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Following a facility’s policy and procedures is very important as well as doing proper documentation. If not done properly and accurately, it can put a patient in harm. Therefore, every RN should practice keeping accurate and complete medical records for documentation purposes. Inaccurate documentation can lead and can cause negative outcomes. If you are in such a situation, it is best to consult a nurse attorney to know the proper measures to take in facing cases.

At the time of the incident, she was employed as an RN at a hospital in Galveston, Texas, and had been in that position for two (2) months.

On or about April 4, 2020; April 9, 2020; April 18, 2020 and April 19, 2020, while employed as an RN at a hospital in Galveston, Texas, the RN withdrew Pain Medication 2mg, Hydrocodone 5/325mg and Lorazepam 1 mg from the medication dispensing system for six (6) different patients but failed to document and/or accurately and completely document the administration of the medication in the patients’ Medication Administration Record (MAR) and/or Nurses’ Notes. RN’s conduct was likely to injure the 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.

In response, the RN stated she was a floater who was working in COVID-19 units at the time and as such, the workstation on wheels (WOW) could not be taken into the patients’ rooms. Nurses were expected to withdraw medications, don their PPE, administer the medications, and then document the administration at the nurse’s station. However, each nurse was left to develop their system as there were no specific instructions on how to memorialize information since nothing could be brought in/out of the patients’ rooms. RN states she kept track of medications on a handwritten list, but it proved ineffective due to varying circumstances such as when patients refused their meds and/or interruptions and logjams with nurses while waiting to manually document administrations at the nurse’s station. RN relates she did not divert or misappropriate any medications.

The above actions constitute 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)(A),(1)(B),(1)(C),(4),(6)(G),(8),(10)(C),(10)(E)&(11)(B).

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 over 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.