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The accurate assessment and documentation of patient care are pivotal responsibilities in nursing, ensuring that patients receive the appropriate treatments and interventions. Nurses must adhere to strict protocols to assess vital signs and patient conditions, especially when administering treatments like nebulizer breathing treatments. Any lapses or inaccuracies in this process can lead to incomplete medical records, which, in turn, can compromise patient care. A nurse attorney plays a vital role in cases where nurses’ assessment and documentation practices come into question. They advocate for the legal rights of the nurse while also working to preserve the accuracy and completeness of medical records.

At the time of the initial incident, she was employed as an LVN at a detention facility in Pasadena, Texas, and had been in that position for four (4) months.

On or about June 29, 2021, through July 9, 2021, while employed as an LVN at a detention facility in Pasadena, Texas, LVN failed to assess the oxygen saturation and lung sounds of a patient when he came to the nursing station on four (4) occasions for a nebulizer breathing treatment, as required before and after the treatment. LVN falsely documented the assessments on the SVN Treatment Flow Sheet and failed to document administration of the as-needed (PRN) nebulizer treatment on the patient’s PRN medication administration record. LVN’s conduct resulted in an incomplete and inaccurate medical record and was likely to injure the patient from clinical care decisions based upon incomplete assessment information.

The above actions constitute 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)(B),(1)(C),(1)(M)&(3)(A) and 22 TEX. ADMIN. CODE §217.12 (1)(A),(1)(B),(1)(C),(4)&(6)(A).

As a result, the Texas Board of Nursing decided to place her LVN license under disciplinary action. 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. Her defense would have gotten better if she sought legal consultation from a Texas nurse attorney as well.

So, if you’re facing a complaint from the Board, it’s best to seek legal advice first. Texas Nurse Attorney Yong J. An is willing to assist every nurse in need of immediate help for nurse licensing cases. He is an experienced nurse attorney for various licensing cases for the past 17 years and represented over 500 nurses before the Texas BON. To contact him, please dial (832)-428-5679 for a confidential consultation or for more inquiries.