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Nurses’ written accounts or documentations are critical for planning and evaluation of medical interventions and patient care. Providing inaccurate documentations could lead to incorrect treatment decisions compromising patient safety. This negligence can lead to a case being filed against an RN/LVN and your license could be in danger if not defended by an experienced nurse attorney.

At the time of the initial incident, she was employed as an RN at a hospital in Victoria, Texas, and had been in that position for approximately three (3) years and eleven (11) months.

On or about July 9, 2020, while employed as an RN at a hospital in Victoria, Texas, RN failed to accurately document the correct amount of Fentanyl and Midazolam administered to the patient on the Controlled Substance Administration Records when she calculated the amount of medication that had been used from the patient-controlled analgesia (PCA) pump. RN’s conduct created an inaccurate medical record and left medications unaccounted for.

In response, RN states the patient was on a continuous drip of both Fentanyl and Midazolam. RN adds that documentation of drip titration was done every fifteen (15) minutes and/or hourly and estimations of administration were done as the titrations were adjusted quickly and frequently. According to RN, the continuous drip machine could not calculate total administrations every 15 minutes, only hourly totals, and the totals documented were of the current rate not total amount administered. RN states this could have led to a discrepancy but without ill intent. RN also states she did not get the opportunity to complete a further review of documentation that night after the shift.

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

The evidence against the RN was strong. At the same time, she was not able to properly defend her case in court. As a result, her nursing license was placed under disciplinary action.

Avoid the similar thing from happening on your end. Make sure to find the right defense attorney in case a complaint will be filed against you before the Texas Board of Nursing (BON). For more details or for a confidential consultation regarding accusations, it’s best to contact an experienced Texas nurse attorney. Texas Nurse Attorney Yong J. An is an experienced nurse attorney who represented more than 300 nurse cases for RNs and LVNs for the past 16 years. You can call him at (832)-428-5679 to get started or to inquire for more information regarding nursing license case defenses.