Failure to Change PICC Line Dressing per Physician Order
Penalty
Summary
The facility failed to ensure the safe and appropriate administration of parenteral fluids by not managing a resident's PICC line dressing according to professional standards and physician orders. The resident, who had multiple diagnoses including UTI, type 2 diabetes, vascular dementia, hypertension, and hemiplegia, was admitted with an order for PICC/Midline dressing changes using sterile technique every 7 days or as needed if the dressing became wet or soiled. Observations revealed that the PICC line dressing was dated 10 days prior, exceeding the 7-day interval specified in the physician's order and facility policy. Interviews with staff, including an LVN, ADON, Director of Clinical Operations, and the Administrator, confirmed that only RNs were permitted to change PICC line dressings and that the dressing had not been changed as required. The staff were not aware that the dressing change was overdue until it was pointed out during the survey. The facility's policy and the physician's order both required dressing changes at least every 7 days, but this was not followed for the resident in question. The failure to change the dressing as ordered was acknowledged by multiple staff members, who also recognized that not adhering to the schedule could place residents at risk for infection.