Failure to Accurately Document and Perform PICC Line Dressing Changes
Penalty
Summary
The facility failed to maintain accurate documentation and perform required dressing changes for a resident with a peripherally inserted central catheter (PICC) IV line. The resident, who was admitted with multiple diagnoses including venous insufficiency, cardiac arrest, seizures, major depressive disorder, and muscle weakness, had a physician's order for the PICC line dressing to be changed every seven days using sterile technique. Upon observation, the dressing was found to be dated eighteen days prior, indicating it had not been changed since before the resident's admission. Despite this, the Treatment Administration Record (TAR) showed that nurses documented the dressing was changed on three separate occasions during that period. Interviews with staff revealed that the nurses responsible for the documentation had not actually performed the dressing changes as recorded. One LPN admitted to documenting the change without performing it, while the other could not be reached for comment. The facility's policy required weekly dressing changes and accurate documentation upon completion of the procedure, but there was no policy specifically addressing documentation accuracy. The deficiency was identified through observation, record review, and staff interviews.