Failure to Follow PICC Line Dressing Change Protocols for IV Therapy
Penalty
Summary
The facility failed to ensure the safe and appropriate administration of IV fluids for a resident by not following professional standards of practice and physician orders regarding the care and maintenance of a PICC line. After returning from the hospital with a PICC line in place for IV antibiotic therapy, the resident did not have the PICC line dressing changed as required by facility protocol and standard practice. The dressing, dated from the time of hospital discharge, remained unchanged for an extended period, as confirmed by both observation and photographic evidence provided by the resident's family member. Record reviews revealed that there was no order for changing the PICC line dressing upon the resident's readmission, and nursing staff failed to initiate or follow up on obtaining such an order. Multiple nurses interviewed acknowledged that dressing changes were scheduled weekly, typically on Sundays, but none noticed or addressed the lack of a current order or the outdated dressing. The responsibility for obtaining the order was not fulfilled by the admitting nurse, and subsequent staff did not identify or correct the oversight. The resident, who had a history of recurrent infections and sepsis, was eventually sent back to the hospital with a fever, where it was discovered that the PICC line dressing had not been changed since the initial hospital discharge. Interviews with staff and the DON confirmed that the dressing was not changed during the resident's stay, and the facility's protocol for weekly dressing changes and daily site assessments was not followed. The failure to adhere to these protocols was acknowledged by the DON and staff during interviews.