Failure to Follow Physician Orders for PICC Line Flushing
Penalty
Summary
A registered nurse (RN) failed to follow physician orders for the administration of intravenous (IV) fluids for a male resident with a peripherally inserted central catheter (PICC) line. The resident, who had been admitted with diagnoses including pneumonia, hypertension, lymphedema, respiratory failure, and pulmonary embolism, had a physician order specifying that both lumens of the PICC line should be flushed with 10 cc normal saline—one before and after medication administration, and the blood port specifically every evening antibiotic dose. During an observed medication administration, the RN only flushed the medication port and did not flush the blood port as ordered. Upon interview, the RN acknowledged not flushing the blood port and admitted to not remembering the specific order to do so. The Director of Nursing (DON) confirmed that the nurse was responsible for flushing both lumens according to the physician's order and facility policy, which requires each lumen to be flushed with a separate syringe as ordered. Facility policy and the care plan both supported the need for flushing the ports as directed by the physician.