Meticulous and accurate documentation stands as a fundamental pillar of responsible and ethical practice in the medical field. Proper documentation not only ensures that patients receive comprehensive care but also serves as a critical reference for healthcare decisions and the continuity of care. When lapses occur in the documentation process, it raise concerns about the completeness and accuracy of a patient’s medical record, potentially impacting patient care and legal compliance. In situations like this, the involvement of a nurse attorney is pivotal in addressing the legal and ethical aspects of the matter. Throughout any investigations or legal inquiries that may follow, the nurse attorney will vigilantly safeguard the legal rights of the RN, ensuring due process and a fair assessment of the situation.
Incident Scenario: Failure to Appropriately Document Neurological Assessments
At the time of the initial incident, she was employed as an RN at a healthcare facility in Galveston, Texas, and had been in that position for one (1) year and eight (8) months.
On or about May 19, 2021, through May 20, 2021, while employed as an RN at a health care facility in Galveston, Texas, working in the Emergency Room, and providing care for a patient, the RN failed to appropriately assess, and/or document her neurological assessments. RN’s conduct could have contributed to an incomplete medical record.
RN’s Response to the Allegation
The RN responded to the allegation without partnering with a Texas nurse defense attorney. The RN then stated that during the period she monitored the patient, there was not any seizure activity present. RN provided for the Board’s consideration before mediation the most recent job evaluation conducted by her then and current employer, which evaluation was favorable. Additionally, the RN provided two letters of support from two of the emergency room physicians who were tending to the patient on the night of May 19, 2021, one of which specifically observed that there was no seizure activity during his overlapping shift with this RN and that none of her care resulted in delay of treatment of this patient. Additionally, the RN provided a letter of accommodation from the Administrative Director of Emergency Services for her employer. Additionally, the RN and the record point out that the patient had been cleared for discharge and ordered discharged by the attending emergency room physician as of 11:00 p.m. on the night of May 19, 2021, four hours into the RN’s shift. Due to the mother’s insistence that the patient be admitted to the hospital, the patient was admitted to the hospital without any indication of additional seizure activity prior to leaving the emergency department.
Following the incident, the Texas Board of Nursing (BON) conducted an investigation and summoned the RN involved. After the investigation, the RN was found guilty of the allegation. If the nurse had hired a Nurse Attorney, a lawyer who specializes in nursing cases, they could have helped defend against the accusations. It’s important for nurses facing accusations to think about hiring a Nurse Attorney because they can help with different kinds of accusations.
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Texas Nurse Attorneys, Yong J. An is skilled and qualified to take care of your Nursing License needs. With years in the field and a passion for our clients, we continue to defend our healthcare professionals. You can directly contact him at (832) 428-5679 to get started or to inquire for more information regarding nursing license case defenses.