Failure to Complete PICC Line Dressing Changes as Ordered
Penalty
Summary
A deficiency occurred when the facility failed to ensure that care and services for a peripherally inserted central catheter (PICC) line site were completed as ordered for a resident with multiple complex diagnoses, including Evan's syndrome, systemic lupus erythematosus, hereditary hemolytic anemia, and drug-induced diabetes. The resident was admitted for treatment of a urinary tract infection and required intravenous antibiotics administered through a PICC line in the right upper extremity. Physician orders specified that the PICC line dressing was to be changed weekly on Sundays. Medical record review showed that the Medication Administration Record (MAR) and Treatment Administration Record (TAR) had been signed off by two LPNs for dressing changes on two occasions, but there was no evidence of any dressing changes after those dates, and the order was discontinued later. Progress notes and interviews revealed that the PICC line dressing had not been changed since placement, and the dressing was visibly soiled and dated from the time of insertion when the resident attended a follow-up appointment. The PICC line was removed at the appointment after this was discovered. Staff interviews confirmed that the LPNs had signed off on the dressing changes without actually performing them. One LPN reported not receiving the necessary dressing supplies, while the other believed all assigned dressings had been completed but could not recall specifics. The facility's policy required assessment of the insertion site at each dressing change and labeling of the dressing, but did not specify the frequency of changes. The deficiency was identified through review of records, staff interviews, and facility policy.