Failure to Maintain and Monitor Central Line Dressing
Penalty
Summary
The facility failed to ensure proper care and management of a central line for a resident who was admitted with multiple diagnoses, including end stage renal disease and diabetes mellitus. The resident had a central line in place, and the plan of care included interventions such as changing the dressing as ordered and per facility policy, and monitoring for signs of infiltration and infection. However, there were no physician orders for monitoring the IV site or for dressing changes, including the type or frequency. Medical record review showed no evidence that the central line dressing had been changed since admission. During observation, the central line dressing was found to be rolled back, discolored, and the line was completely uncovered and exposed, with the date on the dressing illegible. Staff interviews confirmed that there were no orders for dressing changes or site monitoring, and that the dressing had not been changed since admission. Facility policy required sterile dressings to be maintained and changed every five to seven days or when compromised, with documentation of dressing changes and site assessments, but these standards were not met for this resident.