Failure to Include PICC Line Care in Resident's Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with multiple medical conditions, including a PICC line for intravenous access. Despite physician orders for regular PICC/Midline dressing changes and the presence of the PICC line, the resident's care plan did not include any interventions or maintenance instructions related to the PICC line. The care plan only addressed antibiotic therapy for infections but omitted the specific needs and care associated with the resident's IV access. Interviews with facility staff, including the MDS Coordinator, Director of Clinical Operations, and Administrator, confirmed that the care plan was incomplete and did not reflect the resident's current needs regarding the PICC line. The staff acknowledged that the omission could result in the resident not receiving necessary care. Facility policy requires that care plans be comprehensive, person-centered, and updated as resident conditions change, but this was not followed in this instance.