Documenting the administered medication to a patient is crucial in the treatment journey of a patient. A patient’s medical record will be the basis for the treatment of the patient. That is why it is very important to document every patient’s medical records correctly to avoid problems in the future. But if something happens and you are being accused of inaccurate or incorrect documentation, you can look for a nurse attorney to help you deal with the case.
At the time of the initial incident, an RN was employed as a Registered Nurse at a hospital in Arlington, Texas, and had been in that position for one (1) year and four (4) months.
It was on or about October 1, 2019, when the RN removed one (1) syringe of 4mg of Morphine from the medication dispensing system for the patient but failed to document the administration of the medication in the patient’s Medication Administration Records and/or nurses’ notes. The RN’s conduct was likely to injure the patient in that subsequent caregivers would rely on her documentation to further medicate the patient which could result in an overdose. Additionally, the RN’s conduct placed the hospital in violation of Chapter 481 (Controlled Substances Act) of the Texas Health and Safety Code.
Another incident was on or about October 3, 2019, when the RN placed a normal hub device on the port-a-cat of a patient instead of a Clave needleless connector. The RN’s conduct exposed the patient to risk of harm from non-efficacious care of the port-a-cath.
In response to the incident, the RN states she scanned the medication but that the scan may have not been saved to the computer. And that the RN states that the port-a-cath was no longer in use and the lines should have been de-accessed several days prior after the patient decided to cease all life-saving measures. The RN notice the patient was in the shower without a needleless connector, so she placed the hub cap to keep water out to the line.
The RN will be facing the Board unprepared as she failed to fully hire a nurse attorney to help her. She is subjected to disciplinary action due to inaccurate and incorrect documentation. This will have a different outcome if the RN had only hired a nurse attorney for the case.
Do you have questions about the Texas Board of Nursing disciplinary process? 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.