Failure to Complete PICC Line Dressing Change and Required Assessments
Penalty
Summary
A deficiency occurred when the facility failed to follow a physician's order for a resident who was admitted with multiple complex medical conditions, including a colostomy infection, osteomyelitis, diabetes mellitus type II, necrotizing fasciitis, an indwelling catheter, an ostomy, an unstageable pressure ulcer, and a peripherally inserted central catheter (PICC) for intravenous medications. The physician's order required the PICC dressing to be changed every seven days with a transparent dressing, and for the nurse to measure both the PICC catheter length and the upper arm circumference as part of the care protocol. Record review revealed that there was no documentation in the electronic treatment administration report (eTAR) that the PICC dressing had been changed or that the required measurements were completed as ordered. Interviews confirmed that the dressing had not been changed during the resident's stay, and the DON was unaware of the missed dressing change. Facility policy required these actions upon admission and at specified intervals, but the clinical record only noted that the dressing was clean, dry, and intact, without evidence of a dressing change or measurement completion.