Failure to Document and Order PICC Line Dressing Changes for Resident Receiving IV Therapy
Penalty
Summary
The facility failed to ensure complete and accurate medical records for a resident who was receiving intravenous (IV) medication via a peripherally inserted central catheter (PICC) line. Upon admission, the resident had a PICC line in place and was receiving IV antibiotics as ordered by the physician. The care plan identified the resident as being at risk for complications related to IV therapy and included interventions such as administering IV medications as ordered, performing IV flushes, changing IV tubing per protocol, and performing IV site care as ordered. However, a review of the resident's physician orders revealed there were no orders for PICC line dressing changes, and the medication and treatment administration records for the relevant months showed no documentation that PICC dressing changes were completed. During an interview, the LPN Unit Manager confirmed that when residents are admitted with a PICC line, it is necessary to select and enter orders for dressing changes, flushes, and monitoring for infection. The LPN stated that if there is no order for a PICC dressing change, nurses are expected to enter the order and document the dressing change. The facility's policy requires sterile dressing changes for PICC lines at least weekly, with documentation in the clinical record. The absence of both physician orders and documentation for PICC dressing changes indicated a failure to maintain complete and accurate records in accordance with professional standards.