Failure to Change and Label IV Catheter Dressings as Required
Penalty
Summary
The facility failed to ensure the timely and appropriate changing of intravenous (IV) catheter dressings for two residents, as required by their care plans and the facility's policies and procedures. For one resident with a history of osteomyelitis and diabetes, the physician's order and care plan specified that the central line and midline catheter dressings should be changed every seven days. However, observation and record review revealed that the midline IV catheter dressing had not been changed for at least 14 days, and staff confirmed that the dressing change had not occurred as ordered. The facility's policy also required weekly dressing changes and proper labeling, which was not followed in this case. For another resident with diabetes and hemiplegia, the care plan required dressing and securement device changes every seven days, or every 48 hours if using gauze. During observation, the resident was found with a midline IV covered by a white gauze dressing that was not labeled with the date of insertion or last change. The nurse present acknowledged that the dressing should have been labeled to track when it was last changed, in accordance with facility policy. The DON confirmed that dressings should be changed every seven days and labeled appropriately to maintain infection control. Both residents were assessed as having intact cognition but required varying levels of assistance with activities of daily living. The failure to change IV dressings as ordered and per policy, as well as the lack of proper labeling, was confirmed through interviews with nursing staff and review of facility procedures. These actions and omissions had the potential to result in infection and negatively impact the residents' health conditions.