Failure to Provide Proper PICC Line Care and Documentation
Penalty
Summary
The facility failed to provide intravenous (IV) services in accordance with professional standards of practice for a resident who was cognitively impaired, had a diagnosis of pneumonia, and was receiving IV antibiotic therapy via a peripherally inserted central catheter (PICC). Physician orders required regular PICC dressing changes every 72 hours, measurement of external catheter length and arm circumference with each dressing change, and monitoring of the IV site for infection. However, there was no documentation that these tasks were completed as ordered, and staff signed off on tasks that were not performed. Additionally, the physician orders did not include instructions to flush the PICC line before and after medication administration or to change the needleless injection caps with dressing changes, after blood draws, or as needed. Observation revealed that the PICC dressing was not changed as scheduled, despite staff documentation indicating otherwise. There was also no evidence in the electronic health record that the required measurements of external catheter length and arm circumference were performed. The Resident Care Manager confirmed the lack of documentation and acknowledged that staff had erroneously signed for incomplete tasks on multiple occasions. These failures were identified during review of the resident's records, direct observation, and staff interviews.