Failure to Address PICC Line Care in Resident Care Plans
Penalty
Summary
The facility failed to develop and implement care plans that addressed the presence of Peripherally Inserted Central Catheters (PICC) and associated risk factors for two residents. For one resident with severely impaired cognition and diagnoses including heart failure, anemia, and hypertension, the care plan did not document the existence of a PICC line or include interventions and monitoring related to the device, despite the resident receiving IV medications through the PICC. The Director of Nursing acknowledged that the care plan lacked this essential information. Similarly, another resident with intact cognition and diagnoses of osteomyelitis, pneumonia, and hypertension was discharged from the hospital with a PICC line and received IV medications in the facility. However, the care plan for this resident also failed to document the presence of the PICC line, associated risk factors, or necessary monitoring. These omissions were identified through clinical record review, staff interview, and policy review, and were inconsistent with the facility's policy requiring comprehensive, person-centered care plans that address all identified needs and services.