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Based on observation, medical record review, and policy review, the facility failed to ensure nursing staff followed the facility policy for Intravenous (IV) access dressing changes. This affected three of five patients observed (Patients #11, #13, and #15) and two of ten medical records reviewed (Patients #1 and #9). The facility census was 89.

Findings include:

1. Observations of IV site dressings were made on 12/17/24 from 10:00 AM to 10:15 AM and from 1:26 PM to 2:00 PM. Patient #11 was observed to have two right upper arm midline IV dressings dated 12/05/24. This was verified at the time of discovery by Staff E. Patient #13 was observed to have a left upper arm midline IV dressing dated 12/04/24. This was verified at the time of discovery by Staff A. Patient #15 was observed to have a left upper arm midline IV dressing dated 12/09/24. This was verified at the time of discovery by Staff F.

Review of the Nursing IV Assessment Flowsheet for Patient #11 revealed documentation the two right upper arm midline IV dressings were changed on 12/06/24 when these IVs were placed. Review of the Nursing IV Assessment Flowsheet for Patient #13 revealed documentation the left upper arm midline IV dressing was changed on 12/11/24. Review of the Nursing IV Assessment Flowsheet for Patient #15 revealed documentation the left upper arm midline IV dressing was changed on 12/16/24 and was placed on 12/09/24. On 12/17/24 at 3:20 PM, Staff D verified the above findings. Staff D stated the staff may be putting the date the IV was placed instead of the date the dressing was changed.

2. Review of the medical record for Patient #1 revealed a peripheral IV placed in the right upper arm on 07/28/24 and removed on 08/20/24. The only dressing change documented for this IV was on 08/18/24. An IV was placed in the right hand on 09/12/24 and removed on 10/17/24. The only dressing change documented was on 09/23/24. An IV was placed in the left hand on 10/24/24 and was removed on 11/08/24. The medical record lacked documentation of any dressing changes for this IV. On 12/17/24 at 11:34 AM, Staff D verified the above findings.

3. Review of the medical record for Patient #9 revealed an IV was placed in the left hand on 11/08/24 and removed on 11/23/24. The dressing was documented to be changed on 11/22/24. An IV was placed in the left upper arm on 11/08/24. The dressing was documented to be changed on 11/23/24 and 12/10/24. On 12/17/24 at 3:42 PM, Staff D verified the above findings.

Review of the, "Intravenous Therapy: Short Peripheral and Midline IV Therapy" policy, revised 07/01/24, revealed site rotation is only done based on complications not a defined time frame. Dressing changes are to be done every seven days for a TSM (transparent semipermeable membrane) dressing or whenever the dressing becomes damp, loosened, or visibly soiled. After changing the dressing, label the dressing with date, time, and initials.