Failure to Maintain Sterile Technique and Timely PICC Line Dressing Changes
Penalty
Summary
The facility failed to ensure the safe and appropriate administration and maintenance of peripherally inserted central catheters (PICC) for two residents. For one resident with multiple complex medical conditions, including diabetes, chronic kidney disease, and pressure ulcers, the PICC line dressing was observed to be peeling and dated well beyond the required weekly change interval. The responsible LPN confirmed the dressing was overdue for change and, during the observed dressing change, did not follow sterile technique as outlined in facility policy. Specific lapses included not establishing a clean field, handling sterile items with non-sterile gloves, and multiple instances of cross-contamination during the procedure. Another resident, also with significant medical issues such as open wounds, cirrhosis, and chronic kidney disease, was found with a PICC line dressing that was dislodged, peeling, and dated beyond the required change interval. The site was observed to have dried blood around the insertion area. The LPN confirmed the dressing was overdue for change and acknowledged the expectation for weekly dressing changes. Review of the facility's policy confirmed that PICC dressings are to be changed weekly or as needed, using a sterile technique to minimize infection risk. The policy details specific steps for maintaining sterility, including hand hygiene, use of masks, establishment of a clean field, and proper handling of sterile supplies. The observed failures to follow these procedures resulted in non-compliance with physician orders and facility policy for PICC line care and dressing changes.