Failure to Provide Complete PICC Line Dressing Changes per Standards
Penalty
Summary
A deficiency occurred when a resident with a right upper extremity peripherally inserted central catheter (PICC) did not receive dressing changes in accordance with professional standards of practice. Upon the resident's readmission, the physician's order for PICC line care was incorrectly entered, specifying only the transparent portion of the dressing to be changed weekly, rather than the entire dressing as required. Facility staff, including LPNs and CNAs, followed this order and only changed the transparent cover, not the full dressing, for several weeks. The facility's own policy and standard practice require the entire dressing to be changed every 5-7 days or sooner if compromised. The error in the order entry was attributed to the use of a pre-set order template in the facility's electronic library, which only referenced the transparent dressing. Staff interviews revealed that the process for entering orders involved supervisors and higher-level staff, and the LPNs relied on these orders for care delivery. The deficiency was identified during a surveyor's observation and interviews, which confirmed that the resident's entire PICC line dressing had not been changed weekly since readmission, contrary to both facility policy and accepted standards of care.