Failure to Address PICC Line in Resident Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with a peripherally inserted central catheter (PICC) line. The resident, who was admitted with diagnoses including osteomyelitis, congestive heart failure, and hypertension, was receiving intravenous antibiotic treatments via the PICC line. Despite having an active physician order for PICC line dressing changes and daily intravenous antibiotics, there was no documented evidence that the PICC line was addressed in the resident's individualized comprehensive care plan. During the survey, the resident was observed with the PICC line in place and was cognitively intact according to the Minimum Data Set assessment. The Registered Nurse/Unit Manager confirmed that residents with a PICC line should have this addressed in their care plan and stated that Unit Managers are responsible for initiating and updating care plans. However, the RN/UM could not explain why the PICC line was not included in the care plan. Review of facility policy indicated that care plans should be based on admission orders and information from the transferring provider, but this was not followed in this case.