Failure to Maintain Intact PICC Line Dressing During IV Medication Administration
Penalty
Summary
A deficiency occurred when a resident receiving intravenous (IV) antibiotic therapy via a peripherally inserted central catheter (PICC) line was observed with a loose, unsealed, and non-intact PICC line dressing. The dressing was visibly lifted on one side, with the bio patch exposed to air, and the paper tape previously used for reinforcement was hanging off and not sealing the dressing. The dressing was dated from a previous week and had not been changed despite its compromised condition. The resident was non-interviewable, and her family was unsure if the dressing had been changed since admission. The nurse responsible for administering the resident's antibiotics acknowledged noticing the loose and unsealed dressing prior to starting the IV medication but chose to complete the antibiotic infusions before planning to change the dressing. The nurse was not immediately aware of the specific schedule for dressing changes without consulting the resident's orders and stated that dressing changes were typically performed every seven days or as needed. The nurse confirmed that the dressing was not changed or reinforced before administering the IV medication, despite recognizing the importance of maintaining an intact dressing for infection control. Interviews with other nursing staff and facility leadership confirmed that the expectation was for PICC line dressings to be changed if they became loose, soiled, or non-intact, in addition to the routine schedule. Facility policy also required dressing changes under these circumstances. Documentation showed that the dressing was eventually changed later that day, but at the time of the deficiency, the resident received IV medication through a compromised PICC line dressing, contrary to professional standards of practice and physician orders.