Failure to Obtain PICC Line Care Orders for Resident Receiving IV Antibiotics
Penalty
Summary
The facility failed to obtain and document provider orders for the care and management of a resident’s PICC (peripherally inserted central catheter) line despite ongoing IV antibiotic therapy. The resident was admitted with diagnoses including nontraumatic subarachnoid hemorrhage, acute and subacute infective endocarditis, pleural effusion, and psychoactive substance-induced mood disorder, and had admission orders for two IV antibiotics to be administered via the PICC line two to three times daily. However, the admission orders did not include any directives for PICC line care, such as flushing, dressing changes, or other maintenance. Nursing staff, including an RN and the DON, reported that routine PICC line care (flushes, weekly dressing changes, checking for a cap, measuring the line and arm circumference) is normally performed and is supposed to be included in batch orders entered at admission, but acknowledged that these orders were not entered for this resident. This omission resulted in the resident receiving IV medications through a PICC line without corresponding written orders for line care and maintenance, as confirmed by interview and record review.
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