Failure to Maintain and Assess PICC Line
Penalty
Summary
The facility failed to properly assess and maintain a Peripherally Inserted Central Catheter (PICC line) for a resident, identified as Resident 21. The deficiency involved the lack of assessment of the PICC line insertion site at least once every shift and the failure to change the dressing every seven days. This oversight was identified during a review of the resident's records and an interview with the Director of Nursing (DON), who confirmed that the site had not been assessed by a Registered Nurse (RN) and the dressing had not been changed since insertion. The facility's policy required regular monitoring and documentation of the PICC line site to prevent infection and ensure resident safety. Resident 21 had a medical history that included sepsis, diabetes mellitus, and hypertension, and was dependent on staff for personal hygiene. The resident was prescribed Meropenem intravenously for sepsis, necessitating the use of a PICC line. The DON acknowledged the importance of monitoring the PICC line for signs of infection, such as redness, swelling, and pain, and documenting these assessments in the IV Medication Administration Record (MAR). The facility's policy on PICC line maintenance emphasized the need for regular assessments and documentation to prevent complications.
Plan Of Correction
How corrective actions will be accomplished for those residents found to have been affected by this deficient practice: On 3/5/25, Resident 21 PICC line orders for monitoring signs and symptoms, flushing, and maintenance including but not limited to dressing changes were inputted by the facility's Registered Nurse. There were no negative or adverse outcomes noted for Resident 21 regarding this deficient practice. How do facility will identify other residents, having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have the potential to be affected by this deficient practice. On 3/14/25, the Medical Records Director conducted an audit on active residents to ensure residents who have PICC line/Peripheral Intravenous (IV)/Midline lines have orders for monitoring signs and symptoms, flushing and maintenance orders including but not limited to dressing changes. No other residents were affected by this deficient practice. What measures will be into place or what systemic changes the facility will make to ensure that the deficient practice is not recur: On 3/10/25, the Director of Nursing in-serviced nursing staff, including but not limited to Licensed Vocational Nurses and Registered Nursing Staff, on the facility's policy and procedure titled "PICC Line Maintenance and Cleaning in a Skilled Nursing Facility," with emphasis on the facility ensuring safe and effective maintenance and cleaning of Peripherally Inserted Central Catheters (PICC lines) to prevent infection, maintain patency, and ensure patient safety. The in-serviced also included recording all assessments, dressing changes, flushing, cap changes, and any observed complications in the patient's medical records. The Medical Records Director/designee will conduct an audit on residents who are admitted or re-admitted with line orders, or receive IV orders in the facility, to ensure such residents have monitoring orders, flush orders, and maintenance orders including but not limited to dressing changes for their lines daily for 5 days, weekly for 2 weeks, and monthly thereafter. How the facility plans to monitor its performance to make sure that solutions are maintained: The Director of Nursing will report to the Quality Assessment and Assurance Committee during its monthly meeting the status of the compliance for residents who have PICC line, Peripheral IV, midline lines, and have monitoring orders, flush orders, and maintenance orders for three months or until compliance is met.