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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.

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, 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, LVN reports she never saw the new orders to document on the wound vacuum because they were not entered into the EMR by the appropriate personnel, as they should have been. LVN did, however, assess the wound and vacuum as appropriate.

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

However, without enough evidence to prove she’s not guilty, the LVN lost the case. This is the reason why the Texas Board of Nursing placed her LVN license under disciplinary action. 

Do not be stressed or anxious if you find yourself in a similar situation as that of the LVN mentioned above. All you need to do is to find the right RN/LVN license attorney who can help you in the case. Equip yourself with the knowledge and expertise you need for a successful outcome by consulting a knowledgeable and experienced Texas RN/LVN license attorney. Texas Nurse Attorney Yong J. An is an experienced nurse attorney for various licensing cases for the past 16 years and represented over 300 nurses before the Texas BON. Contact the Law Office of Yong J. An 24/7 through text or call at (832) 428-5679.