Failure to Change PICC Line Dressing per Physician Orders
Penalty
Summary
A deficiency occurred when the facility failed to ensure that parenteral fluids were administered in accordance with professional standards of practice and physician orders for one resident. The resident, a cognitively intact female with a history of Staphylococcal arthritis, sepsis, and methicillin-susceptible staphylococcus aureus infection, was admitted with orders for IV medication and a peripherally inserted central catheter (PICC) line. The care plan required weekly monitoring and dressing changes for the PICC line, and physician orders specified that the dressing should be changed every week and as needed. Upon review, it was found that the resident's PICC line dressing was dated eight days prior to the observation, despite documentation indicating that the dressing had been changed as scheduled. The dressing was signed off as changed by an LVN, but direct observation and the date on the dressing indicated that the change had not actually occurred. The DON confirmed that the dressing had not been changed as required and that it was inappropriate for staff to document completion of a task that was not performed. Facility policy also required dressing changes at least every seven days to prevent complications, but this was not followed in this instance.