Failure to Document PICC Line Measurements During Dressing Changes
Penalty
Summary
The facility failed to ensure that physician's orders were followed for the care and maintenance of a peripherally-inserted central catheter (PICC) for one resident. According to facility policy, staff were required to measure the external catheter length of PICC lines on admission, with each dressing change, and as needed. Physician's orders also specified that the catheter length should be measured with each dressing change, the measurements should be documented in the order notes, and the physician should be notified if the length changed since the last measurement. Review of the resident's clinical records and the Medication Administration Record (MAR) showed that while PICC line dressing changes were performed on multiple occasions, there was no documented evidence that the catheter length was measured at the time of these dressing changes as required. An interview with the Director of Nursing confirmed the absence of documentation regarding catheter length measurements during dressing changes, indicating non-compliance with both facility policy and physician's orders.