Failure to Change Peripheral IV Catheter and Dressing per Physician Order
Penalty
Summary
A peripheral intravenous (PIV) catheter was inserted into a resident's left arm on 4/29/25, as documented on the dressing. The resident had a physician's order to change the PIV line and dressing every 48 hours, with scheduled changes on 5/1/25, 5/3/25, and 5/5/25. Observations conducted on 5/5/25, 5/6/25, and 5/7/25 confirmed that the PIV catheter and dressing had not been changed since the initial insertion date. Licensed nurses interviewed during these observations acknowledged that the PIV should have been changed according to the physician's order to prevent infection and ensure the line remained functional. The resident involved had been admitted with severe sepsis, urinary tract infection, and bacteremia, conditions that require careful infection control. The Director of Nursing confirmed that the facility's protocol is to follow physician orders for IV site rotation and dressing changes, and that the failure to change the PIV as ordered placed the resident at risk for further infection. Review of facility policy indicated that all IV dressing changes should be labeled and documented, and that site rotation is a required component of complete orders.