Incomplete Documentation of PICC Line Dressing Changes
Penalty
Summary
The facility failed to maintain complete and accurate documentation regarding Peripherally Inserted Central Catheter (PICC) dressing changes for two residents. Facility policy required PICC line dressings to be changed at least every seven days or sooner if the dressing became damp, loosened, or soiled. Physician orders for both residents specified weekly PICC line dressing changes. However, review of the treatment administration records showed missing documentation for several scheduled dressing changes for both residents over multiple weeks. One resident, admitted with diagnoses including hypertension, cellulitis, and diabetes, had no documented evidence of PICC line dressing changes on several specified dates in May and June. Another resident, admitted with osteomyelitis, bacteremia, and gastroesophageal reflux disease, also lacked documentation of PICC line dressing changes on multiple scheduled dates in April and May. The Regional Clinical Director confirmed that the treatment records for both residents were incomplete and that dressing changes should be performed and documented as ordered by the physician.