Failure to Document PICC Line Measurements During Dressing Changes
Penalty
Summary
The facility failed to provide necessary care and services for the maintenance of a peripherally inserted central catheter (PICC) line for one resident. Specifically, the facility did not obtain or document the required measurements of the external catheter length and arm circumference during dressing changes, as outlined in their own policy and procedure for central venous catheter care. The resident's care plan and physician's orders also lacked directives to measure and record these parameters, and there was no evidence in the treatment administration records that these assessments were performed. Interviews with nursing staff confirmed that while they were aware of the need to monitor for infection and perform dressing changes, they did not include the required measurements in their assessments or documentation. The resident involved had a PICC line placed in the facility for IV antibiotic administration and was observed with the line in place and a dressing dated from a previous week. Both the licensed vocational nurse (LVN) and registered nurse (RN) acknowledged that the measurements were not taken or documented, and the director of nursing (DON) verified these findings. The absence of these documented assessments had the potential to delay the identification of PICC line-related complications for the resident.