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Documenting a patient’s medical record accurately and correctly is very important. Accurate documentation is the basis of a patient’s correct treatment. Once an inaccurate record is followed during treatment, this can harm a patient due to wrong or incomplete documentation. If involved in such trouble, always consider asking help from a nurse attorney.

At the time of the incident, an RN was employed as a Registered Nurse at a hospital in Fort Hood, Texas, and had been in that position for six (6) years and five (5) months.

It was on or about May 14, 2019, the RN failed to accurately document the administration of medication to a patient, including documentation of the administration of gabapentin at 10:12 when the patient requested to take the medication later with food; and documentation of famotidine at10:12, despite having returned the medication to the dispensing system at 09:48.  RN’s conduct resulted in an inaccurate medical record and unnecessarily exposed the patient to the risk of harm in that subsequent caregivers did not have accurate information on which to base their decisions for further care.

In response to the incident, the RN states that the patient had been an overnight admission who had been placed NPO (nothing by mouth) on admission, pending possible further diagnostic testing. The RN states that she updated the patient on the latest plan of care, which included removing the NPO order so that she could order breakfast and Respondent could administer her oral medications. The RN states that the patient agreed to take her medications, proceeded to order her breakfast, and the RN started the process to administer the medications that the patient had agreed to take. The RN states that she scanned each medication, took them out of their original packaging, and placed them into a medication cup. The RN states that the patient then proceeded to take her medications, but when she got down to the last of the pills, she stated she wanted to wait until she had eaten something to take the rest of the medication. The RN states that the patient requested the remaining pills be left with her and she would take them after her breakfast had arrived.

The RN states that she explained that she was unable to leave the medications unattended at the patient’s bedside and had to witness the patient taking them, but she would be able to place them back into a medicine cup, place the cup in a sealable plastic bag with the patient’s name on it, to bring back when the patient was ready. The RN states that the patient agreed she would call and let the RN know when she was ready for the rest of her medications. She also states that a few minutes later the unit director approached her outside the patient’s room to ask if the patient was appropriate for patient satisfaction questions. The RN states that the unit director then approached her again, as she left the room, and informed her that the patient was asking for her medication. The RN explained she had the medications ready and Respondent proceeded to get them and go into the room to give them.

The incident above resulted in disciplinary action of the RN, the decision of the Board was based on the evidence presented which is cause pursuant to Section 301.452(b)(13) of the Texas Occupations Code. This happened to the RN for the reason that she failed to hire a nurse attorney to assist her on the case.

Avoid a similar thing from happening on your end. Make sure to find the right nurse attorney in case a complaint will be filed against you before the Texas Board of Nursing (BON).

Consult with Texas nurse attorney Yong J. An today if you have any questions about your disciplinary process by calling or texting him at (832) 428-5679 day, night or weekends.