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In the field of home healthcare, the timeliness and accuracy of patient documentation are vital elements in ensuring continuous and effective care. Unfortunately, there are instances when healthcare professionals, like RNs, face challenges in this critical aspect of their responsibilities. In situations where lapses in timely documentation can impact patient care, the assistance of a nurse attorney becomes invaluable. A nurse attorney possesses the expertise to guide healthcare professionals through the legal dimensions of such situations, fostering accountability and upholding the standards of patient care ethics.

At the time of the incident, she was employed as an RN/Clinical Team Lead with a home health care service provider in Irving, Texas, and had been in that position for five (5) months.

On or about December 30, 2021, through January 2, 2022, while employed as an RN/Clinical Team Lead with a home health care service provider in Irving, Texas, RN failed to timely and completely document the start of care assessment for a patient. In addition, RN failed to appropriately and timely follow-up with the provider to complete the patient’s plan of care and schedule a follow-up home health visit to reassess the patient and his transition to home. Subsequently, on or about January 2, 2022, when the patient’s family contacted the on-call nurse to report the patient’s decline in health, the on-call nurse was unable to locate any information on the patient as documentation had not been completed and submitted. RN’s conduct resulted in an incomplete medical record and was likely to injure the patient in that subsequent caregivers would not have accurate and complete information on which to base their decisions.

Without consulting and asking for assistance from a nurse attorney, RN responded to the above incident and states that she assessed the patient on a Wednesday morning, discussed the plan of care with the patient and family, explained to them that physical therapy would be there later in the day for an assessment, and discussed nursing visits. RN states that, due to it being a holiday weekend, the family did not see a need for anyone to come out, especially since a Visiting Physician nurse practitioner would be coming out the next day to assess the patient. RN states that she explained that at the next nurse visit, she would go over the nurse practitioner visit and see if any medication changes or orders were made. RN states she explained when and how to call the agency with any concerns/changes in patient condition or questions. RN states that during the visit she phoned the Visiting Physician office to verify the appointment time and requested a call back with any changes or concerns regarding the plan of care. RN states that she spoke to the physical therapist who called after his assessment. RN states that she completed her physical assessment in the home, but she still had parts of the visit to complete the note. RN states she completed the note on Sunday and submitted it to the office.

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)(B),(1)(D)&(1)(P) and 22 TEX. ADMIN. CODE §217.12 (1)(B)&(1)(C).

However, without valid evidence to defend her side of the story, the RN lost the case. Furthermore, the RN failed to hire a Texas nurse attorney to help her with her case. Because of this, the Texas Board of Nursing disciplined the RN’s license.

Do not be stressed or anxious if you find yourself in a similar situation as that of the RN 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 17 years and represented over 500 nurses before the Texas BON. Contact the Law Office of Yong J. An 24/7 through text or call at (832) 428-5679.