Failure to Follow Physician Orders for PICC Line Dressing Changes
Penalty
Summary
A deficiency was identified when a resident with a peripherally inserted central catheter (PICC line) did not receive dressing changes as ordered by the physician. The resident was receiving IV antibiotics and reported not knowing why the dressing was left on in a soiled condition, and could not recall the last time it was changed. During an observation, the PICC line dressing was found to be dated from several weeks prior, indicating it had not been changed since the line was placed. Further investigation included an interview with the resident's nurse, an LPN, who confirmed that the dressing was supposed to be changed weekly but acknowledged that this had not occurred. Review of the medical record showed a physician order for weekly dressing changes and as needed, but documentation and direct observation confirmed the dressing had not been changed according to the order.