Failure to Perform Routine PICC Line Dressing Changes
Penalty
Summary
The facility failed to ensure that dressing changes for a resident's peripherally inserted central catheter (PICC) line were performed on a routine, ongoing basis as required. Upon admission, the resident had a double lumen PICC line and an order for intravenous antibiotics, but there were no documented orders regarding PICC line care at that time. Medical record review and staff interviews confirmed that there was no documentation of PICC dressing changes until the PICC line was replaced, despite the facility's policy requiring dressing changes at least every five to seven days and as necessary. The resident reported that the dressing had been changed no more than twice since admission, and the dressing in place was dated several days after the initial placement. The resident's diagnoses included methicillin-resistant staphylococcus aureus infection, bacteremia, and a post-surgical site infection, all of which require careful management of central lines to prevent further complications. A nursing note indicated the PICC line became clogged, leading to its replacement. Orders for routine dressing changes and site monitoring were only written after the replacement, and staff were unable to locate documentation of prior dressing changes. The facility's policy emphasized the importance of keeping dressings clean, dry, and intact to prevent catheter-related infections, but this standard was not met for the resident in question.