Failure to Measure PICC Line Length After Removal
Penalty
Summary
The facility failed to provide services according to professional standards of quality for one resident when the DON removed a Peripherally Inserted Central Catheter (PICC) from a resident's right upper arm and did not measure the length of the catheter before discarding it. The resident had been admitted with an infection and inflammatory reaction due to an internal left knee prosthesis and Methicillin Resistant Staphylococcus Aureus (MRSA), and was cognitively intact at the time of the incident. The clinical record documented the initial internal catheter length as 42 cm, and there was a physician's order for PICC removal. During the removal, the DON pulled out the PICC line and immediately threw it in the trash without measuring its length, as observed by surveyors. In a subsequent interview, the DON acknowledged not measuring the catheter and stated that this step should have been performed to ensure the entire catheter was removed, as per facility guidelines and best practices. Facility guidelines and external references both specify that the catheter should be measured after removal to confirm it matches the documented pre-insertion length.