was floated to the Med-Surg floor. RN states there also may have been an issue with Omnicell when sending requests from one dispenser to another. RN states that she gave the appropriate medications to her patients as needed but acknowledges problems with the documentation.

The above actions constitute grounds for disciplinary action in accordance with Section 301.452(b)(10)&(13), Texas Occupations Code, and a violation of 22 TEX. ADMIN. CODE §217.11(1)(A),(1)(B),(1)(C)&(1)(D) and 22 TEX. ADMIN. CODE §217.12(10)(C).

A case was ultimately filed against her before the Texas Board of Nursing (BON). The said allegation was fatal to the RN’s capability to perform the essential functions and duties. Sad to say, the nursing defense attorney who handled her case was not able to properly defend her interests and rights before the Board. The Texas Board of Nursing (BON) found her guilty of the offense alleged in the complaint and decided to place her 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 200 nurse cases for the past 16 years. You may contact him 24/7 at (832) 428-5679 for more information or if you want to schedule a private consultation.