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Accurate and comprehensive documentation of nursing assessments is a fundamental aspect of patient care, ensuring effective communication among healthcare professionals and facilitating proper treatment plans. However, instances of incomplete or missing documentation can raise concerns about the quality of patient records and may impact the continuity of care. Such omissions in the patient’s medical record can lead to potential gaps in patient care management and may raise questions about the LVN’s adherence to professional standards. When confronted with allegations related to documentation errors, seeking the support and guidance of a nurse attorney can prove crucial in navigating the legal complexities, safeguarding the LVN’s rights, and ensuring a fair and unbiased evaluation of the situation.

Incident Scenario: Failure to Document Wound Care Assessments of a Patient

At the time of the incident, she was employed as an LVN at a hospital in Lewisville, Texas, and had been in that position for four (4) months.

On or about September 28, 2021, and September 29, 2021, while employed as an LVN at a hospital in Lewisville, Texas, and providing care for the patient, the LVN failed to document her nursing assessment of drainage, vacuum dressing, and vacuum pump settings for the post-operative wound vacuum drain. LVN’s conduct resulted in an incomplete and inaccurate medical record.

In response to the accusations, LVN reported she never saw the new orders to document the wound vacuum because they were not entered into the EMR by the appropriate personnel, as they should have been. The LVN did, however, assess the wound and vacuum as appropriate. These responses were given by the LVN to the board without seeking an advice from a nurse defense attorney first.

The above actions constitute grounds for disciplinary action in accordance with Section 301.452(b)(13) of the Texas Occupations Code and are a violation of 22 TEX ADMIN. CODE §217.11(A),(1)(B),(1)(D)&(2)(A).

However, the LVN lost the case without enough evidence to prove her innocence. This is the reason why the Texas Board of Nursing placed her LVN license under disciplinary action. 

Find the right RN/LVN license attorney who can help you defend your case. A nurse defense attorney will protect your rights throughout the investigation and disciplinary process. They will ensure that you are treated fairly and that your side of the story is heard. Texas Nurse Attorney Yong J. An is a dedicated nursing defense attorney who has been in the field for over 18 years and has successfully defended nurses before the board.

Contact the Law Office of Yong J. An 24/7 through text or call at (832) 428-5679.