Conducting incomplete documentation could cause RNs to lose their hard-earned license. Such conduct could contribute to inaccurate and poor quality care to patients. If an RN is in such trouble, ask a nurse attorney to help you fight against allegation cases.

At the time of the incident, the RN was employed as a Registered Nurse at a hospital in Amarillo, Texas, and had been in that position for one (1) year and five (5) months.

On or about October 21, 2017, the RN failed to document her own assessment findings and interventions performed and failed to verify the documentation completed by staff vocational nurses, after the patient experienced respiratory distress and required transfer to the hospital. As soon as emergency medical services arrived, they began providing cardiopulmonary resuscitation (CPR) and transferred the patient to a local emergency department, where the patient was pronounced deceased shortly thereafter. The RN’s conduct created an incomplete medical record and contributed to the facility receiving an Immediate Jeopardy (IJ) citation for nurses not providing CPR and not documenting appropriate information in the medical record.

In response, the RN states she was ending her shift when she responded to a code called in the Resident’s room. Although this patient was not assigned to the RN’s care, the RN immediately intervened by assessing and monitoring the patient’s vitals. She called out her findings to another nurse who transcribed the information. Then she continued monitoring and assessing the patient until EMS arrived and took over care. And she further states that she verified the transcribed vitals and the information was handed over to another nurse to complete the SBAR documentation. And lastly, she indicates this was the procedure for handling arising emergencies at the facility.

As a conclusion to the above incidents, the RN is subjected to a discipline. Prior to the proceedings, the RN was given the opportunity to show compliance. But the RN will receive a sanction in accordance with the terms of the Order wherein both the Board and the RN agreed. This result and decision made by the Board were caused pursuant to Section 301.452(b) (10)&(13), Texas Occupations Code. The result could have been different if the RN had hired and consulted a nurse attorney to represent her. Hiring a nurse attorney is a game-changer for you.

Do you have questions about the Texas Board of Nursing disciplinary process? Contact The Law Office of RN License Attorney Yong J. An for a confidential consultation by calling or texting 24/7 at (832) 428-5679 and ask for attorney Yong.