Failure to Maintain and Document PICC Line Care and Monitoring
Penalty
Summary
The facility failed to provide care and maintenance of a Peripherally Inserted Central Catheter (PICC) consistent with professional standards of practice for one resident. The facility did not ensure documentation of PICC line dressing changes, did not measure and document the external catheter length to monitor for migration, did not measure and document arm circumference, and did not measure and document the total catheter length when the PICC line was pulled out by the resident. The facility's policy required these actions to prevent complications such as infection and catheter migration, but these were not followed or documented in the resident's medical record. The resident involved had severe cognitive impairment and was receiving IV antibiotics for sepsis through a PICC line. Upon observation, the resident was found with a PICC line in place but without a transparent dressing, and a loosely wrapped gauze was present instead. The resident was observed touching and playing with the PICC line. Nursing staff stated that a dressing change had been performed the previous day, but there was no documentation of this, nor of the required measurements of external catheter length or arm circumference. Additionally, after the resident pulled out the PICC line, there was no documentation of the total catheter length to confirm the catheter was intact, as required by policy and manufacturer guidelines. Interviews with nursing staff and facility leadership revealed a lack of clear orders for PICC line dressing changes and required measurements. Staff were unsure of the protocol for dressing changes and did not consistently document required information. The Medication Administration Record and Treatment Administration Record did not have designated areas for documenting these measurements. The absence of documentation and adherence to policy was acknowledged by staff and leadership during the survey.