F0684

D

Midline Dressing Not Changed as Ordered and per Policy

Columbus, Ohio Survey Completed on 03-23-2026

Penalty

No penalty information released

Summary

Failure to provide appropriate treatment and care occurred when nursing staff did not change a midline catheter dressing as ordered and per facility policy for one resident. The resident, who was cognitively intact, had diagnoses including cellulitis of the left lower limb, chronic diastolic congestive heart failure, chronic obstructive pulmonary disease, and obesity. A midline catheter was inserted into the left cephalic vein on 02/27/26, and a transparent dressing was applied at that time. Physician orders dated 03/03/26 directed that the external catheter length be measured with each dressing change every day shift on Fridays and that the needleless connector be changed with the site change weekly on Fridays. The Treatment Administration Record for March 2026 showed that on 03/06/26 and 03/13/26, staff documented measuring the external catheter length with each dressing change and changing the needleless connector with each site change.

Despite these documented dressing and connector changes, observation of the midline insertion site on 03/16/26 at 9:08 A.M. revealed the dressing in place was still dated 02/27/26. During an interview at 9:21 A.M. the same day, an RN confirmed that the dressing was dated 02/27/26 and acknowledged it should have been changed. Review of the facility’s “PSG Infusion Intravenous (IV) Access Line Maintenance Protocol” effective 04/15/23 showed that transparent dressings for midline catheters were to be changed 24 hours after insertion, then weekly and as needed. The discrepancy between the dressing date, the documented TAR entries, the physician orders, and the facility policy demonstrated that the midline dressing had not been changed as required.