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F0694
D

Failure to Document and Perform Timely PICC Line Dressing Change

Pasadena, California Survey Completed on 09-04-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when the facility failed to provide care and dressing changes for a peripherally inserted central catheter (PICC line) in accordance with professional standards and the facility's own policy for one resident. The resident, who had diagnoses including obstructive hydrocephalus, type 2 diabetes mellitus, and malignant neoplasm of the brain, was admitted with a right antecubital PICC line. The facility's policy required that the PICC line dressing be changed at least every seven days or sooner if the dressing became damp, loosened, or soiled. However, there was no documentation that the dressing was changed on or before the required date. During interviews and record reviews, the DON confirmed that it was the responsibility of the Treatment Nurse or RN Supervisor to change the dressing and document the procedure. The Assistant DON stated she had changed the dressing but could not recall the date and admitted she did not document the change in the medical record. The DON acknowledged that if the dressing change was not documented, it was considered not done, and confirmed that the facility's policy was not followed in this instance.

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