Missed Weekly PICC Line Dressing Change for Resident Receiving IV Antibiotics
Penalty
Summary
A deficiency occurred when the facility failed to change the dressing for a peripherally inserted central catheter (PICC) according to the physician's order for a resident receiving intravenous antibiotics for endocarditis and sepsis. The resident was admitted from the hospital with a PICC line and a clear dressing dated from the hospital stay. The care plan identified the resident as being at risk for infection related to the intravenous access, and an order was entered for weekly dressing changes on Sundays using aseptic technique. However, the initial dressing change was not performed as ordered, and the original hospital dressing remained in place beyond the recommended interval. Nursing documentation indicated that the dressing change was signed off as completed, but the nurse later admitted this was done in error due to a busy shift and issues with the electronic medical record. Multiple observations confirmed that the dressing had not been changed since the resident's admission, and interviews with the resident, nurse, administrator, and physician all corroborated that the required weekly dressing change was missed. The resident did not exhibit signs or symptoms of infection at the time of observation.