Problem
Case Study
Registered nurse Mr Muhamad was given a directive to monitor a patient who had taken a fall in an aged care facility for signs of injury to the brain. Mr Muhammad failed to conduct any neurological observations (assessment for detecting a head injury) and recorded in progress notes (medical records) that the patient had settled throughout the night with no behavioural issue (sometimes associated with a brain injury) of concern.
The patient then deteriorated and spent time in the hospital, only to return to the facility for palliative care; the patient died shortly after.
Out of concern for professional and personal ramifications, Mr Muhammad made amendments to the progress notes (medical record) and recorded false neurological observations. When questioned, Mr Muhammad denied making any changes but, when confronted with time stamps, alleged that his observations were written on a piece of tissue at the time. He forgot to transfer the details into the progress notes (medical record) that night. The facility manager following up on the incident, discovered that Mr Muhamad wasn't a registered nurse.
i. Identify and clearly state two standards and the relevant criteria from the NMBA Standards of Practice that relate to the case. You should also state clearly established links between them.
ii. Identify two legal issues that relate to the case, stating the relevant laws and potential consequences.