Failure to Change PICC Line Gauze Dressings per Standards
Penalty
Summary
The facility failed to provide care and maintenance of Peripherally Inserted Central Catheters (PICC) consistent with professional standards of practice for two residents who were receiving intravenous therapy. Both residents had PICC lines with a 2 cm x 2 cm split gauze placed over the insertion site, covered by a transparent dressing. Observations revealed that the dressings, which included gauze under the transparent dressing, were not changed according to facility policy and professional guidelines, which require gauze dressings to be changed at least every two days. For both residents, the transparent dressings with gauze underneath were observed to have been in place for more than two days without being changed. Interviews with the nurse responsible for changing the dressings confirmed that he routinely placed gauze over the insertion site before applying the transparent dressing and changed the entire dressing every seven days, regardless of the presence of gauze. This practice was in accordance with his understanding of facility policy, but did not align with the stated requirement to change gauze dressings every two days. The Regional Clinical Coordinator also confirmed that both residents had gauze under their transparent dressings and acknowledged, upon review of the facility policy, that the gauze dressings should have been changed every two days for infection control purposes. The failure to change the gauze dressings at the required frequency constituted a deviation from both facility policy and established infection control guidelines.