Failure to Timely Change and Document PICC Line Dressing and Absence of Care Plan
Penalty
Summary
A resident with a history of diabetes, wound care needs, vascular access management, and chronic infections was admitted with a peripherally inserted central catheter (PICC) in place. The facility failed to change the resident's PICC line clear dressing within the required seven-day interval, as the dressing was observed to be ten days old. Nursing staff acknowledged that the dressing change was not performed as scheduled, and documentation of the dressing change was either missing or incorrectly recorded in the electronic health record. The dressing was also not properly initialed and dated by the nurse who performed the change, contrary to facility policy and professional standards. Further review revealed that there was no care plan in place for the resident's PICC line, despite active physician orders and the resident's ongoing need for parenteral therapy. Interviews with nursing staff, the infection preventionist, and the director of nursing confirmed that the absence of a care plan was not in line with facility expectations or policy. The care plan is intended to guide staff in the safe and appropriate care of the PICC line, including monitoring, interventions, and infection prevention measures. Facility policies and professional guidelines reviewed during the survey emphasized the importance of timely dressing changes, proper documentation, and individualized care planning for residents with central lines. The lack of adherence to these standards in this case resulted in a deficiency related to the safe administration and management of IV fluids and vascular access devices.