I wish that I would have caught it sooner. I didn't put it together until the very end of my shift while I was giving report to the on coming nurse. My charge nurse and the on coming nurse both agreed that it should have been addressed sooner. Of course I agree! I just feel like I dropped the ball on this, but I don't think I was the only one to do that in this case since a physician didn't address the issue either. Thank you for the perspective!