Failure to Label Dressings per Facility Policy
Penalty
Summary
The facility failed to follow its own resident care policies regarding the labeling of dressings, as required by their written procedures and professional standards of practice. Observations revealed that three residents had dressings or bandages that were not dated, timed, or initialed as specified in the facility's policy. Specifically, one resident was observed with an occlusive dressing on the left side that was not dated, another resident had three undated dressings on the right lower extremity, and a third resident had a dressing on the lower left lateral area with no date, time, or initials. These findings were confirmed through interviews with staff, who acknowledged that the expectation is to label dressings with the date and initials after care is provided. Record reviews showed that all three residents had medical conditions requiring wound care, such as wounds on the lower extremities and other chronic diagnoses. The facility's own policy and staff interviews confirmed that labeling dressings is a required step in the care process. However, the observed failure to consistently label dressings as per policy demonstrated noncompliance with both facility procedures and professional standards of practice.