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In healthcare, accurate and thorough documentation of vital signs is crucial for monitoring and ensuring patient well-being. However, there are instances where healthcare professionals may fall short of these standards, potentially impacting the completeness of patient records. In such situations, the guidance of a nurse attorney is vital for navigating the legal and ethical complexities surrounding incomplete documentation, ensuring adherence to protocols, and upholding the highest standards of patient care. 

At the time of the incident, she was employed as an LVN at a hospital in Garland, Texas, and had been in that position for eight (8) months.

On or about January 26, 2022, while employed as an LVN at a hospital in Garland, Texas, LVN did not document complete vital signs, including urine output, throughout her shift for her assigned patient. Specifically, LVN did not document the patient’s complete vital signs and only documented that the patient had fifty (50) milliliters of urine output throughout her entire shift.

In response to the above incident, LVN stated that during the alleged delay in documentation the patient became unstable and LVN had to stop charting. LVN claims that she was monitoring vital signs and urine output throughout her shift but entered them after her shift was over. LVN states that she could not document vital signs due to the patient’s deteriorating status. Furthermore, LVN states that the blood pressure was stable, and the patient was not on any vasopressors. LVN states that after 1100, she was not able to obtain a blood pressure reading. LVN states that there was no order for a Foley catheter so she could not monitor the continuous trend. LVN states that she routinely discussed urine output during morning rounds with the physicians. LVN gave reports and communicated patient’s needs to the oncoming nurse, as it is expected, in furtherance of the continuity of care. Additionally, the LVN states physicians were informed and were aware of the patient’s conditions. All these responses were given by LVN without consulting first with an experienced nurse attorney to handle her case.

The above action constitutes 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)(C),(1)(D),(1)(M),(1)(P)&(3)(A) and 22 TEX. ADMIN. CODE §217.12 (1)(A),(1)(B),(1)(C)&(4).

A case was ultimately filed against her before the Texas Board of Nursing (BON). The said allegation was fatal to the LVN’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 500 nurse cases for the past 17 years. You may contact him 24/7 at (832) 428-5679 for more information or if you want to schedule a private consultation.