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Nursing documentation must provide an accurate, complete, and honest account of the events that occurred, and medications administered to the patient. Any incomplete documentation can lead to a disciplinary action from the board, suspension, or worst revocation of RN/LVN license. If this happens, you need to seek the right nurse attorney to defend your case.

At the time of the incident, she was employed as an RN at a pediatric hospital in Arlington, Texas, and had been in that position for twenty-one (21) years and ten (10) months.

On or about June 26, 2020, while employed as an RN at a pediatric hospital in Arlington, Texas, RN failed to document the care of a patient accurately and completely, a neonate with a pneumothorax during transport, including failure to document vital signs from 18:00 until 19:33 and failure to document times and amounts of air obtained via needle aspiration. RN also failed to timely submit the documentation at the end of transport. In addition, RN falsely documented the number of intubation attempts performed on the patient and forged the respiratory therapist’s signature on the Neonatal Transport Record. RN’s conduct resulted in an inaccurate and incomplete medical record and was likely to injure the patient in that subsequent caregivers would not have accurate and complete information on which to base their decisions for further care.

In response, RN states that six sets of vital signs were documented because there were not enough staff or team members to write detailed vital signs minute to minute during transport because the respiratory therapist was continually working on the patient’s ventilator while RN never took her hands off the patient in order to continually monitor and remove air from the pneumothorax in order to keep the patient’s oxygen saturation levels over 90%.   RN states that the transport team was typically allowed up to 72 hours to complete all transportation documentation. RN states that she had been awake since 5:00 am and had to return to work the following morning and believed that she had at least 24-48 hours to get the paperwork completed and/or edited. RN states that she recorded the names of the members who were part of the transport team.

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) and 22 TEX. ADMIN. CODE §217.12(1)(B), (1)(C),(6)(A)&(6)(H).

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 300 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.