Failure to Investigate PICC Line Injury Incident
Penalty
Summary
The deficiency involves the facility’s failure to conduct a complete and thorough investigation of an incident in which a resident’s peripherally inserted central catheter (PICC) line was accidentally cut by an RN during a dressing change, resulting in the resident being sent to the emergency department. The facility’s abuse prevention and reporting policy required investigation of events suggesting possible abuse or neglect and documentation of such events, including appropriate corrective action if an allegation was verified. However, review of the facility’s incident logs for January and February 2026 showed no incident related to this PICC line event, despite a progress note documenting that the PICC line was accidentally cut and the resident was transferred to the hospital. Interviews with multiple staff revealed that no incident report or formal investigation was initiated at the time of the event. The interim CNO acknowledged that no incident report was completed because the resident was discharged home from the hospital and stated they were only going to complete an incident report on the day of the survey. The interim CNO also reported that, after reviewing internal guidance (“Purple Book”) with the intradisciplinary team, they had determined the event did not meet the definition requiring an incident report. A resident care manager stated that incident reports were usually started by the cart nurse or nursing managers, but in this case they were never directed to complete one and viewed the event as a mistake for which the nurse was educated. The interim administrator believed an incident report existed in the risk management system or had been reviewed in stand-up, but none was found, and stated they would have expected an investigation. The company lead CNO also stated they had been told an investigation was being conducted and would have expected one to be done.
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