Failure to Maintain Safe PICC Line Care and IV Antibiotic Management
Penalty
Summary
The deficiency involves the facility’s failure to provide safe, person-centered PICC line care and IV antibiotic administration for a resident receiving long-term IV therapy. The resident was admitted with a left leg fracture and active MSSA infection and had a PICC line inserted in the hospital for long-term IV antibiotics. The comprehensive care plan identified the presence of a PICC line for antibiotic therapy but did not include measurable goals, specific interventions, or monitoring related to PICC line care and IV antibiotic administration. Physician orders directed weekly PICC dressing changes on Tuesdays and as needed, and ordered IV vancomycin 1000 mg twice daily through a specified end date. Clinical documentation showed that on one occasion the PICC line was not patent, would not allow infusion of vancomycin, and had been pulled out 5 cm from the insertion site, resulting in the resident being sent to the emergency room, where the PICC was replaced. After replacement, there was no documented evidence that staff monitored arm circumference or measured and documented the external catheter length, despite the known prior complications with the PICC line. This lack of monitoring occurred even though the hospital documentation specified the new catheter length and external measurement at the skin. During an observation, the resident’s PICC dressing was found peeling at the bottom, with yellow drainage throughout most of the surface, and was dated from a prior month, indicating it had not been changed in accordance with the facility’s seven-day dressing change policy or the physician’s weekly order. The resident reported it had been a long time since the dressing was changed, and the RN Unit Manager confirmed the dressing should have been changed. At the same time, an empty antibiotic bag was observed on the IV pole connected to unlabeled IV tubing that lacked a sterile end cap and was hanging freely. No emergency PICC kit or supplies were present in the room, and there were no physician orders or documentation requiring or monitoring an emergency kit at the bedside. The Treatment Administration Record showed a dressing change documented as completed the day before, which was inconsistent with the observed condition and date on the dressing. The DON confirmed the failures related to PICC dressing maintenance, tubing management, catheter monitoring, absence of emergency supplies, and inaccurate documentation.
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