Failure to Provide Proper PICC Line Care and Documentation
Penalty
Summary
The facility failed to provide proper care and maintenance for a resident's tunneled PICC (Peripherally Inserted Central Catheter) line. Upon admission to the hospital, the resident's PICC line dressing was found to be 22 days old, despite orders and facility policy requiring dressing changes every 7 days. Documentation in the resident's Medication Administration Record (MAR) indicated that dressing changes were performed on two dates, but the LPN who documented these changes later admitted that she did not actually perform the dressing changes and was unsure if an RN had done so. Additionally, there was no documentation of required PICC line cap changes in the MAR or Treatment Administration Record (TAR) for the month reviewed. Interviews with facility staff revealed a lack of clarity and training regarding central line care responsibilities and procedures. The LPN stated she had not received training on central line dressing changes and did not know the frequency for cap changes, believing these tasks were the responsibility of an RN. The DON confirmed that only RNs should perform central line dressing changes and acknowledged that staff needed reeducation on central line care. The facility's policy required dressing changes every 5-7 days and documentation of all interventions, which was not followed in this case.