Failure to Timely Change Soiled Central Venous Catheter Dressing
Penalty
Summary
A deficiency occurred when the facility failed to follow its policy regarding the timely changing of a central venous catheter dressing for one resident. The resident was observed with a soiled, discolored, and lifting dressing on a midline IV site, and was unsure how long it had been in place or the cause of the discoloration. Staff interviews revealed confusion about responsibility and policy for dressing changes, with the Infection Preventionist needing to check the policy and the Director of Nursing stating that dressings should be changed weekly or when soiled or not intact. Record review showed the midline was inserted 12 days prior, exceeding the facility's policy of changing dressings every 5 to 7 days or as needed if soiled, wet, or not intact. The dressing was not dated, and staff could not explain why it had not been changed as required. The facility's policy, dated 10/25/14, specifies that central venous catheter dressings must be changed at specific intervals or when soiled, wet, or not intact to prevent infection, but this was not followed for the resident in question.