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Following a facility’s policy and procedures is very important as well as doing proper documentation. If not done properly and accurately, it can put a patient in harm. Therefore, every RN should practice keeping accurate and complete medical records for documentation purposes. Inaccurate documentation can lead to and can cause negative outcomes. If you are in such a situation, it is best to consult a nurse attorney to know what proper measures to take in facing cases.

At the time of the incident, an RN was employed as a Registered Nurse at a hospital in Killeen, Texas, and had been in that position for twenty-two (22) years.

On or about April 11, 2018, while employed as a Registered Nurse, the RN failed to accurately and completely assess and/or document the assessment of a patient. Additionally, the RN falsified the patient behaviors and responses exhibited on the restraint release assessment. The RN’s conduct resulted in an inaccurate medical record and was likely to injure the patient in that subsequent caregivers would not have complete information on which to base their care decisions.

On or about April 11, 2018, the RN caused neglect to a patient by authorizing the transportation of the patient from the quiet/seclusion room without an assessment of the patient to determine if this was appropriate. Furthermore, the RN failed to ensure the patient maintained 1:1 continuous observation when he authorized the patient to be taken to his room. Additionally, the RN failed to assess the patient to ensure the patient was awake. The RN’s conduct exposed the patient unnecessarily to risk of harm in that failure to assess the patient resulted in the patient not getting the care he needed.

In response, the RN states that being a nurse he cannot stress the importance of accurate and timely communication between caregivers. The RN states that false information given to a caregiver can lead to delay inpatient treatment and possibly an adverse event. The RN states that at the time he released the patient he instructed PNA RR to stay with the client until he awakens. The RN states he did give the PNA approval to assist the patient to his bed area. The RN states PNA RR was assigned 1:1 observation at that time and should have continued to observe the client until he awoke and could be re-assessed by the mg. The RN states he was not aware that PNA RR did not stay with his assigned observation, and had in fact shut the client’s door so the client could not be visualized by staff. The RN states that at no time was he notified that the client was in distress. The RN states that at the time it was reported to him that the client was asleep, his assessment revealed no signs of distress. The RN states he was unaware that the patient had been asleep for one hour prior to the time he released him.

As a  result, the Texas Board of Nursing then decided to subject the RN and her license to disciplinary proceedings. The said proceedings shall ensure the safety of the patient, along with a better future for the RN’s career. However, she should contact a nurse attorney in order to receive assistance regarding the case, especially if the RN sincerely thinks of it as an accusation.

For more details or for a confidential consultation regarding accusations, it’s best to contact an experienced nurse attorney. Nurse Attorney Yong J. An is an experienced nurse attorney which helped RNs and LVNs defend against several cases since 2006. You can call him at (832) 428-5679 to get started or to inquire for more information regarding nursing license case defenses.