Failure to Assess and Document PICC Line Status for Residents Receiving IV Therapy
Penalty
Summary
The facility failed to follow professional standards for the assessment and documentation of Peripherally Inserted Central Catheter (PICC) lines for two residents who required IV medications. For one resident with severe cognitive impairment and diagnoses including heart failure, anemia, and hypertension, there was no documentation in the electronic health record of any assessment of the PICC site, its location, or length during the resident's stay. The admission assessment also did not note the presence of a PICC line, and the discharge summary indicated the central line was removed due to occlusion. The Director of Nursing confirmed that nurses were expected to assess the site when administering medication but acknowledged that there was no documentation to support that these assessments occurred, nor were measurements of the catheter performed to ensure it had not moved out of place. Similarly, another resident with intact cognition and diagnoses of osteomyelitis, pneumonia, and hypertension had a PICC line on admission, but the electronic health record lacked documentation of any assessment of the PICC site, location, or length. The admission assessment also failed to document the presence of a PICC line. Facility policy required nurses to monitor the dressing, line, and resident every shift for signs of infection, malposition, or occlusion, and to document these assessments, but this was not done for either resident.