Case study: Tribunal orders cancellation of registration of nurse after falsifying medical records.

23 Jun 2022

A tribunal has ordered the cancellation of a registered nurse’s registration after she failed to conduct necessary observations of a patient and made false amendments to the patient’s medical records.

On 26 May 2019, Ms Funmilayo Thomas was given a directive to monitor a patient who had taken a fall in an aged care facility (the facility) for signs of injury to the brain. Ms Thomas failed to conduct any neurological observations and recorded in progress notes that the patient had settled throughout the night with no behavioural issue of concern.

The patient then deteriorated and spent time in the hospital, only to return to the facility for palliative care. On 5 June 2019 the patient died.

Out of concern for professional and personal ramifications, Ms Thomas made amendments to the progress notes and recorded false neurological observations. When queried Ms Thomas denied making any changes, but when confronted with time stamps, alleged that her observations were written on a piece of tissue at the time and she forgot to transfer the details into the progress notes that night.

Ms Thomas’ employment was terminated on 18 June 2019, and a notification was made by the facility to the Australian Health Practitioner Regulation Agency (Ahpra), and the Nursing and Midwifery Board of Australia (NMBA).

The NMBA initially proposed immediate action in the form of suspension, as at this time Ms Thomas maintained that she had made the necessary observations. The NMBA imposed conditions to her registration which, among other things, required her to be supervised by another registered nurse when practising.

On 30 March 2020, the NMBA referred Ms Thomas to the Victorian Civil and Administrative Tribunal (the tribunal). Ms Thomas formally admitted to falsifying the patient’s progress notes and that she failed to conduct the necessary observations of the patient. The tribunal found that Ms Thomas had engaged in professional misconduct and ordered that she:

• be reprimanded
• have her registration cancelled, and
• be disqualified from applying for registration until 1 May 2023.

The Tribunal agreed with the NMBA that a fundamental assumption made by patients, clients, colleagues, employers and the community in general is that nurses will faithfully record true observations in clinical records and said that Ms Thomas’ conduct “amounted to behaviour that was inconsistent with her being a fit and proper person to hold registration in the profession”.

The tribunal’s decision was published on 23 March 2022 and decision is available on the Austlii website. Critically analyse the above case study with regards to the legal and professional issues raised. Your discussion is to be supported by references to contemporary, scholarly literature. You are to include reference to specific governing nursing codes, policies and documents in your assignment.