Failure to Document and Measure PICC Line Length as Ordered
Penalty
Summary
Facility staff failed to provide care and services for a peripherally inserted central catheter (PICC) in accordance with professional standards and the resident's plan of care. Specifically, staff did not measure and document the external length of the PICC line weekly as ordered by the physician and required by facility policy. Documentation review showed that the external catheter length was not recorded on several occasions when dressing changes were performed, and there were instances where neither the dressing change nor the measurement was completed as scheduled. The Lippincott Manual of Nursing Practice and facility policies both require regular measurement and documentation of the external catheter length to monitor for migration and related complications. The resident involved was admitted with acute and subacute endocarditis and severe sepsis with septic shock, and was receiving IV antibiotic therapy via a PICC line. The resident's care plan and physician orders specified weekly measurement of the external catheter length, but this was not consistently performed or documented. Interviews with the resident and the DON confirmed that the required weekly measurements were not being done, despite the importance of monitoring for PICC migration and associated medical complications.