F0694

G

Improper PICC Line Dressing Change and Inadequate Nurse Competencies

Bellingham, Washington Survey Completed on 02-13-2026

Penalty

Fine: $15,935

Summary

The deficiency involves the facility’s failure to ensure safe and appropriate administration of IV therapy by not following professional standards and aseptic technique during a PICC line dressing change for Resident 20. The facility’s own 2025 Facility Assessment identified that its resident population required nursing care for IV peripheral and central lines, and that competencies were to be monitored through leadership rounding, mentoring, skills checks, and annual staff competencies. The facility had a policy for central venous access device dressing changes that required careful removal of old dressings, stabilizing the catheter to minimize movement, and using alcohol to loosen adhesive. Resident 20 was admitted with osteomyelitis of the thoracic and lumbar vertebrae, type 2 diabetes, and vancomycin resistance, and had a PICC line in the left upper arm with care plan interventions for enhanced barrier precautions and dressing changes to maintain patency and keep the site infection-free.

During a scheduled weekly PICC line dressing change, the nurse performing the procedure used general wound care scissors, which were unsterile, to cut tape on the dressing. The nurse reported attempting to cut the tape and believed they had cut the dressing, but the PICC line was in fact cut. The resident and collateral contact reported that the nurse took scissors from their scrub pocket and cut near the line while trying to remove “gummy stuff” from the dressing. After the dressing was mostly removed and a new dressing placed over the insertion site, the resident noticed bleeding and felt blood under the armpit. The nurse initially stated the line had “broke” or “snapped,” while the resident asserted that it had been cut. The facility’s progress note documented that the PICC line was accidentally cut during the dressing change and that a pressure dressing was applied before the resident was transferred emergently to the emergency department for PICC line replacement and additional diagnostic procedures, including ultrasound and X-ray.

Interviews and record review showed that licensed nurse competencies related to central/PICC/CVAD care and central line/midline dressing changes for multiple nurses were past due as of the review date. One RN stated they were unaware of any in-service instructing staff not to use scissors during PICC line dressing changes, though they knew sharps should not be used. The RN who cut the line stated they had not received much training at the facility, were previously certified to insert IVs at another facility, and felt unsupported due to lack of education. The resident, their family member, and staff interviews indicated that few nurses were comfortable or experienced with PICC line care, that staff had difficulty managing IV antibiotics, IV pumps, and air bubbles, and that the resident’s PICC line care appeared problematic throughout the stay. The facility’s failure to ensure current nurse competencies and adherence to its own PICC dressing change policy resulted in the use of unsterile scissors during a PICC line dressing change, cutting the line and necessitating emergency transfer and replacement of the central line, and placed the resident at serious risk for central line–associated bloodstream infection as stated in the report.

The report also documents that the resident and their family perceived that staff did not know how to care for the PICC line or administer IV antibiotics properly. The family member stated it appeared there was only one nurse who knew how to work with a PICC line and described wasted IV antibiotic while staff attempted to remove air bubbles, as well as a dropped and broken medication vial. The resident reported that staff repeatedly had problems with the IV pump jamming, excessive air bubbles, and understanding how the antibiotics were to be infused, and that staff told them they were the only resident with an IV like theirs. The resident described the nurse’s visible panic after cutting the line and uncertainty about what to do next, including the nurse asking about resuscitation preferences while the resident was bleeding and waiting for emergency services. These observations and statements, combined with the documented lapse in competencies and deviation from the facility’s dressing change procedure, form the factual basis for the cited deficiency.