RN’s Delayed Assessment of Patient Fall and Documentation Inaccuracy

RN's Delayed Assessment of Patient Fall and Documentation Inaccuracy

The accurate and timely assessment of patients is a cornerstone of nursing practice, ensuring the swift and appropriate delivery of care, especially in situations involving injuries or changes in condition. However, the incident involving an RN's failure to perform a complete assessment after a patient's fall and subsequent inaccuracies in documentation resulted in a delay in the diagnosis and treatment of an acute ankle fracture dislocation. In such challenging situations, a nurse attorney becomes an invaluable ally for RNs. A nurse attorney's expertise is crucial in guiding RNs through the legal intricacies, safeguarding their rights, and formulating a robust defense strategy to address potential professional and legal consequences arising from lapses in patient care and documentation.

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sm by smartsites January 9, 2024

At the time of the initial incident, she was employed as an RN at a hospital in Carrollton, Texas, and had been in that position for thirteen (13) years and three (3) months.

On or about April 28, 2021, while working as an RN at a hospital in Carrollton, Texas, the RN failed to perform a complete assessment, including an assessment of the injury site and palpation of pedal pulses, after she was notified that her assigned patient fell in the hallway. Specifically, the RN was notified that the patient had a witnessed fall and a visibly rotated right foot. Additionally, the RN inaccurately documented that the patient had a completely rotated right foot to ninety (90) degrees but could walk normally, then edited the documentation to reflect that the musculoskeletal system was within normal limits. The patient required a wheelchair after the injury. Furthermore, the RN failed to ensure timely physician assessment and/or timely escalation of care when the physician did not arrive at the unit to assess the patient's change in condition for approximately five (5) hours. Subsequently, the patient was later taken to the emergency department where she was assessed and found to have an acute ankle fracture dislocation. RN's conduct resulted in an inaccurate medical record and was likely to injure the patient from a delay in treatment.

In response to the above incident, the RN stated that she recently was involved in a peer review and the committee determined her conduct did not expose patients or other persons to unnecessary harm and her continuing to practice nursing does not pose a threat of harm to patients or others. The RN deliberately stated this without consulting with a nurse attorney first.

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

Sadly, the RN has been found guilty of misconduct, leading to disciplinary measures against her RN license by the Texas Board of Nursing. It appears that the nurse did not seek the assistance of an experienced Texas nurse attorney to represent her case effectively, which might have led to a more favorable outcome. Consequently, the Board's ruling stands, and the nurse must accept the consequences. Seeking legal counsel in such instances is important to protect your rights and present your case favorably.

Make sure that you will not make the same mistake as the RN mentioned above in her case before the Texas Board of Nursing (BON). Contact a Texas nurse attorney today who can provide you with a free legal consultation to assess your case and counsel you on the best steps to take. Texas Nurse Attorney Yong J. An is a seasoned nurse attorney with a wealth of experience in handling legal matters related to nursing. He has successfully represented numerous nurses facing legal challenges from the Texas BON. 

Contact the law office of Attorney Yong J. An today for a free legal consultation.