Failure to Follow Professional Standards for PICC and GT Care
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality for two residents. For one resident with a peripherally inserted central catheter (PICC line), physician orders and facility policy required that the external catheter length be measured with each dressing change and documented. However, review of the Medication Administration Record (MAR) and interviews with nursing staff and the Director of Nursing (DON) confirmed that these measurements were not performed or documented during April. The DON acknowledged that measuring and documenting the PICC line length was a standard of practice and should have been completed as ordered. In a separate incident, a resident with a gastrostomy tube (GT) did not have tube placement checked prior to medication administration. Observation of a licensed nurse administering medications revealed that the nurse flushed the GT and administered medications without verifying tube placement, as required by facility policy. The nurse admitted to not checking placement, and the DON confirmed that verifying GT placement before administering medications was necessary to prevent complications.