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Accurate documentation has a huge impact on a patient’s improvement in health recovery. Doing accurate and clear documentation is essential in nursing care. It is also in the clinical guidelines of nursing and is one of many responsibilities of nurses. Some nurses tend to disregard the guidelines of appropriate documentation and then later, regret it. So, if the Board summoned you, hire a nurse attorney for help in facing the Board.

At the time of the incident, she was employed as an LVN with a home healthcare services provider in Midland, Texas, and had been in that position for fifteen (15) years.

On or about December 1, 2020, while employed as an LVN with a home healthcare services provider in Midland, Texas, LVN failed to timely notify the physician of a change in condition and obtain orders for the patient, before performing wound care on the patient. LVN described the wound as excoriated in her nursing notes and noted that the patient had dark urine in his Foley bag. Additionally, LVN failed to timely document the wound care and her attempt to notify the patient’s physician in her visit notes. Subsequently, there was no documentation that the LVN attempted to notify her supervisor or the patient’s physician of the change in condition. The patient was admitted to the hospital three (3) days later with a stage four (4) pressure injury and a urinary tract infection. LVN’s conduct prevented the physician from being informed about the patient’s wound and urinary status and exposed the patient to risk of infection.

In response, LVN states that she received a call from the patient’s assisted living facility that the entire buttocks region was bleeding. LVN states that she notified the clinical supervisor, who instructed her to perform the skilled nursing visit on the patient. LVN states that she cleansed the patient’s entire bottom area several times with soap and water. LVN reports that during the assessment, the entire bottom and scrotum were noted to be very excoriated and red, with the appearance of a diaper rash. LVN reports that the buttock on each side of the gluteal fold had a couple of areas that were seeping serous fluid and there were no observable open areas. LVN states that she cleansed the area one final time with soap and water and then dried with a clean towel. LVN states that after drying, she applied a sterile foam dressing to the two (2) areas that appeared to be weeping, and to off load pressure, then secured with tape. LVN states that she also applied corona cream to the exposed bottom area because that had previously been prescribed. LVN states that she instructed assisted living staff to keep the patient clean and dry, and apply skin barrier multiple times daily. LVN states that the physician’s office was closed, so she used standard protocol to care for the patient by cleaning the excoriated area and applying dressing, then reported to her supervisor and the physician as soon as possible. LVN states that at the time of the visit, she did not plan on performing wound care and just happened to have a package of foam and tape in her nursing bag at the time. LVN states that the patient continued to deny any other signs or symptoms of infection, uncontrolled pain, or other issues at this time. LVN states that urine drops on the Foley catheter tubing and in the continuous drainage urinary bag were dark in color. LVN states that there was no observable odor. LVN states that she instructed on the signs and symptoms of urinary tract infections, and staff denied any issues at that time, and they verbalized understanding. LVN states that on Monday, she placed a call to the physician’s office to notify him of the findings and obtain orders for the care she provided, as well as instructions to give the assisted living staff. LVN states that she left a detailed message with the receptionist as the nurse and physician were unavailable.

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)(B),(1)(C),(1)(D),(1)(N),(1)(P)&(2)(A) and 22 TEX. ADMIN. CODE §217.12.(1)(A),(1)(B),(1)(C)&(4).

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 16 years and represented over 300 nurses before the Texas BON. To contact him, please dial (832)-428-5679 for a confidential consultation or for more inquiries.