Failure to Document and Monitor PICC Line Site as Ordered
Penalty
Summary
Nursing staff failed to carry out a physician's order for a resident who had a Peripherally Inserted Central Catheter (PICC line) in place for the treatment of acute osteomyelitis and a Methicillin Resistant Staphylococcus Aureus (MRSA) infection. The physician's order required monitoring the PICC line insertion site every shift for signs and symptoms of infection, including redness, drainage, and pain, and to alert the physician if any signs of infection were noted. However, a review of the resident's IV Administration Record showed that from 3/28/25 to 4/11/25, there was no documentation by licensed nurses that the PICC line site was monitored as ordered. Interviews with the Director of Nursing (DON) and the Infection Preventionist (IP) nurse revealed that the monitoring order was placed on the IV Administration Record instead of the Medication Administration Record (MAR), which led to the nursing staff not completing the required documentation. The facility's policy on preventing intravenous catheter-related infections also required observation and documentation of the insertion site every shift. The lack of documentation indicated that the monitoring was not performed as required by both physician order and facility policy.