Failure to Change PICC Line Dressing as Ordered
Penalty
Summary
A deficiency occurred when the facility failed to change the dressing on a resident's Peripherally Inserted Central Catheter (PICC) line as ordered. The resident, who was admitted with osteomyelitis and MRSA, had a nurse practitioner order for the PICC dressing to be changed every seven days using sterile technique. Observation revealed that the dressing had not been changed for over three weeks, with the last documented change dated 7/2/25. The treatment administration record (TAR) did not have staff initials or a scheduled timeframe for the dressing change, and the order was not correctly entered into the computer system, resulting in the task not appearing for nursing staff to complete. Interviews with facility staff confirmed that the dressing change order was not visible to the nursing staff due to the incomplete order entry. The Clinical Coordinator and DON both verified that the dressing had not been changed since the documented date, and the Infectious Disease clinic nurse practitioner also noted the lapse during a clinic visit. The resident did not exhibit signs of infection at the time of assessment, but the required dressing change had not been performed as ordered.