Improper PICC Line Dressing Change and Inadequate Nurse Competencies
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.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
IV access and medication labeling deficiencies: A resident with a PICC line had no documented admission measurement of external catheter length or arm circumference, another resident’s IV tubing was observed without the required date, time, and RN initials, and a third resident’s meropenem IV bag was not labeled with the date, time, and initials. Facility policy required labeling of IV solutions and documentation of PICC measurements.
Failure to Document Baseline Midline IV Measurements: A resident receiving IV antibiotics via a midline IV had no documented baseline external catheter length or arm circumference measurements when admitted from the acute hospital. The resident’s care plan did not address the midline IV, and the IV MAR lacked baseline documentation. RN confirmed staff performed dressing changes and measurements, but could not verify any baseline values from the acute care hospital; the DON verified the findings.
A resident with a PICC line, diabetes, obesity, atrial fibrillation, and CHF had no documented PICC-related care plan interventions, and the PICC dressing was found stained, loosening, and dated well beyond the weekly change schedule. Although the MAR showed the dressing change as completed, staff interviews confirmed it was overdue and should have been changed sooner, with the DON acknowledging it was late and that loose or soiled dressings require more frequent attention.
A resident received IV Cefepime multiple times through a long-term IV catheter, but the MAR lacked documentation that the catheter was flushed before and after administration as required by facility policy. The DON confirmed the nurse should have flushed the IV catheter pre- and post-medication administration.
A resident receiving IV antibiotics through a PICC had no documented baseline or weekly catheter length and arm circumference measurements, despite an order for the RN to record them after each Sunday dressing change. RNs stated the measurements were needed to confirm the catheter remained in position, but the IV MAR showed only dressing changes and no measurements. The DON confirmed the record lacked both admission and weekly measurements, and the complaint noted the catheter had moved, leading to a hospital return, PICC removal, and replacement catheter placement.
PICC Line Removal Not Timely or Fully Documented: A resident with severe cognitive impairment, dependence for all ADLs, and IV antibiotic therapy had a PICC line that was not removed when the antibiotic ended, and nursing documentation showed conflicting removal entries. The chart lacked a physician order for removal, lacked confirmation that the full line including the tip was removed, and lacked documentation of post-removal site inspection or monitoring for complications.
IV access and medication labeling deficiencies
Penalty
Summary
The facility failed to provide the necessary care and services to maintain intravenous access for Resident 23, who had a right upper arm single lumen PICC line and a BIMS score of 12 on admission. The resident’s medical record showed a physician’s order to measure the external catheter length of the PICC and midlines upon admission and with each dressing change, and to include arm circumference for the midline device every seven days and as needed. However, the Nursing Admission/readmission Evaluation/assessment did not document the measurement and assessment of the PICC line, and the record did not show evidence that the length of the catheter above the insertion site or arm circumference were obtained upon admission. The facility also failed to ensure Resident 123’s IV tubing was labeled. During an initial tour, Resident 123 was observed with a peripheral IV in the left hand and a one-liter bag of 0.9% Sodium Chloride infusing at 75 mL per hour. The IV tubing was not labeled with the date, time, and nurse’s initials. The resident’s order summary showed an order to change IV tubing every 24 hours for intermittent IV infusion and TPN and every 72 hours for continuous IV infusion. In addition, the facility failed to ensure Resident 9’s IV medication was correctly labeled. During medication administration observation, Resident 9 was observed with a right upper arm three lumen PICC line and meropenem 1 gram was prepared and administered through the PICC line. The IV tubing was labeled by the RN, but the meropenem medication bag was not labeled with the date, time, and initials of the RN who administered the medication. Facility policy stated that the nurse hanging IV solutions will label the bag with the date, time, and initials.
Failure to Document Baseline Midline IV Measurements
Penalty
Summary
The facility failed to provide the necessary care and services to maintain the intravenous access for Resident 68, who had a midline IV in the left upper arm with two lumens and a transparent dressing. The resident had physician orders for antimicrobial disc use, routine flushing of the midline lumen, monitoring for inflammation or infiltration every shift, measuring arm circumference 5 cm above the insertion site during dressing changes, changing the midline dressing and Stat-lock weekly, and measuring the external catheter length during dressing changes with notification to the MD if the length increased by 2 cm or more. Medical record review showed no baseline documentation of the external catheter length or arm circumference above the insertion site when the resident arrived from the acute hospital where the midline was inserted. The resident’s care plan did not address the midline IV, and the IV Administration Record for April and May 2026 did not show baseline arm circumference or catheter length measurements documented on admission. During interview and record review, RN 1 confirmed the resident was receiving IV antibiotics through the midline and stated nursing staff were responsible for dressing changes and measurements, but could not verify any baseline measurements from the acute care hospital. The DON later reviewed and verified these findings.
PICC Dressing Not Changed as Ordered
Penalty
Summary
The facility failed to ensure parenteral fluids and central venous catheter care were provided in accordance with professional standards of practice and physician orders for one resident with a PICC line. The resident was admitted with diagnoses including cellulitis of the left lower limb, type 2 diabetes mellitus, morbid obesity, unspecified atrial fibrillation, and acute-on-chronic systolic heart failure, and had a BIMS score of 15 indicating intact cognition. The baseline care plan contained no documented interventions, monitoring, or care planning related to the PICC line or IV antibiotic therapy. The order summary included an order to monitor the PICC site every shift for signs and symptoms of infection and an order to change the PICC dressing weekly and every Monday. Although the MAR documented the PICC dressing change as completed on 05/18/26, an observation and interview on 05/19/26 found the PICC dressing visibly stained, loosening around the edges, and dated 05/08/26. The resident stated the dressing had not been changed since admission. Staff interviews confirmed the dressing should have been changed the prior day, that a loose or rough dressing could be changed more frequently under PRN orders, and that the RN charge nurse was going to change it that day. The DON stated PICC lines are to be changed every 7 days and acknowledged the dressing should have been changed the day before.
Failure to Flush IV Catheter During Antibiotic Administration
Penalty
Summary
Professional standards of practice were not followed for the care of a resident's long-term IV catheter. Resident 8 had physician orders for IV Cefepime HCl, including 2 grams every 12 hours for seven days and a one-time 2 gram dose, and the facility's IV catheter policy required flushing the catheter with 5 ml of normal saline before and after infusion. Review of the MARs for April and May 2026 showed that staff administered IV Cefepime 14 times, but there was no documented evidence that the IV catheter was flushed before or after medication administration. The DON confirmed in interview that the nurse should have flushed the IV catheter pre- and post-medication administration.
PICC Line Measurements Not Documented
Penalty
Summary
The facility failed to ensure a PICC line was measured weekly for a resident receiving IV antibiotics for a bone infection. Resident 1 was admitted with diagnoses including an infection in the bone and had a physician order for the RN to change the PICC dressing and securement device every Sunday and to measure the catheter length and arm circumference in centimeters after each dressing change. RN interviews stated that the measurements were important to confirm the catheter remained in the correct position and to monitor for infection, and that the Sunday dressing change process included use of a measuring tape. Record review of the IV MAR for April and May 2026 showed dressing changes were documented on 4/19/26, 4/26/26, and 5/3/26, but no catheter length or arm circumference measurements were recorded. The DON stated the admission measurements should have been obtained from the hospital or measured on arrival to establish a baseline, and that the absence of both admission and weekly measurements meant the facility could not compare values to confirm the catheter remained in place. The complaint also stated the catheter had moved out of its original position, and Resident 1 returned to the hospital with chest pain, had the PICC removed, and received another catheter to complete medication administration.
PICC Line Removal Not Timely or Fully Documented
Penalty
Summary
The facility failed to provide services consistent with the standards of care related to Resident 4’s PICC line when the physician’s order for in-facility removal after completion of IV antibiotic therapy was not followed for three days. Resident 4 had diagnoses including anxiety, diabetes mellitus, aphasia following cerebral infarction, and pressure ulcers to both heels, and the MDS documented severely impaired cognition with a BIMS score of zero, dependence on staff for all ADLs, impairment of both upper and lower extremities, and receipt of IV medications during the observation period. The care plan did not address the PICC line or associated care. The record showed orders for PICC dressing changes, cap changes, and daily saline flushes, and documentation stated to continue Daptomycin/Cerftiax through 05/08/26 and then remove the PICC line. Nursing notes documented the PICC line was removed on 05/12/26 and again on 05/13/26, but the chart lacked a physician order to remove the line and lacked documentation confirming the full removal of the line, including the tip. The record also lacked documentation of inspection of the PICC line after removal to ensure it was fully removed without complications. Administrative nurses stated the order had been sent to department heads, nursing had not done anything with it, and the facility should document the removal and any monitoring or complications.
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