Failure to Complete Daily Dressing Change as Ordered
Penalty
Summary
A deficiency occurred when a resident with a post-surgical lower back incision did not receive a dressing change as ordered. Observation revealed that the dressing on the resident's back was dated two days prior, despite orders for daily dressing changes. The resident confirmed that dressing changes were supposed to occur every day and noted that he left the facility for a physical therapy home evaluation the previous day, but not until after 11:00 AM. Interview with the RN on duty indicated that she did not perform the dressing change before the resident left, and she cited frequent new admissions and discharges as factors affecting her ability to complete treatments. Review of the Treatment Administration Record showed that the night shift nurse had documented the dressing change as completed, but the physical observation contradicted this, showing the dressing had not been changed since two days prior. The DON confirmed that dressing changes should be completed as ordered and, if missed by one shift, should be done by the next.