Failure to Follow PICC Line Dressing Change Orders
Penalty
Summary
The deficiency involves the facility’s failure to follow a Nurse Practitioner’s order for PICC line dressing changes for a resident receiving IV antibiotic therapy. The resident was cognitively intact, had a PICC line for a 38‑day course of IV antibiotics, and had an order dated 03/20/26 for the PICC dressing to be changed every seven days on Fridays. The care plan and MDS reflected the presence of the PICC and the need for dressing changes per order. The MAR included an order to change the PICC dressing every Friday on dayshift starting 03/27/26, but the entry for 03/27/26 was left blank and not signed, and there was no progress note explaining why the dressing change was not completed. On 03/29/26, observation of the resident’s PICC site showed an intact dressing with curled corners, no redness or drainage, and a date of 03/18/26, indicating the dressing had not been changed as ordered on 03/27/26. The nurse assigned to the resident on 03/27/26 acknowledged he was supposed to change the PICC dressing per the order but did not complete the task. The ADON later confirmed that when she changed the dressing on 03/30/26, the old dressing was still dated 03/18/26 and stated she expected it to have been changed on 03/27/26. The DON stated that IV access dressings must be changed at least every seven days, with daily flushes and daily monitoring for signs of infection, and that the assigned nurse should have recognized the dressing was overdue. The Nurse Practitioner also stated she expected dressing changes every seven days and that exceeding this timeframe increases the risk of infection.
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