Failure to Ensure Timely and Proper Central Line Dressing Changes
Penalty
Summary
Facility staff failed to provide care and services consistent with professional standards of practice for two residents with central intravenous (IV) lines. For one resident with multiple diagnoses including interstitial pulmonary disease and chronic respiratory failure, the medical record indicated that the central line dressing was to be changed every seven days. However, during an observation, the dressing was found to be dated ten days prior, and a registered nurse confirmed that the dressing had not been changed within the required timeframe, contrary to both facility policy and physician orders. For another resident with a history of hemiplegia, hemiparesis, and anoxic brain injury, physician orders also required central line dressing changes every seven days. Documentation showed a dressing change was completed two days prior to observation, but the transparent dressing on the IV site was not labeled with the date of the last change. The unit manager acknowledged that there was no visible date on the dressing, which is inconsistent with CDC guidelines and facility policy requiring dressings to be labeled with the date of change.