RN Failed to Document and Communicate Medication Rationale
RN Failed to Document and Communicate Medication Rationale
Accurate and thorough documentation is a fundamental aspect of healthcare practice, ensuring transparency, patient safety, and adherence to ethical standards. In such instances, wherein RNs encountered allegations related to deficient documentation practices, a nurse attorney plays a pivotal role in providing support and guidance to nurses facing legal concerns related to documentation lapses. Additionally, nurse attorneys collaborate with nurses to develop a robust defense strategy, aiming to mitigate potential professional and legal consequences.
At the time of the incident, the RN was employed as a Family Nurse Practitioner at a healthcare facility in Pharr, Texas, and had been in that position for two (2) years and ten (10) months.
On or about August 9, 2021, while employed as a Family Nurse Practitioner at a healthcare facility in Pharr, Texas, the RN failed to document in the patient's medical record his rationale for prescribing hydroxychloroquine and Levaquin for a patient. Additionally, the RN failed to document a discussion with the patient of potential risks and that the use of the medications was off-label to treat the patient's diagnosis. RN's conduct resulted in an incomplete medical record and may have exposed the patient to a risk of harm.
Without seeking guidance from an experienced nurse attorney, the RN responded to the above incident and stated that he planned to prescribe an antibiotic due to the patient's history of moderate intrinsic asthma with a history of several acute exacerbations over the past year. RN stated that he explained to the patient that her rapid strep test was negative but because of her asthma and frequent exacerbations, he was going to prescribe an antibiotic Levaquin 750 mg daily for 7 days, and instructed her to take Bromfed DM as directed. RN stated that at the time he prescribed the medication, he explained to the patient the potential side effects of hydroxychloroquine including nausea, loose stools, and abdominal pain. RN stated that he also explained his rationale for prescribing hydroxychloroquine to the patient and she acknowledged understanding it. RN added that he has subsequently met with his supervising physician to discuss his care of this patient and his decision to prescribe hydroxychloroquine to her. RN stated that he and the physician have reviewed current literature and new treatments available, and RN will be following the recommendations of his supervising physician.
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)(M)&(4)(B), 22 TEX. ADMIN. CODE §217.12 (1)(A),(1)(B)&(4) and 22 TEX. ADMIN. CODE §222.4 (f).
Unfortunately, the Texas Board of Nursing found him guilty of his deeds. His RN license was subjected to disciplinary action. He did not hire a skilled Texas nurse attorney to fully defend his case which led to this decision by the Texas Board of Nursing.
Do you have questions about the Texas Board of Nursing disciplinary process?
Contact The Law Office of Texas Nurse Attorney Yong J. An for a free legal consultation by calling or texting 24/7 at (832) 428-5679. Texas Nurse Attorney Yong J. An is an experienced nurse attorney who successfully represented more than 600 nurse cases for RNs and LVNs over the past 18 years.