Failure to Ensure Physician Orders and Care for PICC Line
Penalty
Summary
The facility failed to ensure that physician orders were in place and care was provided for a resident with a peripherally inserted central catheter (PICC line) used for long-term intravenous access. Medical record review showed that after a hospital visit for a urinary tract infection, the resident was discharged with a new PICC line and an order for IV vancomycin. The care plan indicated the need for IV antibiotics and monitoring of the PICC line, including site evaluation, dressing changes, and tubing management. However, there were no physician orders for monitoring, flushing, or dressing changes for the PICC line from the time it was placed until 15 days later. Review of the Treatment Administration Record (TAR) confirmed that during this period, there was no documentation of PICC line flushing, monitoring, or dressing changes. The Director of Nursing verified that there were no orders for these essential care activities during the specified timeframe, despite facility policy requiring regular flushing, monitoring, and documentation for IV catheters. This lapse was identified during a complaint investigation and affected one resident with a PICC line.