Failure to Timely Change IV Dressing per Physician Order
Penalty
Summary
A deficiency occurred when the facility failed to ensure the intravenous (IV) catheter dressing for a resident was changed every seven days as ordered by the physician. The resident, who was admitted with a fracture of the neck, intraspinal abscess, and cervical spinal stenosis, was receiving IV antibiotic therapy. Physician orders and the care plan specified that the IV site should be observed every shift and the transparent dressing changed weekly, specifically on the night shift every Sunday. However, review of the Medication Administration Record and progress notes showed no documentation that the dressing had been changed between the time of admission and the survey dates. Direct observation by surveyors revealed that the IV dressing was dated eight days prior to the survey, exceeding the seven-day interval required by both physician orders and facility policy. Nursing staff, including an LPN and the DON, confirmed that the dressing change had been missed and that the order for the next change was incorrectly scheduled, resulting in the dressing remaining in place for almost two weeks. The facility's policy required transparent dressings to be changed every five to seven days, but this was not followed in this instance.