Failure to Label IV Dressing with Date of Last Change
Penalty
Summary
A deficiency occurred when a resident with multiple diagnoses, including obstructive uropathy, pneumonia, and type 2 diabetes, was observed with a midline catheter dressing that did not indicate the date of the last dressing change. The resident required substantial assistance with activities of daily living and had physician orders for regular flushing of the IV lumen and dressing changes every 48 hours. Facility policy required midline dressings to be changed every seven days or as needed if soiled, loose, or leaking, and to be labeled with the date and time of the last change. During observations, the resident was found with a loose and soiled transparent dressing on the upper arm, which the resident reported became loose after a shower. Interviews with the ADON and DON confirmed that the dressing was not labeled with the date of the last change, contrary to facility policy and professional standards. Both nursing leaders acknowledged that the absence of labeling could prevent staff from knowing when the dressing was last changed, potentially increasing the risk of infection at the insertion site.