Failure to Follow Professional Standards During Blood Draw for Resident with PICC Line
Penalty
Summary
A deficiency occurred when a resident with a PICC line in the left upper arm had blood drawn by venipuncture from the same arm, contrary to professional standards and facility policy. The resident was receiving antibiotics through the PICC line at the time, and a folded gauze dressing was observed below the left elbow, which the resident stated was from a blood draw performed earlier that morning. The facility's Director of Nursing confirmed that blood should not be drawn by needle stick from the same arm as a PICC line, as this could lead to complications. The Infection Prevention Nurse was unable to find any nursing resources supporting the practice of venipuncture on the same arm as a PICC line and noted that laboratory staff did not communicate with facility staff before performing the blood draw. The facility did not provide laboratory staff with reminders or warnings to avoid venipuncture on the arm with the PICC line, and there was no documentation of communication regarding the blood draw. Review of facility policy and national guidelines indicated that venipuncture, peripheral IV insertion, and blood pressure measurements should be avoided on the same arm as a PICC line, and that reminder signs should be placed for healthcare team members. The failure to follow these standards resulted in a deficiency related to professional standards of nursing practice.