Failure to Follow Physician Orders for Weekly PICC Line Dressing Changes
Penalty
Summary
The deficiency involves the facility’s failure to ensure services met professional standards of practice by not following physician orders for a resident’s peripherally inserted central catheter (PICC) line dressing changes. The resident, who was cognitively intact and admitted with diagnoses including end stage renal disease, a stage 4 sacral pressure ulcer, diabetes, depression, muscle weakness, and cognitive communication deficit, had a care plan and physician order specifying that the PICC dressing on the left brachial vein be changed weekly, on the night shift every Thursday, and that the insertion site be kept clean and protected with a sterile dressing. Review of the February medication administration record (MAR) showed the weekly PICC dressing changes were documented as completed on each scheduled date, and the March MAR showed the same weekly schedule. A progress note dated the day of the survey indicated the PICC dressing had been changed that afternoon with no difficulty and that the line remained patent and intact. However, during observation earlier that same day, the resident was seen in bed with a PICC line to the left upper arm, and the dressing date was worn off and illegible, with the dressing lifting at the corners and not adhering properly. The resident was unsure when the dressing was last changed but reported receiving antibiotics through the PICC line. The Assistant Director of Nursing (ADON) confirmed that the PICC dressing should be changed once a week and that the date on the dressing should reflect the prior week, not have an older date. The following day, the ADON reported that when the dressing was changed the previous day, it appeared old and the date was difficult to read, possibly from mid-February or even January, and acknowledged that the date should have been more recent and that staff should not have charted the dressing change as completed when it had not been done. The Administrator and the Registered Nurse Consultant both stated they expected staff to follow physician orders and not document treatments as done if they were not actually performed.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.