Following a facility’s policy and procedures is very important as well as doing proper documentation. If not done properly and accurately, it can put a patient in harm. Therefore, every nurse should practice keeping accurate and complete medical records for documentation purposes. Inaccurate documentation can lead to and can cause negative outcomes. If you are in such a situation, it is best to consult a nurse attorney to know what proper measures to take in facing cases.
At the time of the incidents, the LVN was employed as a Licensed Vocational Nurse at a hospital in Fort Worth, Texas, and had been in that position for five (5) years and eleven (11) months.
On or about July 8, 2018, while employed as a Licensed Vocational Nurse, the LVN failed to document a focused pain assessment for two (2) Pediatric patients. Additionally, the LVN failed to document vital signs every four (4) hours as ordered for the aforementioned patients. The LVN’s conduct created incomplete medical records and was likely to injure the patients from clinical care decisions based upon incomplete assessment information.
On or about July 8, 2018, while employed as a Licensed Vocational Nurse, the LVN failed to document a focused physical assessment on a pediatric patient. Additionally, the LVN failed to document a focused pain assessment for the aforementioned patient. The LVN’s conduct created an incomplete medical record and was likely to injure the patients from clinical care decisions based upon incomplete assessment information.
In response to the incidents, the LVN states she was not given adequate time to learn a new computer charting system implemented by the facility.
The Texas Board of Nursing has jurisdiction over all cases that may affect the license and career of an RN or LVN. Therefore, based on the findings of the Board, the RN received disciplinary action to ensure further safety and accurate documentation as she works in the future. She should hire a nurse attorney for instances such as this.
For more details and to schedule a confidential consultation, you must approach one of the most experienced nurse attorneys in Texas, Nurse Attorney Yong J. An. He has assisted numerous nursing license cases since 2006. You may contact him by dialing (832) 428-567 if you wish to learn more information should you undergo accusations or any other case that may affect your license.