Failure to Perform Timely PICC Dressing Change as Ordered
Penalty
Summary
A deficiency occurred when the facility failed to perform a weekly dressing change to a resident's peripherally inserted central catheter (PICC) as ordered. The resident, who was admitted with chronic idiopathic venous hypertension and ulcers, had a physician order for weekly sterile PICC dressing changes and daily monitoring for catheter migration. Despite these orders, there was no documentation that the PICC dressing had been changed since admission, and the Medication Administration Record (MAR) showed that the dressing change was marked as not applicable on the scheduled day. Observations confirmed that the PICC dressing remained unchanged for more than a week, with the original dressing date still present during multiple checks. Interviews with nursing staff revealed confusion regarding responsibility for the dressing change and the correct timing, with Nurse #1 stating she did not change the dressing because she believed it was not yet due and was told to record it as not applicable. Team leaders and the Assistant Director of Nursing clarified that the assigned nurse was responsible for the dressing change and that the order should have been followed as written. Further interviews indicated a lack of communication and clarity among staff regarding the implementation of the physician's order and facility policy. The Director of Nursing and Administrator both confirmed that the dressing should have been changed according to the order and policy, but this was not done. The deficiency was identified through record review, observation, and staff interviews, which established that the facility did not ensure the safe and appropriate administration of IV fluids by failing to perform the required PICC dressing change.