Failure to Document and Monitor PICC Line Care for Resident Receiving IV Antibiotics
Penalty
Summary
The facility failed to adhere to professional standards of practice for the administration and monitoring of intravenous (IV) therapy for a resident with a peripherally inserted central catheter (PICC) who was receiving IV antibiotics for enterococcal bacteremia. The resident was admitted with a PICC line in place and had physician orders for regular dressing changes, as well as for documentation of the external catheter length and upper arm circumference, with instructions to notify the practitioner if the catheter length changed. However, the hospital transfer documentation did not include the required initial measurements, and subsequent facility records did not show evidence that these measurements were ever obtained or documented. Medication Administration Records indicated that PICC line dressing changes were signed off as completed by a registered nurse on two occasions, but during interviews, the nurse admitted to signing off in error and stated she had never performed the dressing changes. Additionally, there was no documentation of the required measurements on the dates dressing changes were recorded. Observations confirmed discrepancies in the dressing change dates and staff involved. Facility leadership and clinical staff were unable to provide evidence that the necessary monitoring and documentation for the PICC line had been completed as ordered.