Failure to Label IV Dressing According to Facility Policy
Penalty
Summary
A deficiency occurred when a resident with a history of Type 1 Diabetes Mellitus, muscle wasting, atrophy, and dehydration was found to have a peripheral intravenous (IV) lock covered with a transparent dressing that was not dated or initialed. The resident's care plan required frequent monitoring of the IV site for signs of infection or infiltration, and the facility's policy specified that the dressing should be labeled appropriately. During observation, the dressing on the resident's right hand lacked both a date and initials, and interviews with nursing staff and the DON confirmed that the nurse who inserted the IV was responsible for labeling the dressing. The staff acknowledged the importance of labeling to track when the IV was placed or last changed. Record review and staff interviews revealed that the facility's policy and standard nursing practice require IV dressings to be dated and initialed to ensure timely changes and proper monitoring. The DON and nursing staff were unable to determine who had placed the IV due to missing documentation, and the nurse assigned to the resident could not recall recent training on IV administration. The failure to label the IV dressing was directly observed and confirmed by staff, and the facility's own policy outlined the requirement for proper labeling of IV dressings.