Failure to Manage PICC Line for Resident
Penalty
Summary
The facility failed to ensure the safe and appropriate administration of intravenous (IV) fluids for a resident, specifically concerning the management of a peripherally inserted central catheter (PICC). Resident #16, who was readmitted to the facility with a PICC in their left upper arm, did not have physician orders or assessments for monitoring the PICC, including arm circumference, external length, dressing changes, and flushes. Additionally, the comprehensive care plan for the resident did not include interventions related to the PICC. Observations and interviews revealed that the PICC dressing was dated over a month prior and was soiled and lifting, indicating a lack of attention to the catheter. Both Registered Nurse #2 and Licensed Practical Nurse #1 Unit Manager were unaware of the PICC's presence, and there were no orders or care plan updates for it. The lack of attention to the PICC was acknowledged as an infection risk by the staff. Interviews with the Physician's Assistant and the Director of Nursing highlighted the expectation that the admitting nurse should have entered orders and updated the care plan for the PICC. The absence of these orders and updates was recognized as putting the resident at risk for infection, as the PICC required regular flushing, assessment, and dressing changes. The deficiency was noted as a failure to adhere to professional standards of practice and the facility's policies.
Plan Of Correction
Plan of Correction: Approved March 11, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #16 was assessed by medical provider; no adverse effect was noted due to lack of PICC line/site monitoring and care. On 2/11/25, orders were initiated for PICC line assessment, monitoring arm circumference, external length, dressing changes and PICC line flushes. The comprehensive care plan was developed for PICC line on 3/10/25. Nurses who completed admission assessments and weekly skin checks for resident #16 will be counseled by the DON regarding accurate assessments and documentation of PICC lines. All other residents with PICC lines were reviewed to ensure there are physician orders [REDACTED]. All other residents with PICC lines will be reviewed to ensure that comprehensive care plan includes peripherally inserted central catheter. All licensed nurses will be reeducated by the RN Educator regarding PICC line monitoring/care, [MEDICATION NAME] fluids, physician’s order and Care plan initiation. This will also include monitoring for arm circumference, external length, dressing changes, and flushes. Accuracy of New admission assessments for PICC lines will be stressed. All Registered Nurses will have a competency completed for PICC line dressing change and flush administration. DON/Designee will conduct PICC line audits of all residents with PICC lines weekly x 8 weeks to ensure all orders related to central catheters have been initiated including monitoring, flushing, care plan initiation and observation of PICC line dressing to ensure they are intact and dated. Audit findings will be reported to the QAPI committee for review and input. Responsible Person: DON