Failure to Timely Change PICC Line Dressing per Physician Orders
Penalty
Summary
A deficiency occurred when the facility failed to ensure that parenteral fluids were administered in accordance with professional standards of practice and physician orders for a resident with a PICC line. The resident, a female admitted with an active infection related to hardware in her right lower leg, was receiving IV antibiotics through a PICC line. Physician orders specified that the PICC line dressing should be changed every seven days and as needed, and the facility's policy also required weekly dressing changes or sooner if the dressing was not intact. During observation, it was noted that the resident's PICC line dressing was dated 14 days prior and was coming off on one side, although the immediate area around the insertion site was clean and intact. Interviews with nursing staff revealed that the dressing change had been missed; one LVN admitted she noticed the overdue dressing but delayed changing it until after administering antibiotics, while another LVN responsible for the dressing change stated she forgot due to being busy with admissions and discharges and failed to communicate this to the oncoming nurse. The infection control preventionist and DON both confirmed that the dressing change had not been completed as ordered and were unaware of the overdue status until the survey. Record review and staff interviews confirmed that the facility's policy and physician orders were not followed, resulting in the PICC line dressing remaining unchanged for longer than the prescribed interval. The staff acknowledged that the failure to change the dressing as ordered could increase the risk of infection, and the breakdown in communication and time management contributed to the deficiency.