Failure to Document PICC Line Flushing as Ordered
Penalty
Summary
The facility failed to ensure that peripherally-inserted central catheters (PICCs) were flushed as ordered by physicians for two residents. Facility policy required that intravenous catheters be flushed with 0.9% sodium chloride before and after medication administration. For one resident with cognitive impairment and multiple diagnoses, including heart failure and a urinary tract infection, physician orders specified administration of intravenous antibiotics. However, review of the medication administration records showed no documented evidence that the resident's PICC line was flushed after antibiotic administration, as required by policy. Another resident, who was cognitively intact and had diagnoses including peripheral vascular disease and diabetes, returned from the hospital with a PICC line and orders for daily intravenous Vancomycin, with instructions to flush the IV access site with saline before and after medication administration. The medication administration records indicated that the resident received the IV antibiotics, but there was no documentation that the PICC line was flushed with saline before and after each administration. Staff interviews confirmed the lack of documentation for both residents.