Failure to Maintain PICC Line as per Standards
Penalty
Summary
The facility failed to maintain a peripheral inserted central catheter (PICC) for a resident diagnosed with osteomyelitis of the vertebra, who was receiving intravenous antibiotics through the PICC line. The facility's policy required that the PICC dressing be changed immediately if compromised and at least every seven days. However, during an observation, the dressing was found to be soiled and not adhering properly, with a date indicating it had not been changed since January 11, 2024, despite the resident's treatment administration record indicating a change had been documented the previous day. Interviews with the Assistant Director of Nursing (ADON) and a Licensed Practical Nurse (LPN) revealed discrepancies in the documentation and actual care provided. The ADON acknowledged the dressing should have been changed, and the LPN admitted to never having changed the resident's PICC line, despite records suggesting otherwise. This discrepancy indicates a failure to adhere to professional standards of practice and physician orders, as well as a lack of compliance with the comprehensive person-centered care plan for the resident.
Plan Of Correction
1. R110's PICC dressing was changed immediately. No adverse effects were noted. 2. An initial audit was conducted of residents to validate that their PICC dressings were changed per order. Variances were addressed at the time of the audit and placed on the facility audit tool. 3. DON/Designee will re-educate the licensed nursing staff on changing PICC line dressings per order. 4. DON/Designee will conduct random audits of residents with PICC lines to ensure dressing changes are completed per order. This audit will be conducted 3 times per week for 4 weeks, then 1 time a month for 2 months. Audit findings will be addressed and submitted to the Quality Assurance Performance Improvement Committee for further review and recommendations as needed.