Failure to Follow PICC Line and IV Medication Labeling Protocols
Penalty
Summary
The facility failed to provide adequate treatment and care for a resident with a peripherally inserted central catheter (PICC) in accordance with professional standards of practice. Facility policy required that intermittent infusion medication containers and administration sets be labeled with the date, time, and nurse's initials, and that PICC dressings be changed weekly or as needed. During an observation, the resident's PICC site dressing was found to be dated from admission, with only a piece of tape added later to reinforce it, rather than a full dressing change as required. Additionally, the IV medication solution container hanging at the resident's bedside was not labeled with a date or time. The resident involved had a history of infection and inflammatory reaction due to an internal right knee prosthesis, atrial fibrillation, and high blood pressure, and was receiving IV antibiotics for an infection. Staff interviews confirmed that the dressing had not been changed according to policy and that the IV medication container was not properly labeled. These actions and inactions resulted in the facility not meeting professional standards for the safe and appropriate administration of IV fluids and care of the PICC line.