Failure to Maintain and Change Compromised PICC Line Dressing
Penalty
Summary
The facility failed to provide care and maintenance of a Peripherally Inserted Central Catheter (PICC) line consistent with professional standards of practice for one resident. The resident, who was admitted with diagnoses including osteomyelitis of the vertebra, intraspinal abscess, and low back pain, was receiving IV medications through a PICC line. Observations revealed that the PICC line dressing was peeling off and the insertion site was covered with gauze, preventing visualization of the site. The resident reported having to apply tape to the dressing for several days due to it peeling off. Despite facility policy and physician orders requiring immediate dressing changes if the dressing was compromised, the dressing remained in a compromised state for an extended period. Nursing documentation and direct observation confirmed that the PICC line dressing was lifting and the insertion site was not visible, which is inconsistent with both facility policy and professional standards that require the site to be visible and the dressing to be changed immediately if compromised. The DON stated that nurses are expected to observe the PICC line during each room entry and to change the dressing immediately if it begins to lift. However, these expectations were not met, as evidenced by the ongoing compromised dressing and lack of site visibility.