Failure to Perform Ordered IV Midline Dressing Change
Penalty
Summary
The facility failed to provide a physician-ordered IV midline dressing change for one resident receiving IV therapy. A physician’s order dated 07/09/25 directed that the resident’s IV midline dressing be changed on the day shift weekly on Friday, or sooner if the dressing became damp, loose, soiled, or if problems at the site required further inspection. The MAR for 07/11/25 showed the IV midline dressing change was missed, with no documented reason. The resident’s admission assessment dated 07/12/25 documented severe cognitive impairment with a BIMS score of 07, dependence in ADLs, and active IV access, with diagnoses including septicemia and renal failure. The resident’s care plan dated 07/28/25 indicated the resident was on IV therapy for infection and that medications and treatments were to be administered as ordered. A grievance form dated 07/16/25 documented that the resident’s family reported the IV dressing had not been changed since admission, and that the dressing present at that time was dated 07/03/25. Family reported being told by nursing staff that the dressing change had been missed because the resident was at dialysis when it was scheduled, and that it would be changed that day. A nurse progress note dated 07/18/25 stated the IV dressing change was not performed because it had been changed on 07/16/25. During interviews, the DON stated the resident had been out of the facility for an appointment and that the dressing change should have been done upon return, and the regional nurse consultant confirmed there was no documentation that the IV dressing change was performed before 07/16/25.
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