Failure to Label Wound Dressings with Change Date and Shift
Penalty
Summary
Surveyors determined that the facility failed to ensure wound dressings were properly labeled to indicate when dressing changes occurred, as required by facility protocol. During observations, two residents receiving wound care for a skin tear and a knee wound, respectively, were found to have dressings that were not initialed, dated, or labeled to show when the last dressing change took place or on which shift it was performed. Review of clinical records confirmed that physician orders specified scheduled dressing changes, but the actual dressings lacked the required labeling. Interviews with the wound nurse confirmed that the standard practice was for licensed nurses to initial, date, and label dressings after each change. However, the nurse was unable to identify who performed the most recent dressing changes or on which shift they occurred. The deficiency was acknowledged by both the wound nurse and the nurse educator during the survey process.