Failure to Cap Peripherally Inserted Central Catheter Hubs
Penalty
Summary
Surveyors observed that three out of four sampled residents with peripherally inserted central catheters (PICCs) did not have protective caps placed on the end of their catheter hubs, leaving the hubs exposed. These observations were made during routine checks, where the catheter hubs in the residents' upper arms were found uncapped. Review of the facility's policy on catheter insertion and care indicated that a sterile end cap should be applied to the end of primary tubing when disconnected from the catheter, but did not specifically address capping the catheter hub itself. However, physician orders for all three residents explicitly required caps to be placed at the end of the PICC hubs. Interviews with nursing staff and facility leadership revealed inconsistent understanding and implementation of the capping procedure. The acting Infection Preventionist and Assistant DON both acknowledged that caps should be placed on the catheter hubs after disconnection, as per physician orders and standard practice. Nursing staff described their usual practice of cleaning the hub with alcohol and placing a cap after medication administration, but the observed lack of caps on the sampled residents indicated a failure to consistently follow these procedures and physician orders.