Every medication administered to a patient should be accurately and completely documented on a patient’s medical record. It is one of the nurse’s roles to ensure that a patient’s medical record is correct. If an RN does incorrect and inaccurate documentation there’s a tendency of harming the patient. The RN who is assigned to do that can be sued by the patient or by the family and can lead to license suspension or revocation. This can be avoided or prevented if the RN involve is ready to face the Board together with a nurse attorney.

At the time of the initial incident, an RN was employed as a Registered Nurse at a hospital in Allen, Texas, and had been in that position for approximately three (3) months.

On or about June 17, 2019, through June 20, 2019, an RN withdrew a total of ten (10) Hydrocodone /APAP 5/325mg tablets from the Pyxis for three patients but failed to document and/or completely and accurately document the administration of five (5) of the tablets in the patient’s Medication Administration Record (MAR) and/or nurse’s notes. The RN’s conduct was likely to injure patients in that subsequent caregivers would rely on her documentation to further medicate the patients 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.

On or about June 17, 2019, through June 20, 2019, an RN withdrew a total of ten (10) Hydrocodone/APAP 5/325mg tablets from the Pyxis for three patients but failed to follow the facility’s policy and procedure in documenting wastage/return of the unused portions of the medication. The RN’s conduct left medications unaccounted for and could have unintentionally deceived the hospital pharmacy and placed them in violation of Chapter 481 (Controlled Substances Act) of the Texas Health & Safety Code.

In response, the RN states that after 12 years at Cy Fair, she had become accustomed to their Cerner electronic medical record (EMR) system and was still learning how to use the system. During the dates in question, the RN was still on orientation and was being trained and supervised by a preceptor. To the best of her recollection, the RN states on June 17, 2019, she pulled two Norco tablets for a patient but only administered one, which she duly documented. According to the RN, when she went to return the unused table to the Pyxis, the Pyxis prompted her to enter a count for the Norco. The RN entered “1” since she was returning one tablet, not realizing that the Pyxis was prompting her for the resulting count of Norco after the return. Over the following three days, The RN states whenever she withdrew two Norco tablets, she would scan one of the tablets twice at the patient’s bedside prior to administering both, as is common practice at many facilities. Unbeknownst to her at the time, the RN states the system did not recognize multiple scans of the same medication and instead required each tablet to be scanned separately. As a result, the RN explains that the medication administration records (MARs) only showed one tablet as being administered, when she in fact had given them both. The RN states she volunteered to undergo drug testing, which returned negative results. The RN expresses that is committed to learning from this experience.

As a result, the Texas Board of Nursing has put the RN into disciplinary action. If only the RN could have hired a nurse attorney for the defense, everything could have been different. Hiring a nurse attorney should be an RN’s sole priority in dealing with such cases. A right nurse attorney with years of experience in handling nurse cases is the best fit to hire.

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.