Failure to Follow Physician Orders for PICC Line Dressing Change
Penalty
Summary
The facility failed to provide prescribed treatment and services related to the care of a peripherally inserted central catheter (PICC) line for one resident. The resident, who had a history of diabetes and sepsis, was admitted with a PICC line in place. According to a physician's order, the PICC dressing and caps were to be changed every seven days, specifically on Wednesdays during the day shift. However, documentation in the treatment administration record indicated that the dressing was changed as ordered, but direct observation revealed that the dressing was dated from a previous week, indicating the order was not followed. Further review and staff interviews confirmed that the PICC dressing had not been changed according to the physician's order. The discrepancy between the documented care and the actual condition of the dressing was verified by both a registered nurse and the nursing home administrator. This failure to follow physician orders and facility policy for PICC line care constituted a deficiency in the administration of parenteral fluids and related nursing services.
Plan Of Correction
NotSpecified Resident R1 was assessed no negative outcome for not following physician order for dressing change. R1 dressing immediately changed. Facility residents with current PICC Line dressings treatment orders were audited to ensure appropriate and current order in place for treatment. Don, or designee will educate licensed staff on treatment and following physicians orders policy, and verifying orders. DON, or designee will conduct an audit to ensure that treatment orders are being followed, for PICC Line dressing changes are being completed per physicians orders weekly times 2 weeks, then monthly times 2 months. Results of the audits will be reviewed at the Quality Assurance meetings until substantial compliance has been met.