Failure to Timely Change Mid-line Dressing
Penalty
Summary
The facility failed to ensure timely changes of a mid-line dressing for a resident, leading to a deficiency in the administration of fluids as per professional standards and physician orders. The policy review indicated that changes should occur if the dressing becomes damp, loosened, or visibly soiled, and at least every seven days. However, the resident's mid-line dressing was observed to be loose around the perimeter and dated, indicating it was not changed in a timely manner. The resident expressed dissatisfaction, stating that they had to request changes and that staff were reluctant to perform the task. Interviews with staff revealed a lack of clarity and adherence to the policy regarding mid-line dressing changes. A Licensed Practical Nurse (LPN) acknowledged the delay in changing the dressing and noted that the task should appear on the computer system as a reminder. However, the LPN was unable to locate the specific order for the mid-line change in the system. This oversight contributed to the deficiency, as the resident had a multi-drug resistant organism (MDRO) infection, necessitating strict adherence to infection control protocols.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required. (1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? On 4.1.25 resident #29 was assessed by licensed nurse, no concerns identified. On 4.1.25 the site was changed for resident #29 by LPN staff L.. (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken: On 4.11.25 a quality review was completed by Director of Nursing/designee on current residents in with sites in place to ensure place, changed timely and physician orders for monitoring being followed. Any issues identified were corrected. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur; On 4.22.25 Director of Nursing completed education with current licensed nursing staff on the components of F694 nutrition/ fluids with emphasis on ensuring in place, changed timely and monitoring per physician orders by the Director of Nursing/designee. Newly hired licensed nursing staff will be educated on the components of F694 nutrition/ fluids with emphasis on ensuring in place and monitoring per physician orders by the Assistant Director of Nursing/Designee during orientation as part of the systematic change. (4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: Director of Nursing/Designee to conduct audits of 5 residents with sites twice a week for 4 weeks, then once a week for 4 weeks and then monthly for 1 month to ensure in place, changed timely and monitored per physician orders. The findings of these quality monitoring...s to be reported to the Quality Assurance/Performance Improvement Committee monthly until the committee determines substantial compliance has been met.