Failure to Change PICC Line Dressing as Ordered
Penalty
Summary
The facility failed to ensure that peripherally-inserted central catheters (PICC lines) site dressings were changed according to physician's orders for one resident. The facility's policy required that PICC line dressings be changed weekly. However, for one resident, the dressing had not been changed since December 13, 2024, despite physician's orders to change it weekly. This was confirmed through clinical record reviews, observations, and interviews with the resident and staff. The resident, who was cognitively impaired and required assistance for daily care needs, expressed concern that the dressing was not sticking and might fall off, potentially leading to the PICC line being pulled out. The resident had improvised by using a sock cuff to hold the dressing in place. Interviews with a registered nurse and the Director of Nursing revealed that the dressing was on back order from the pharmacy, and there was uncertainty about why it was not sourced from elsewhere. The deficiency was noted as a failure to adhere to physician's orders and facility policy.
Plan Of Correction
1. Resident 2's peripherally inserted central catheter line dressing changed on December 26, 2024. Resident 2 noted to not have any complications from the incident. Resident 2 assessed with no noted/additional concerns as well. 2. All residents having peripherally inserted central catheter line dressings have the ability to be affected by this alleged deficient practice. A whole house audit completed for residents with peripherally inserted central catheter line dressings to ensure licensed nurses changed dressing weekly. 3. Licensed nursing staff, including agency licensed nursing staff, were re-educated on the facility Peripherally Inserted Central Catheter Line Maintenance and Care Policy, including the importance of changing the dressings weekly and proper documentation of dressing changes on the medication/treatment administration records. 4. Registered Nurse Charge Nurse/Designee will audit residents with peripherally inserted central catheter line dressings to ensure proper weekly dressing changes are completed by licensed nurses three times per week times four weeks then monthly until resolved. Findings from audits will be reviewed by the Quality Assurance Performance Improvement Committee for recommendations and/or resolution at its regularly scheduled meetings times three for results, areas of improvement and/or continuation of audits.