Failure to Ensure Proper PICC Line Care and Documentation
Penalty
Summary
The facility failed to ensure proper care and monitoring of a peripherally inserted central catheter (PICC) line for a resident with multiple diagnoses, including osteomyelitis, stroke, and post-surgical wound care. Observations revealed that the PICC line dressing was not changed weekly as required, with the dressing date indicating it had not been changed for ten days. Additionally, there were no physician's orders for PICC line flushes, dressing changes, or other aspects of PICC care. Review of the resident's medical record and medication administration records showed a lack of documented instructions for these essential PICC line care procedures. Nursing progress notes inconsistently documented PICC line flushes and assessments, with several gaps in documentation and no consistent evidence that the line was flushed or assessed according to the care plan. The care plan indicated the site should be assessed during infusions and at least every shift when not in use, and that the line should be flushed with normal saline and heparin, but these interventions were not consistently documented. Facility policy required regular flushing and dressing changes every five to seven days, but these standards were not met for this resident.