Failure to Change IV Dressings Timely
Penalty
Summary
The facility failed to ensure the timely change of short peripheral catheter cover dressings for two residents, leading to a potential risk of local and systemic infection. The policy for Vascular Access Devices and Infusion Therapy Procedures requires that short peripheral catheter dressings be changed every 7 days or when the integrity of the dressing is compromised. However, observations revealed that the dressing for one resident was dated 1/22, and for another resident, it was dated 1/31, both exceeding the 7-day requirement. The Medication Administration Records (MAR) for both residents inaccurately documented that the dressings were changed according to the schedule, despite evidence to the contrary. Interviews with staff, including an LPN Supervisor and the Director of Nursing (DON), confirmed that the dressings were not changed as per the physician's orders and facility policy. The DON acknowledged that the MARs were incorrect and that the nurses documented completion of dressing changes that were not performed. There was no documentation indicating that either resident refused the dressing changes, suggesting a lapse in adherence to the established protocols for IV catheter care.
Plan Of Correction
1: What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice; A. Resident #271 and #23 was changed. B. LPN staff V was educated on change. 2: How you will identify other residents having potential to be affected by the same deficient practice and what corrective action will be taken; A. Complete Audit of resident with lines and any abnormal findings were corrected. 3: What measures will be put into place or what systematic changes you will make to ensure that the deficient practice does not recur: A. License Nurses was educated on changes. B. Nursing Management will review 24-hour report and order listing report for any new placement and any refusal of care related to change and follow up to ensure appropriate interventions are being followed. C. License nurses was educated on F694, documentation of care and services provided and refusal of care and services, this education will also be provided during new hire orientation and annually. 4: How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into place. The Director of Nursing/Designee will do audits of resident receiving 's has received their change weekly for four weeks then monthly for one quarter. The Director of Nursing/Designee will submit a report of findings to the Quality Assessment, Assurance and Compliance Committee monthly for one quarter. 1: What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice; A. RN staff R and RN staff K was educated on medication administration. 2: How you will identify other residents having potential to be affected by the same deficient practice and what corrective action will be taken; A. Audit was completed to ensure residents was receiving correct medications and abnormal finding was corrected. 3: What measures will be put into place or what systematic changes you will make to ensure that the deficient practice does not recur: