Failure to Ensure Timely and Documented PICC Dressing and IV Tubing Changes
Penalty
Summary
The facility failed to ensure proper infection control practices related to dressing changes and intravenous (IV) tubing changes for two residents with peripherally inserted central catheters (PICCs). Observations revealed that one resident's PICC insertion site was dressed but not labeled with a date or time, and the IV tubing was also unlabeled. The resident reported that staff did not change his PICC dressing weekly as required. Another resident had antibiotics infusing via a PICC line with tubing that was not labeled, and reported that his PICC dressing had not been changed for almost two weeks, with IV medication tubing in use for four days instead of the required 24 hours. Interviews with nursing staff revealed inconsistent knowledge and practices regarding the frequency of IV tubing and PICC dressing changes, as well as documentation requirements. Some staff stated that IV tubing should be changed every 24 hours, others said every 72 hours or three days, and there was confusion about labeling and documentation. Review of treatment administration records confirmed that required dressing changes were missed and not documented as completed. Facility policies required IV tubing to be labeled with date, time, and initials, and for PICC dressings to be changed weekly and documented, but these procedures were not consistently followed.