Failure to Follow PICC Line Care Protocols and Placement Verification
Penalty
Summary
A deficiency occurred when the facility failed to follow its own policy and physician's orders regarding the care and management of a resident's Peripherally Inserted Central Catheter (PICC) line. The facility's policy required weekly dressing changes for transparent dressings and dressing changes every 48 hours for gauze dressings, or as ordered by the physician. However, the resident reported that the PICC line dressing had not been changed since insertion, and observations confirmed that the dressing was not dated or timed, and included gauze under a transparent dressing. Staff interviews revealed inconsistent practices regarding dressing changes and a lack of adherence to established protocols. Additionally, after the PICC line was reinserted, a chest x-ray to confirm placement was not ordered or performed, despite this being a standard requirement and expectation communicated by the PICC line insertion company. The resident's medical record did not contain documentation of a chest x-ray following the new PICC line insertion, and the line was used for intravenous therapy without confirmation of proper placement. Interviews with staff, including the DON and ADON, confirmed that the chest x-ray was not completed and that the line had been used daily since insertion. During an observed dressing change, further deviations from protocol were noted, including a break in sterile technique, failure to change the stabilization device and antibacterial disk, and incomplete use of enhanced barrier precautions. The resident had a history of infection, recent surgical procedures, and required IV antibiotics via the PICC line. The facility's failure to follow established protocols and physician orders for PICC line care, dressing changes, and placement verification led to the identified deficiency.