Failure to Change Soiled PICC Line Dressing per Policy
Penalty
Summary
The facility failed to ensure the intravenous catheter dressing for a resident with a peripherally inserted central catheter (PICC) was changed according to professional standards and facility policy. Observations revealed that the resident's PICC line dressing was soiled, with a dark dry-looking substance and a red wet-looking substance visible under the clear dressing. The dressing was dated several days prior and had not been changed as required. Review of the resident's physician orders indicated that the IV dressing was to be changed every 7 days and as needed (PRN) for soiling or dislodgement. However, the Medication Administration Record (MAR) showed that while the dressing was documented as changed on certain dates, it was not actually changed when soiled, as required by the orders. Interviews with the Director of Nursing (DON) confirmed that the dressing had not been changed as documented and that the dressing should have been changed when soiled. The facility's infection prevention policy required transparent, semi-permeable membrane dressings to be changed at least every 7 days and PRN if the dressing became wet, loose, soiled, or if skin integrity was compromised. The failure to change the dressing as needed for soiling was confirmed through observation, record review, and staff interviews.