A Nursing and Midwifery Board Australia (NMBA) disciplinary tribunal has
cancelled a nurse’s registration after the nurse failed to conduct necessary
observations and entered false observations in the patient’s medical record.
Nurse X, was instructed to monitor a patient, Ms Y, who had fallen in her aged
care facility. Nurse X was instructed to complete and document regular
neurological observations on Ms Y, as per the aged care facilities fall policy, and
report signs of brain injury. Nurse X failed to conduct any assessments, and noted
in the medical record that the patient had ‘slept well overnight, nil concerns’. The
patient deteriorated on the following shift and died in hospital a few days later.
Nurse X, out of concern for the personal and professional ramifications of her
actions, made amendments to the medical record and entered false neurological
observations. When questioned, she denied making any changes; when confronted
with time stamps of her alterations, she reported that she had written the
observations on some scrap paper and forgot to transfer them to the medical
record.
The aged care facility reported this incident to the NMBA. At the formal
disciplinary tribunal hearing, Nurse X admitted that she had made false entries to
the medical record, and had not conducted the necessary observations of Ms Y.
Question 1:
Identify one ethical and one legal factor that has been breached in this
situation and explain how each have been breached (600 words).
Question 2:
Identify and explain two relevant aspects of the Code of Conduct and the
Code of Ethics for Nurses that were not upheld in this scenario (600 words).