F0684

E

Failure to Follow PICC Line Flushing and Monitoring Orders

Clearlake, California Survey Completed on 02-19-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to follow physician orders and facility policy for PICC line care for one resident. The resident was admitted with metabolic encephalopathy and bacteremia and had a physician order for the PICC line to be monitored every shift on the day shift for signs and symptoms of infection. Review of the Medication Administration Record (MAR) for February showed that this monitoring order was not documented as completed on multiple specified day shifts. The resident also had a physician order for a daily heparin lock flush solution to maintain PICC line patency, which was not documented as administered on several ordered dates and times. The facility’s policy required flushing catheters at regular intervals to maintain patency, monitoring for IV complications, and recording the date and time medications were administered in the medical record.

During interviews, the licensed staff member who worked several of the shifts in question confirmed that documentation of PICC line care was missing from the MAR and stated that, as he was not an RN, he could not flush the line himself and instead reminded RNs to perform the task, but could not verify it was done without documentation. He also stated he monitored the PICC site daily, although this was not consistently documented. The resident reported that staff flushed and monitored the PICC line less than half of the required times and not daily, despite his repeated reminders, and stated he felt neglected and feared infection. The DON acknowledged that a PICC line not flushed consistently could become clogged, that lack of monitoring could miss a reaction or infection, and that if a task was not documented, it meant it was not completed, confirming the missing documentation on the resident’s MAR.