Failure to Follow PICC Line Dressing Change Orders and Maintain Dressing Integrity
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards of practice when staff did not follow orders for a PICC line dressing change and did not ensure the dressing was secure. A resident with osteomyelitis of the vertebra was admitted with a PICC line in the left upper extremity for long-term IV antibiotics. The medical record included an order dated 1/15/26 for a central line dressing change every seven days and as needed. Review of the treatment administration records for January and February 2026 showed that the PICC line dressing changes were not documented as completed, and the next scheduled treatment to prompt staff to change the PICC line dressing was not set to trigger until 2/11/26. During observation and interview on 2/5/26, the resident reported being admitted with the PICC line for antibiotics and stated that the dressing had only been changed once at the facility, on 1/29/26, when it was coming off. The resident and the resident’s parent reported that the infection control doctor had said the PICC dressing needed to be changed at least weekly and that staff were not changing it. At the time of observation, IV antibiotics were infusing through the left arm PICC line, and the outer aspect of the dressing was hanging loosely. The resident demonstrated that the edge of the dressing could be lifted almost to the insertion site. The Nurse Consultant/Interim DON stated that if a dressing is changed as needed, it does not change the due date for the next treatment, and that if a treatment is loose or falling off, staff should clean the site and replace the dressing and contact the physician if there are integrity issues with the PICC line.
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