Deficiency in PICC Line Monitoring and Documentation
Penalty
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.