PICC Line Removed Without Physician Notification or Order
Penalty
Summary
A registered nurse (RN) failed to follow accepted standards of clinical practice regarding the care and removal of a peripherally inserted central catheter (PICC) line for a resident. The resident, who was cognitively intact and required maximum assistance with activities of daily living, had a history of pyogenic arthritis and chronic pain. During an assessment, the RN discovered the resident's PICC line was leaking and was unable to flush it with a syringe. Without notifying the physician or obtaining a provider order, the RN removed the PICC line from the resident's arm. Documentation review and staff interviews confirmed that the facility's policy required physician notification and a provider order prior to the removal of a PICC line. The RN admitted to not being aware of this requirement at the time of the incident. The Director of Nursing also confirmed that the facility policy was not followed in this instance, as there was no documentation of provider notification or an order before the PICC line was removed.