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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 raises 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.

At the time of the initial incident, she was employed as an RN at a health care 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, RN failed to appropriately assess, and/or document her neurological assessments. RN’s conduct could have contributed to an incomplete medical record.

In response, RN reports during the period she monitored the patient, there was not any seizure activity present. RN provided for the Board’s consideration prior to 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, 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 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.

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)(D),(1)(M)&(3)(A) and 22 TEX. ADMIN. CODE §217.12(1)(A),(1)(B)&(4).

The Texas Board of Nursing then subjected the RN and his license into disciplinary action. The accusation would have been defended by an experienced and skilled Texas Nurse Attorney, had the RN hired one. Hiring a Texas Nurse Attorney for defense is applicable for any kind of accusation laid against an RN or LVN.

For more details and to schedule a confidential consultation, you must approach one of the most experienced Texas Nurse Attorneys, Yong J. An. He is an experienced nurse attorney who represented more than 500 nurse cases for RNs and LVNs for the past 17 years. You can call him at (832) 428-5679 to get started or to inquire for more information regarding nursing license case defenses.