Failure to Follow PICC Line Dressing and Measurement Orders for Two Chemotherapy Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide PICC line care and dressing changes according to physician orders, facility policy, and professional standards of practice for two residents receiving chemotherapy via PICC lines. For Resident ID #1, hospital documentation showed a PICC was inserted in the left arm with a baseline external catheter length of 0 cm, and the resident was to receive chemotherapy through this line. The January 2026 MAR contained a physician’s order to change the central line dressing every 7 days and to measure the external catheter length with each dressing change. The dressing change was signed as completed on 1/31/2026, but the documentation field for the catheter length was left blank. During a surveyor-observed dressing change on 2/6/2026, an LPN measured the external catheter length as 1 cm and acknowledged that the external length had not been documented previously in the resident’s record. For Resident ID #2, hospital records indicated a PICC was inserted in the right arm with a baseline external catheter length of 0 cm, and this resident was also to receive chemotherapy via the PICC. The January 2026 MAR showed a physician’s order to change the central line dressing every 7 days and to measure the external catheter length, but the order was marked incomplete due to the resident being absent from the facility. The PICC dressing was not changed on admission and was not completed until 2/6/2026, nine days later, and there was no evidence in the record that the external catheter length was measured as required by facility policy and the physician’s order. During interviews, the Nurse Practitioner stated she expected PICC dressings to be changed as ordered and the external length measured and reported if different from baseline, and the Director of Nursing Services was unable to provide evidence that the PICC dressing and external length measurements had been completed and documented for either resident until the surveyor brought the issue to the facility’s attention.
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