Failure to Change Central IV Dressings as Ordered and Documented
Penalty
Summary
The facility failed to ensure that intravenous (IV) dressings for three residents receiving IV antibiotic therapy were changed as ordered by physicians and as documented by staff. For each resident, physician orders and facility policy required central IV dressings to be changed every seven days and as needed. Treatment Administration Records (TARs) indicated that the dressings were signed as changed on specific dates; however, direct observation revealed that the actual last changed date on the dressings was earlier than documented, indicating that the dressings had not been changed according to orders or documentation. Specifically, one resident with a bone infection, another with sepsis, and a third with an infection of the heart chambers and valves all had central IV access and were receiving IV antibiotics. Despite TARs showing that dressings were changed on two occasions, observations showed the dressings had not been changed since an earlier date. The Regional Director of Clinical Operations confirmed the discrepancy between the documented and observed dressing change dates and acknowledged the expectation for weekly dressing changes as per policy and physician orders.