Failure to Change PICC Line Dressing as Ordered
Penalty
Summary
A deficiency occurred when nursing staff failed to change the dressing for a peripherally inserted central catheter (PICC) line as ordered by the provider for a resident admitted with diagnoses including congestive heart failure, diabetes, chronic kidney disease, and cellulitis. Physician orders specified that the PICC line dressing should be changed on admission and then every seven days on the day shift, as well as as needed. Documentation on the Medication Administration Record (MAR) indicated that the dressing change was completed on a specific date, but the nurse responsible later confirmed that this was an error and the dressing had not been changed as documented. Observations over several days revealed that the PICC line dressing remained unchanged, with the original date still visible on the label. Interviews with nursing staff indicated a lack of familiarity with the resident's orders, and both the Administrator and DON confirmed that the expectation was for orders to be followed as written. The Nurse Practitioner and Medical Director also stated that weekly dressing changes were expected to prevent infection and maintain catheter integrity. The deficiency was identified when the dressing was finally changed, and it was confirmed that the previous dressing had not been changed for over two weeks.