Failure to Follow PICC Line Dressing Change Policy
Penalty
Summary
Surveyors found that the facility failed to follow its policy for the care and maintenance of a peripherally inserted central catheter (PICC) for one resident. The facility’s policy dated January 31, 2025, required that PICC and midline dressings remain clean, dry, and intact, and be changed every 5–7 days and as needed when wet, soiled, or not intact. The resident involved had an admission MDS showing cognitive impairment, a need for staff assistance with daily care, and diagnoses including sepsis and an ostomy. Physician orders dated November 25, 2025, directed that the resident’s PICC line dressing be changed as needed for slippage or soilage. Review of the resident’s December 2025 treatment record showed that the PICC dressing was changed on December 14, 2025, with no further documented dressing change until December 24, 2025, resulting in a 10‑day interval between changes. Based on the facility’s policy, the PICC dressing should have been changed by December 21, 2025, but there was no documentation that this occurred. In an interview on February 5, 2026, the Director of Nursing confirmed that the dressing should have been changed on December 21, 2025, in accordance with the policy.
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