Failure to Follow Infection Control Protocols for PICC Lines and Enhanced Barrier Precautions
Penalty
Summary
Staff failed to follow infection prevention and control protocols for residents with peripherally inserted central catheters (PICCs) and those on enhanced barrier precautions (EBP). For one resident with a PICC line, the dressing was not changed as ordered, with the dressing remaining in place since hospital admission and not being changed by facility staff, despite ongoing intravenous antibiotic administration. Documentation indicated the dressing had been changed, but the nurse later admitted this was not accurate. The Director of Nursing confirmed that the facility policy requires dressing changes every 5-7 days, and that documentation should not be completed before the task is performed. Another resident with a PICC line for antibiotic infusion also did not have dressing changes documented as required by physician orders. Observation revealed the dressing was outdated, and the Unit Manager stated she could not determine when it was last changed due to lack of documentation. The Unit Manager subsequently changed the dressing and implemented a plan to perform all PICC dressing changes on the same day to avoid confusion, but prior to this, the required infection control interventions were not followed. Additionally, staff did not adhere to EBP protocols for a resident with a suprapubic catheter and multiple chronic wounds. Staff were observed providing high-contact care activities, such as toileting, dressing, and transferring the resident, without donning the required gown, despite EBP signage and available PPE supplies. Both the CNA and LPN involved acknowledged they did not wear gowns as required. The DON noted that staff had been educated on EBP but recognized that the location of PPE supplies may have contributed to non-compliance.