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Correct documentation of a patient’s medical records is very crucial to a patient’s treatment. But if an RN commits such mistakes like this, could cause an RN’s license to be suspended or revoked. This is why every health care professional should ensure accurate and complete clinical documentation at any cost. This matter can be resolved with the help of a nurse attorney.

At the time of the incident, the RN was employed at a hospital in Odessa, Texas, and had been in that position for one (1) month.

On or about August 30, 2019, an RN failed to accurately and completely document the antimicrobial medication, Anasept, in the medication record of a patient. Additionally, the RN failed to accurately and completely document the healing status of pressure ulcers on the back, buttocks, and sacral areas of the aforementioned patient. The RN’s conduct resulted in an inaccurate medical record and was likely to injure the patient in that subsequent caregivers would not have accurate and complete information on which to base their care decisions.

On or about August 30, 2019, through September 5, 2019, the RN failed to appropriately assess the pressure ulcers of a patient who was bedridden and incontinent of bowel and bladder. Respondent’s conduct was likely to injure the patient from the adverse complications of infected pressure ulcers.

In response to the incidents, the RN states she performed the quarterly focused assessment and orally reported her findings to the registered nurse. The RN also states she spoke with the patient’s caregiver regarding recommendations from the wound care physician. The RN further states she also spoke with the service coordinator regarding additional nursing units needed for the patient.

As a result of this incident, the RN has been sanctioned by the Board. This decision was based on the violations made by the RN caused pursuant to Section 301.452(b)(10)&(13), Texas Occupations Code. She is under disciplinary action.

This decision of the Board could have yielded a different result if the RN had asked for help from a nurse attorney in defending him against the case he is in and should not have undergone disciplinary action.

If ever you have questions about the Texas Board of Nursing disciplinary process? Contact The Law Office of RN License Attorney Yong J. An for a confidential consultation by calling or texting 24/7 at (832) 428-5679 and ask for nurse attorney Yong.