Accurate and truthful documentation is important to patient safety and ethical practice in the healthcare industry. However, there have been instances where healthcare professionals, such as registered nurses, have failed to meet these standards. This raises concerns about transparency and the potential impact on patient care. In such situations, the expertise of a nurse attorney becomes essential. They can help address the legal and ethical dimensions surrounding inaccurate documentation, ensuring accountability, and upholding the integrity of patient records.
At the time of the initial incident, she was employed as an RN at a hospital in Grand Prairie, Texas, and had been in that position for one (1) year and eleven (11) months.
On or about October 11, 2021, while employed as an RN at a hospital in Grand Prairie, Texas, the RN inaccurately documented telephone physician’s orders to change the administration times of scheduled Metoclopramide, Midodrine, and Magnesium Oxide for two (2) different patients, without authorization from the physician. RN’s conduct created inaccurate medical records.
The RN responded, without guidance from a nurse attorney, that it is her custom and practice to always consult with the physician by telephone and in person, before obtaining an order for a medication. She then submitted the medication order to the pharmacy. In this facility, over 95% of the time, the medications are ready for administration and are stored in the medication delivery system. Concerning Metoclopramide and Midodrine, she specifically recalls obtaining physician orders and receiving consent to change administration times which she did. As far as Magnesium Oxide, for Patients A and B, she did not specifically recall the telephone order time or place or conversation with the physician. However, it is her custom and practice to always communicate with the physician and follow her usual pattern of conduct which is to notify the pharmacy and document accordingly. She was honest and open with her supervisor that to the best of her recollection, she had given the medications at a different time. She altered the medication, not to deceive or create an inaccurate medical record, but rather to correct a mistake or alternatively, she made an honest mistake of documentation. In no way would she ever attempt to deceive or create an inaccurate medical record which would cause harm to the public.
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)(A),(1)(B),(1)(C),(4),(6)(A),(6)(H)&(10)(B).
The Texas Board of Nursing gave the RN enough time to defend the complaints filed against her. However, there was a failure on the RN’s part to find the right nurse attorney to handle her case. The negligence of the nurse license attorney led to the decision of the Texas BON to place the RN’s license under disciplinary action.
For a successful outcome, consult with a knowledgeable and experienced Texas nurse attorney. Texas Nurse Attorney Yong J. An is one of those dedicated nurse attorneys who is ready to defend your case no matter the circumstances. Contact the Law Office of Attorney Yong J. An 24/7 through text or call at (832) 428-5679 for a confidential consultation regarding any accusations from the Texas BON.