Failure to Follow Professional Standards During PICC Line Dressing Change
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality during a peripherally inserted central catheter (PICC) line dressing change for one resident. During the observed procedure, the registered nurse (RN) turned his back on the sterile field multiple times, left the resident's room to obtain additional supplies after removing the PICC line dressing—leaving the line exposed—and did not follow the recommended cleaning technique or duration for the insertion site. The RN also failed to measure the length of the catheter to monitor for migration and did not wear a protective gown as required. These actions were not in accordance with established professional guidelines for PICC line care. Record review revealed that the RN had not completed training or demonstrated competency in PICC line dressing changes at the facility. Interviews with the RN, the director of nursing (DON), and the infection preventionist (IP) confirmed that neither of the two nurses currently working at the facility had received training for PICC line management. The RN admitted to lacking formal training at the facility and expressed a desire for education, attributing his errors during the procedure to nervousness and unfamiliarity with the facility's protocols.