Failure to Change Soiled Midline Catheter Dressing
Penalty
Summary
Staff failed to observe proper infection control practices by not assessing and monitoring a resident's midline catheter dressing as required. The resident, who had multiple complex medical conditions including pneumonia, candidiasis, dependence on a respirator and renal dialysis, gastrostomy, and tracheostomy, was dependent on staff for all activities of daily living. Physician orders specified that the midline site should be assessed for signs and symptoms of infection every shift, with any concerns reported to the physician. Despite these orders and facility policy, observations revealed that the resident's midline catheter dressing was soiled and soaked with blood for several days, with the dressing dated several days prior to the observation. Interviews with nursing staff and the infection preventionist confirmed that the dressing should have been changed immediately when it became soiled or bloody, in accordance with facility policy. The failure to change the dressing as required was directly observed and acknowledged by staff.