Failure to Follow PICC Line Care Protocol and Maintain Clean Environment
Penalty
Summary
The facility failed to provide necessary treatment and services consistent with professional standards of practice and physician orders for a resident receiving intravenous therapy. Review of the clinical record showed that the resident, who was admitted with diagnoses including orthopedic aftercare, local skin infection, Type 2 Diabetes, and sepsis, had a physician order for a PICC line dressing change every five days by a registered nurse. Documentation revealed that the last dressing change was performed on April 4, 2025, and no further dressing changes were recorded up to the time of observation on April 16, 2025. During this observation, the PICC line dressing was still dated April 4, and a clave was missing its disinfecting swab cap, as confirmed by an LPN. Additionally, the resident's room was found to have a heavily soiled floor and an IV pole with a thick unknown substance, as confirmed by the Director of Nursing. The resident expressed concerns that IV medication was being wasted and that the PICC line dressing had not been changed for several weeks. These findings indicate that the facility did not follow its own policy for monitoring and changing PICC line dressings at established intervals, nor did it maintain a clean environment for the resident receiving intravenous therapy.