Failure to Follow PICC Line Assessment and Documentation Standards
Penalty
Summary
The facility failed to follow professional standards of practice regarding the care and maintenance of a peripherally inserted central catheter (PICC) line for a resident with acute osteomyelitis and a chronic foot ulcer who was receiving intravenous antibiotics. During an observation, an LPN encountered resistance while attempting to administer an antibiotic through the resident's PICC line. The line was found to be excessively long and coiled, causing it to kink under the dressing and impede fluid flow. Upon uncoiling, the line measured 42 cm at the indicator, suggesting possible migration of the catheter. Record review revealed that there was no documentation of the external catheter length at the insertion site upon admission or during subsequent weekly assessments, as required by facility policy. The Assistant Director of Nursing confirmed that the line should have been measured at admission and weekly thereafter, but no such measurements were documented in the medical record. This lack of assessment and documentation meant there was no evidence to determine whether the line had migrated or if it was safe to use.