Failure to Change PICC Line Dressing and Follow Oxygen Therapy Orders
Penalty
Summary
The facility failed to change the peripherally inserted central catheter (PICC) line dressing for a resident diagnosed with osteomyelitis. During an observation and interview, it was noted that the PICC line dressing was dated ten days prior, and the resident was unsure when it was last changed. The DON confirmed that PICC line dressings should be changed weekly, and the physician's order as well as facility policy required weekly dressing changes. The dressing had not been changed within the required timeframe. Additionally, the facility failed to follow a physician's order for oxygen therapy for another resident with chronic obstructive pulmonary disease and respiratory failure with hypoxia. During observation and interview, the resident's oxygen was set at three liters per minute, but the report does not specify if this matched the physician's order. The resident was able to understand and communicate but was unaware of the details of their oxygen therapy.
Plan Of Correction
Parenteral/IV Fluids How the corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: a) Resident # 3 PICC line was changed on 04/30/2025. How the facility will identify other residents having the potential to be affected by the same deficient practice and what action will be taken: b) Audit of current residents with PICC lines was completed on 05/02/2025 by Clinical Resource Nurse to ensure that residents had their PICC lines changed completed consistently. All residents have the potential to be affected by this deficient practice. No other residents were affected by the deficient practice. What measures will be put into place or what systemic changes you will take to ensure that the deficient practice will not recur: c) In-Service was conducted by DON to Licensed Nurses on 04/17/2025 regarding the importance of ensuring that all residents PICC lines are changed. d) DON and/or designee will review treatment administration records to ensure PICC lines are changed. Any issues identified during these audits will be brought forth to the five-day a week department manager morning meeting for review, validation and immediate correction. How the facility plans to monitor its performance to make sure that solutions are sustained. The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented, and the corrective action must be evaluated for its effectiveness. The plan of correction is integrated into the quality How the facility will identify other residents having the potential to be affected by the same deficient practice and what action will be taken: b) Audit of current residents with PICC lines was completed on 05/02/2025 by Clinical Resource Nurse to ensure that residents had their PICC lines changed completed consistently. All residents have the potential to be affected by this deficient practice. No other residents were affected by the deficient practice. What measures will be put into place or what systemic changes you will take to ensure that the deficient practice will not recur: c) In-Service was conducted by DON to Licensed Nurses on 04/17/2025 regarding the importance of ensuring that all residents PICC lines are changed. d) DON and/or designee will review treatment administration records to ensure PICC lines are changed. Any issues identified during these audits will be brought forth to the five-day a week department manager morning meeting for review, validation and immediate correction. How the facility plans to monitor its performance to make sure that solutions are sustained. The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented, and the corrective action must be evaluated for its effectiveness. The plan of correction is integrated into the quality assurance system. e) DON and/or designee will review treatment administration records to ensure PICC lines are changed. Any issues identified during these audits will be brought forth to the five-day a week department manager morning meeting for review, validation and immediate correction. Non-compliance issues identified will be reviewed and resolved. DON and/or designee will do trending/analysis and will report to the quarterly QAPI Committee for further evaluation and/or recommendations. --- Respiratory/Tracheostomy Care and Suctioning How the corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: a) Resident # 49 oxygen order was changed on 04/26/2025. How the facility will identify other residents having the potential to be affected by the same deficient practice and what action will be taken: b) Audit of current residents with oxygen orders was completed on 05/02/2025 by Clinical Resource Nurse to ensure that residents had the correct liters flow per their MD order. All residents have the potential to be affected by this deficient practice. No other residents were affected by the deficient practice. What measures will be put into place or what systemic changes you will take to ensure that the deficient practice will not recur: c) In-Service was conducted by DON to Licensed Nurses on 04/17/2025 regarding the importance of ensuring that all residents oxygen orders are followed. d) LN Supervisor and/or designee will review oxygen orders to ensure that the liters are being followed. Any issues identified during these audits will be brought forth to the five-day a week department manager morning meeting for review, validation and immediate correction. How the facility plans to monitor its performance to make sure that solutions are sustained. The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented, and the corrective action must be evaluated for its effectiveness. The plan of correction is integrated into the quality assurance system. e) LN Supervisor and/or designee will review oxygen orders to ensure the liters are being followed. Any issues identified during these audits will be brought forth to the five-day a week department