Deficiency in PICC Line Monitoring and Documentation
Summary
The facility failed to ensure the safe and appropriate administration of intravenous fluids for a resident with a Peripherally Inserted Central Catheter (PICC). Resident #323, who was admitted with a PICC line in the left upper arm, did not have documented evidence of routine measurement of the external length of the catheter to prevent migration. Additionally, the care plan was not updated to include this measurement, and the physician's order lacked instructions for monitoring the catheter site for signs of infection and measuring the external length with each dressing change. The facility's policy required that the external length of the PICC be measured with each dressing change and that the site be assessed for signs of infection, complications, or dislodgement. However, from February 6 to February 14 and February 18 to February 19, there was no documentation of these assessments in the resident's Medication Administration Record and Treatment Administration Record. Observations and interviews revealed that the nursing staff, including the Assistant Director of Nursing Services and Registered Nurse #1, were unaware of the policy requirements for monitoring the catheter for migration and measuring its external length. Interviews with the Director of Nursing Services and Physician #1 indicated that the medical team was responsible for ensuring appropriate orders were in place upon admission, but this was not done. The Director of Nursing Services acknowledged the absence of physician's orders addressing the assessment of the catheter site for infection and measurement of the external length. This oversight led to a deficiency in the care provided to Resident #323, as the necessary monitoring and documentation were not conducted according to professional standards and facility policy.
Plan Of Correction
Plan of Correction: Approved March 14, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** I. Resident #323 discharged home on [DATE]. MD orders for PICC line site dressing was changed to measure the external length of the catheter, the arm circumference, and to monitor the site for redness, swelling or tenderness on 2/19/25 for Resident #323. II. All residents with PICC lines have the potential to be affected by the same deficient practice. On this date, 3/10/25, there are a total number of 1 out of 223 residents who currently have PICC lines. Residents with PICC line orders have been reviewed to ensure that dressing change orders include monitoring the circumference of the arm, the length of the external catheter, and to monitor for any redness, tenderness and swelling, as well as checking that the dressing is clean, dry and intact. III. The PICC Line and Physician order [REDACTED]. All attending physicians and extenders will be educated to ensure that orders are in place for the care of the Peripherally Inserted Central Catheter, including to measure the external length of the catheter for residents who have orders for PICC lines by the Medical Director. All licensed nursing staff will be re-educated by the Staff Educator regarding PICC Lines and Physician Orders, to include the nurses to document the catheter site monitoring and measurements of the external catheter length and arm circumference with each dressing change. All licensed nurses will also be educated to notify the MD if the measurements vary from the original measurements at time of placement. All licensed nurses will complete a physician’s orders administration and PICC line competency post education. IV. All residents who have PICC lines will be audited by the ADNS and/or designee weekly for one month and monthly for 6 months thereafter. The audit will include documentation of the catheter site monitoring and measurements of the external catheter length with each dressing change. Findings will be brought to the DNS weekly and then brought to QAPI monthly for review and discussion by the DNS and/or designee. V. The Director of Nursing will be responsible for compliance.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
IV access and medication labeling deficiencies: A resident with a PICC line had no documented admission measurement of external catheter length or arm circumference, another resident’s IV tubing was observed without the required date, time, and RN initials, and a third resident’s meropenem IV bag was not labeled with the date, time, and initials. Facility policy required labeling of IV solutions and documentation of PICC measurements.
Failure to Document Baseline Midline IV Measurements: A resident receiving IV antibiotics via a midline IV had no documented baseline external catheter length or arm circumference measurements when admitted from the acute hospital. The resident’s care plan did not address the midline IV, and the IV MAR lacked baseline documentation. RN confirmed staff performed dressing changes and measurements, but could not verify any baseline values from the acute care hospital; the DON verified the findings.
A resident with a PICC line, diabetes, obesity, atrial fibrillation, and CHF had no documented PICC-related care plan interventions, and the PICC dressing was found stained, loosening, and dated well beyond the weekly change schedule. Although the MAR showed the dressing change as completed, staff interviews confirmed it was overdue and should have been changed sooner, with the DON acknowledging it was late and that loose or soiled dressings require more frequent attention.
A resident received IV Cefepime multiple times through a long-term IV catheter, but the MAR lacked documentation that the catheter was flushed before and after administration as required by facility policy. The DON confirmed the nurse should have flushed the IV catheter pre- and post-medication administration.
A resident receiving IV antibiotics through a PICC had no documented baseline or weekly catheter length and arm circumference measurements, despite an order for the RN to record them after each Sunday dressing change. RNs stated the measurements were needed to confirm the catheter remained in position, but the IV MAR showed only dressing changes and no measurements. The DON confirmed the record lacked both admission and weekly measurements, and the complaint noted the catheter had moved, leading to a hospital return, PICC removal, and replacement catheter placement.
PICC Line Removal Not Timely or Fully Documented: A resident with severe cognitive impairment, dependence for all ADLs, and IV antibiotic therapy had a PICC line that was not removed when the antibiotic ended, and nursing documentation showed conflicting removal entries. The chart lacked a physician order for removal, lacked confirmation that the full line including the tip was removed, and lacked documentation of post-removal site inspection or monitoring for complications.
IV access and medication labeling deficiencies
Penalty
Summary
The facility failed to provide the necessary care and services to maintain intravenous access for Resident 23, who had a right upper arm single lumen PICC line and a BIMS score of 12 on admission. The resident’s medical record showed a physician’s order to measure the external catheter length of the PICC and midlines upon admission and with each dressing change, and to include arm circumference for the midline device every seven days and as needed. However, the Nursing Admission/readmission Evaluation/assessment did not document the measurement and assessment of the PICC line, and the record did not show evidence that the length of the catheter above the insertion site or arm circumference were obtained upon admission. The facility also failed to ensure Resident 123’s IV tubing was labeled. During an initial tour, Resident 123 was observed with a peripheral IV in the left hand and a one-liter bag of 0.9% Sodium Chloride infusing at 75 mL per hour. The IV tubing was not labeled with the date, time, and nurse’s initials. The resident’s order summary showed an order to change IV tubing every 24 hours for intermittent IV infusion and TPN and every 72 hours for continuous IV infusion. In addition, the facility failed to ensure Resident 9’s IV medication was correctly labeled. During medication administration observation, Resident 9 was observed with a right upper arm three lumen PICC line and meropenem 1 gram was prepared and administered through the PICC line. The IV tubing was labeled by the RN, but the meropenem medication bag was not labeled with the date, time, and initials of the RN who administered the medication. Facility policy stated that the nurse hanging IV solutions will label the bag with the date, time, and initials.
Failure to Document Baseline Midline IV Measurements
Penalty
Summary
The facility failed to provide the necessary care and services to maintain the intravenous access for Resident 68, who had a midline IV in the left upper arm with two lumens and a transparent dressing. The resident had physician orders for antimicrobial disc use, routine flushing of the midline lumen, monitoring for inflammation or infiltration every shift, measuring arm circumference 5 cm above the insertion site during dressing changes, changing the midline dressing and Stat-lock weekly, and measuring the external catheter length during dressing changes with notification to the MD if the length increased by 2 cm or more. Medical record review showed no baseline documentation of the external catheter length or arm circumference above the insertion site when the resident arrived from the acute hospital where the midline was inserted. The resident’s care plan did not address the midline IV, and the IV Administration Record for April and May 2026 did not show baseline arm circumference or catheter length measurements documented on admission. During interview and record review, RN 1 confirmed the resident was receiving IV antibiotics through the midline and stated nursing staff were responsible for dressing changes and measurements, but could not verify any baseline measurements from the acute care hospital. The DON later reviewed and verified these findings.
PICC Dressing Not Changed as Ordered
Penalty
Summary
The facility failed to ensure parenteral fluids and central venous catheter care were provided in accordance with professional standards of practice and physician orders for one resident with a PICC line. The resident was admitted with diagnoses including cellulitis of the left lower limb, type 2 diabetes mellitus, morbid obesity, unspecified atrial fibrillation, and acute-on-chronic systolic heart failure, and had a BIMS score of 15 indicating intact cognition. The baseline care plan contained no documented interventions, monitoring, or care planning related to the PICC line or IV antibiotic therapy. The order summary included an order to monitor the PICC site every shift for signs and symptoms of infection and an order to change the PICC dressing weekly and every Monday. Although the MAR documented the PICC dressing change as completed on 05/18/26, an observation and interview on 05/19/26 found the PICC dressing visibly stained, loosening around the edges, and dated 05/08/26. The resident stated the dressing had not been changed since admission. Staff interviews confirmed the dressing should have been changed the prior day, that a loose or rough dressing could be changed more frequently under PRN orders, and that the RN charge nurse was going to change it that day. The DON stated PICC lines are to be changed every 7 days and acknowledged the dressing should have been changed the day before.
Failure to Flush IV Catheter During Antibiotic Administration
Penalty
Summary
Professional standards of practice were not followed for the care of a resident's long-term IV catheter. Resident 8 had physician orders for IV Cefepime HCl, including 2 grams every 12 hours for seven days and a one-time 2 gram dose, and the facility's IV catheter policy required flushing the catheter with 5 ml of normal saline before and after infusion. Review of the MARs for April and May 2026 showed that staff administered IV Cefepime 14 times, but there was no documented evidence that the IV catheter was flushed before or after medication administration. The DON confirmed in interview that the nurse should have flushed the IV catheter pre- and post-medication administration.
PICC Line Measurements Not Documented
Penalty
Summary
The facility failed to ensure a PICC line was measured weekly for a resident receiving IV antibiotics for a bone infection. Resident 1 was admitted with diagnoses including an infection in the bone and had a physician order for the RN to change the PICC dressing and securement device every Sunday and to measure the catheter length and arm circumference in centimeters after each dressing change. RN interviews stated that the measurements were important to confirm the catheter remained in the correct position and to monitor for infection, and that the Sunday dressing change process included use of a measuring tape. Record review of the IV MAR for April and May 2026 showed dressing changes were documented on 4/19/26, 4/26/26, and 5/3/26, but no catheter length or arm circumference measurements were recorded. The DON stated the admission measurements should have been obtained from the hospital or measured on arrival to establish a baseline, and that the absence of both admission and weekly measurements meant the facility could not compare values to confirm the catheter remained in place. The complaint also stated the catheter had moved out of its original position, and Resident 1 returned to the hospital with chest pain, had the PICC removed, and received another catheter to complete medication administration.
PICC Line Removal Not Timely or Fully Documented
Penalty
Summary
The facility failed to provide services consistent with the standards of care related to Resident 4’s PICC line when the physician’s order for in-facility removal after completion of IV antibiotic therapy was not followed for three days. Resident 4 had diagnoses including anxiety, diabetes mellitus, aphasia following cerebral infarction, and pressure ulcers to both heels, and the MDS documented severely impaired cognition with a BIMS score of zero, dependence on staff for all ADLs, impairment of both upper and lower extremities, and receipt of IV medications during the observation period. The care plan did not address the PICC line or associated care. The record showed orders for PICC dressing changes, cap changes, and daily saline flushes, and documentation stated to continue Daptomycin/Cerftiax through 05/08/26 and then remove the PICC line. Nursing notes documented the PICC line was removed on 05/12/26 and again on 05/13/26, but the chart lacked a physician order to remove the line and lacked documentation confirming the full removal of the line, including the tip. The record also lacked documentation of inspection of the PICC line after removal to ensure it was fully removed without complications. Administrative nurses stated the order had been sent to department heads, nursing had not done anything with it, and the facility should document the removal and any monitoring or complications.
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