Failure to Change and Document PICC Line Dressing as Ordered
Penalty
Summary
Resident #43, who had diagnoses including acute kidney failure, hypertension, osteoarthritis, and muscle wasting with atrophy, was admitted with a peripherally inserted central catheter (PICC) line for intravenous (IV) therapy, including antibiotics. Physician orders and the resident's care plan required weekly PICC line dressing changes and monitoring for signs of infection or infiltration. Review of the Treatment Administration Record (TAR) showed that the dressing change was not documented as completed for a two-week period, specifically from 03/13/25 to 03/27/25, and there was no documentation that the dressing was changed as ordered on 03/20/25. On observation, the PICC line dressing was found to be loose and peeling, and the date on the dressing indicated it had not been changed as scheduled. An LPN confirmed that she had signed off in the TAR that the dressing was changed, but admitted she had not actually performed the dressing change. The Director of Nursing verified that PICC line dressings were to be changed weekly and that this resident was the only one receiving IV therapy. Facility policy also required dressings to be changed every seven days or sooner if loose, and for nurses to document the procedure and site condition.