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F0694
D

Failure to Provide Timely IV Dressing Change per Standards

Winter Garden, Florida Survey Completed on 09-30-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when the facility failed to ensure proper midline intravenous (IV) dressing care for a resident with multiple complex medical conditions, including a left great toe abscess, stroke, diabetes, heart failure, peripheral vascular disease, elevated white blood cell count, and lymphedema. The resident was observed with a transparent dressing on her right upper arm midline IV site that was dirty, partially detached, and covered with gauze. The Unit Manager acknowledged that the dressing should have been changed earlier, as the presence of gauze required a dressing change every 48 hours according to standard nursing practice and facility policy. Despite ongoing IV therapy and regular flushing of the midline IV, nursing staff failed to recognize and address the need for a dressing change over a period of several days. Record review showed that nursing orders required regular assessment and care of the IV site, including flushing, measurement, and evaluation for signs of infection. The facility's policy and training materials specified that midline catheter dressings should be changed every 5-7 days for clear dressings and every 2 days if gauze is used, or sooner if the dressing is soiled or compromised. However, the dressing was not changed as required, and this lapse was not identified by staff during routine care, resulting in noncompliance with professional standards and facility policy for IV site management.

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