RN’s Inadequate Assessment and Documentation of Vital Signs

RN’s Inadequate Assessment and Documentation of Vital Signs

In nursing, it's really important to keep a close eye on a patient's vital signs and write down everything carefully. This helps healthcare workers quickly react to any changes in the patient's condition. If a nurse gets accused of not assessing and documenting things well, they should seek assistance from a nurse defense attorney. They'll support the nurse in coming up with a strong defense plan, which can help avoid any legal or professional consequences. This way, the healthcare profession can stay accountable and the nurse's reputation stays safe.

Let's take a look at the recent incident at a hospital in Victoria, Texas. The RN failed to assess and/or document the vital signs, including the oxygen saturation level of a patient, or ensure that the vital signs were taken by the patient care assistant and entered into the medical record. Vital signs were documented in the medical record at approximately midnight including an abnormal blood pressure of 177/101mmHg, and no further vital signs were documented during the shift. Additionally, continuous pulse oximeter monitoring was not implemented, as ordered. Further, the RN failed to clarify an as-needed order for hydralazine, which was in place with no parameters, in response to the patient's high blood pressure, or document instructions or verbal orders given regarding the use of this medication. RN's conduct resulted in an incomplete medical record and exposed the patient to a risk of harm from undetected and untreated fluctuations in cardiac or respiratory status.

The RN responded without seeking a bit of advice from a nurse defense attorney and stated that she contacted the nurse practitioner about this patient because he was agitated and had an elevated blood pressure reading of 177/101. RN stated that the nurse practitioner ordered a one-time injection of Ativan, which caused the patient's blood pressure to drop to 155/80. RN stated that the nurse practitioner anticipated this and ordered that the current as-needed blood pressure medications were not to be given unless the patient's systolic blood pressure exceeded 160. RN stated that pulse oximeters were in short supply, and she could not find any on the units, so she notified her charge nurse and supervisor, but they were unable to help. Additionally, the RN stated that she secured a Dinamap with a pulse oximeter which she placed on the patient's index finger; like the telemetry leads, the patient repeatedly took this off and it had to be reapplied. RN stated that after the Ativan, the patient's vital signs stayed within parameters for the rest of her shift. RN added that she was continuously in and out of the patient's room and he was not in distress at any point during her shift. RN added that she entered several notes and spent two hours after her shift finishing her notes, and she distinctly remembers that her documentation included notes about the patient's blood pressure normalizing, being unable to find a pulse oximeter, and reporting this to her supervisors, and notes about her regular monitoring of the patient including his vital signs. RN stated that she doesn't know why the aide didn't document vitals at 0400 but RN says she would have documented it in her own notes.

Texas Board of Nursing Disciplinary Action

The above action of the RN constitutes grounds for disciplinary action per 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) and 22 TEX. ADMIN. CODE §217.12 (1)(A),(1)(B)&(4).

It’s too bad that she failed to hire a nurse attorney for assistance, knowing that she had every reason to defend herself in the first place. As a result, the Texas Board of Nursing decided to place her RN license under disciplinary action. Her defense would have gotten better if she sought legal consultation from a Texas nurse attorney as well.

The Role of a Nurse Defense Attorney

Nurse defense attorneys are trained to provide legal advice and represent nurses in court proceedings, disciplinary hearings, and other legal matters. They help nurses understand their rights and responsibilities, as well as the potential legal implications of their actions. In addition, nurse attorneys can provide guidance on documentation practices, risk management, and other issues related to nursing practice and patient care.

When you find yourself navigating complex legal issues that could potentially threaten your professional license and your ability to continue working, it's important to have experienced legal representation from a nurse attorney on your side. Our team, led by Attorney Yong J. An, has a proven track record of success in handling a wide range of cases involving nurse cases. We understand the importance of your license to your livelihood and your future, and we're committed to helping you explore all available legal options to protect your rights and interests.

Contact him at (832)-428-5679 for a free legal consultation or for more inquiries.