Failure to Perform Timely PICC Dressing Changes per Physician Order
Penalty
Summary
The facility failed to provide care and maintenance of a peripherally inserted central catheter (PICC) in accordance with professional standards and physician orders for one resident. The resident, who was admitted with diagnoses including sepsis and urinary tract infection and was cognitively intact, had a physician's order for weekly routine PICC dressing changes and as-needed changes. Despite this, the PICC dressing was observed to be 19 days old, with part of the dressing lifting and exposing the catheter to air. The resident reported that the dressing had only been changed twice since readmission, and there was no documentation in the nursing progress notes explaining why the dressing was not changed as ordered. Review of the Treatment Administration Record (TAR) showed that nurses documented the dressing change as completed on two occasions when it had not been done. Interviews with nursing staff confirmed that the dressing had not been changed according to the schedule, and staff were unable to provide a rationale for the missed care. The facility's policy required weekly sterile dressing changes using aseptic technique, but this was not followed for the resident in question.