Missed Weekly PICC Line Dressing Change
Penalty
Summary
A deficiency occurred when staff failed to provide appropriate care and treatment for a resident with a peripherally inserted central catheter (PICC) line, as ordered and in accordance with facility policy. The facility's policy required weekly PICC line dressing changes and additional changes if the dressing became soiled, loose, or wet. The resident, who had diagnoses including sepsis, osteomyelitis, and type 2 diabetes, was cognitively intact and had clear orders for weekly dressing changes and monitoring of the PICC line site. Documentation showed that dressing changes were completed on 5/5, 5/12, and 6/3, with a PRN change on 5/27, but there was no record of a dressing change during the week of 5/19 as required. On 5/21, a clinic RN observed that the resident's PICC line dressing was dirty and peeling on three corners, prompting the RN to change the dressing and notify facility staff. The Director of Nursing confirmed that the required weekly dressing change was missed by facility staff during that week, and the dressing was instead changed at the clinic. This lapse in following the prescribed schedule and policy for PICC line care constituted the deficiency identified by surveyors.