Failure to Ensure Timely PICC Line Dressing and IV Tubing Changes
Penalty
Summary
The facility failed to ensure proper management of peripherally inserted central catheters (PICC) for two residents receiving intravenous (IV) antibiotics. For one resident with a right knee prosthesis infection, the PICC line dressing had not been changed for ten days, as indicated by the date on the dressing and confirmed by the resident, despite the facility policy requiring dressing changes every seven days or sooner if compromised. The dressing was observed to be peeling, and the IV medication tubing lacked a date indicating when it was last changed. The resident expressed concern about the condition of both the dressing and the tubing. Documentation showed that site care was not recorded as completed until two days after the observation, and there was no physician order for dressing changes in the resident's records. A second resident with a left knee prosthesis infection also had a PICC line with an undated dressing that was peeling at multiple corners, and the IV tubing was not dated. This resident's orders specified dressing changes every seven days and as needed, but the observed condition of the dressing did not meet these requirements. Interviews with nursing staff and facility leadership confirmed that the expectation was for dressings to be changed every seven days and for IV tubing to be replaced every 24 hours, with dressings to be dated at the time of change. However, these standards were not consistently followed, as evidenced by the observations and documentation reviewed during the survey.