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In the realm of healthcare, accurate and truthful documentation is paramount to patient safety and ethical practice. However, there are instances when healthcare professionals, like RNs, may deviate from these critical standards, raising concerns about transparency and the potential impact on patient care. In such situations, the expertise of a nurse attorney becomes essential for addressing 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, 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.

Without the guidance of a nurse attorney, RN responded and stated it is her custom and practice to always consult with the physician by telephone and in person, prior to obtaining an order for a medication. She then submits 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 Patient A and B, she does 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 RN/LVN nurse attorney to handle her case. The negligence of the RN/LVN license attorney led to the decision of the Texas BON to place the RN’s license under disciplinary action.

Equip yourself with the knowledge and expertise you need for a successful outcome by consulting a knowledgeable and experienced Texas RN/LVN nurse attorney. 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. Contact the Law Office of Yong J. An 24/7 through text or call at (832) 428-5679 for a confidential consultation regarding any accusations from the Texas BON.