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 incident, she was employed as an LVN at a mental health facility in Killeen, Texas, and had been in that position for nine (9) months.
On or about July 30, 2020, while employed as an LVN at a mental health facility in Killeen, Texas, LVN failed to completely and accurately document in the medical record of patient A, that the physician was notified regarding the accidental ingestion of another patient’s medication, that the patient was educated on possible side effects of the medication and monitored appropriately, vital signs were taken and monitored, and one of the patient’s medications was held by the physician. Subsequently, the abovementioned patient’s physician documented the following day that she did not know why the patient’s medication was held. LVN’s conduct resulted in an incomplete and inaccurate medical record and was likely to injure the patient in that subsequent caregivers did not have complete and accurate information on which to base their decisions for further care.
In response, LVN states that she administered the medication to the wrong consumer. LVN states that during medication pass time, nurses call the consumer up to the nursing station desk for medication and consumers are identified by name, date of birth, picture, and identification bracelet before medications are given. LVN states the consumer was properly identified, medication was called out, and the pill was placed in the medication cup. LVN states that at the time the medication was handed to the consumer, another consumer was waiting for medication. LVN states the consumer who received the medication cup put it down and said he forgot his water. The consumer behind him walked up and took the medication like it was his. LVN states that she asked the second consumer why he picked the medication and took it when he had not been called yet. LVN states that the consumer who took the wrong medication was checked on, vitals taken, and the medical doctor on duty was notified, with orders received to hold the consumer’s trazodone that was due for that night. LVN states she completed the incident report and informed her supervisor.
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)(C)&(1)(D) and 22 TEX. ADMIN. CODE §217.12(1)(B)&(1)(C).
Unfortunately, the Texas Board of Nursing found her guilty of her deeds. Her LVN license was subjected to disciplinary action. She did not hire a skilled Texas BON attorney to fully defend her case which led to this decision by the Texas Board of Nursing.
Do you have questions about the Texas Board of Nursing disciplinary process? Contact The Law Office of Texas Nurse Attorney Yong J. An for a confidential consultation by calling or texting 24/7 at (832) 428-5679. Texas Nurse Attorney Yong J. An is an experienced nurse attorney who represented more than 300 nurse cases for RNs and LVNs for the past 16 years.