Failure to Document and Provide PICC Line Care
Penalty
Summary
The facility failed to provide proper care and documentation for a resident with a peripherally inserted central catheter (PICC) line. According to the facility's policy, central line sites should be assessed with each infusion and at least daily, and dressings should be changed at least every seven days or sooner if compromised. The resident was discharged from the hospital with a newly placed tunneled PICC line and required intravenous antibiotics. However, there was no physician's order for central line care, and the medication administration records (MAR/TAR) for October and December did not document any central line care or dressing changes. Progress notes also lacked documentation of daily site assessments or dressing changes from the time of readmission until the line was discontinued. Interviews with nursing staff revealed uncertainty about documentation practices for PICC line care, with one LPN stating they were unfamiliar with the charting system and did not know where or if dressing changes were documented. The DON confirmed that dressing changes should be recorded on the nurse's treatment sheet, but only heparin flushes were documented. Neither the DON nor the administrator could locate any records of site assessments or dressing changes while the central line was in place, despite facility policy and staff statements that such care should occur regularly.