Failure to Identify and Monitor Accessed Implanted Port Leading to Sepsis
Summary
The deficiency involves the facility’s failure to identify, monitor, and provide care for an implanted venous access device (port) that remained accessed after a resident returned from multiple hospitalizations. The resident had a complex medical history including colorectal cancer, recurrent sepsis, chronic anemia requiring multiple blood transfusions, severe protein-calorie malnutrition, recurrent infections, and an implanted vascular access port placed in the left chest. Hospital records repeatedly documented the presence of this implanted port, including notes that it was accessed on several admissions. However, on each readmission to the facility (12/29/25, 01/09/26, 01/20/26, 02/20/26, and 03/12/26), there was no evidence in the facility’s admission assessments, baseline care plans, or progress notes that staff identified the presence of the implanted port. Following the resident’s hospitalization from 02/17/26 to 02/20/26 for anemia and nephrostomy tube concerns, the resident returned to the facility on 02/20/26 with the implanted venous access device still accessed with a Huber needle and covered by a dressing. Despite this, the facility’s admission assessment and baseline care plan dated 02/20/26 did not document the port or that it was accessed. Subsequent skin observations on 02/21/26 and 02/28/26, and daily skilled nursing assessments from 02/21/26 through 02/28/26 and again on 03/02/26, 03/03/26, and 03/04/26, contained no indication that staff recognized the accessed port, provided any site care, or monitored the site. Physician orders from 02/20/26 to 03/04/26 showed no orders for monitoring or care of the implanted device. The facility’s venous access policy required routine assessment and monitoring of venous access sites at least once per shift, but the DON confirmed there was no evidence in the record that the device had been identified or monitored in any way. On 03/04/26, when the resident arrived at an outside oncology infusion center for a chemotherapy appointment, an oncology RN observed that the implanted port was still accessed with a Huber needle and covered by a heavily soiled, partially intact dressing with a date that appeared to be 02/11/26, later clarified as likely 02/17/26. The oncology nurse described the resident as disheveled, unbathed, lethargic, uncomfortable, and unable to keep his head upright, and noted that the dressing edges were peeling and that there was significant concern for infection risk. The oncology nurse removed the dressing, obtained blood return from the port, and, after the resident reported feeling weak and dizzy, the oncology physician directed that the resident be sent to the ED. Hospital records from that day documented sepsis and shock, with blood cultures drawn from the implanted port growing gram-positive cocci and MRSE, and the resident was admitted to the ICU for treatment of sepsis. The DON, facility RNs, and the resident’s physician later acknowledged that the facility did not access ports, that most nurses were not trained in port use, and that the device had not been identified or monitored while the resident was in the facility, despite the port remaining accessed during that time.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with a PICC line for IV therapy did not have appropriate orders or interventions in place for routine line maintenance, including flushing before and after medication administration, dressing changes, or infection monitoring. As a result, the resident missed doses of IV antibiotics due to line occlusion, and there was no documentation of line replacement or discontinuation. Facility policy requirements for central line care were not followed.
A resident with multiple complex conditions and a PICC line for IV antibiotics did not receive required weekly dressing changes as ordered. Two LPNs signed off on the dressing changes in the MAR/TAR without actually performing them, resulting in the dressing not being changed since placement. The issue was discovered when the resident attended a follow-up appointment and the soiled, unchanged dressing was noted, leading to removal of the PICC line.
A resident with a PICC line for IV antibiotics did not have physician orders or documented care for monitoring, flushing, or dressing changes for 15 days after the line was placed, despite facility policy requiring these actions. The lapse was confirmed by the DON and identified during a complaint investigation.
Two residents with PICC lines did not receive timely dressing changes, and staff failed to follow sterile technique during dressing changes. Dressings were observed to be overdue and improperly maintained, with staff handling sterile supplies with non-sterile gloves and not establishing a clean field, contrary to facility policy and physician orders.
A resident with a central line did not have appropriate physician orders for dressing changes or site monitoring, and the dressing was not changed since admission. Observation revealed the dressing was rolled back, discolored, and the line was exposed. Staff confirmed the lack of orders and dressing changes, which did not meet facility policy requiring regular sterile dressing changes and documentation.
A resident with a PICC line for IV antibiotics did not have their dressing changed or documented as ordered for a two-week period. Observation revealed the dressing was loose and peeling, and an LPN admitted to signing off on the dressing change without actually performing it. Facility policy and physician orders required weekly dressing changes and documentation, which were not followed.
Failure to Maintain and Monitor PICC Line for IV Therapy
Penalty
Summary
The facility failed to implement appropriate interventions and orders for the maintenance of a peripherally inserted central catheter (PICC) line for a resident who required intravenous (IV) access for treatment of a wound infection. The resident had significant medical conditions, including diabetes with a foot ulcer, local skin infection, and MRSA. Medical orders included daily flushing of the PICC line, administration of thrombolytic agents for de-clotting, and IV antibiotics. However, there were no orders in place to monitor the PICC line for infection, change the dressing, or flush the line before and after medication administration, as required by facility policy. The care plan only included monitoring for infection and leaking, with no interventions for routine PICC line care. Review of the medication administration record showed that the prescribed thrombolytic agent was not administered, and progress notes documented missed antibiotic doses due to PICC line occlusion. There was also no documentation regarding when the PICC line was replaced or discontinued. The DON confirmed the absence of necessary orders for PICC maintenance and flushing after medication administration. Facility policies required regular flushing and dressing changes for central venous catheters, but these were not followed for the resident in question.
Failure to Complete PICC Line Dressing Changes as Ordered
Penalty
Summary
A deficiency occurred when the facility failed to ensure that care and services for a peripherally inserted central catheter (PICC) line site were completed as ordered for a resident with multiple complex diagnoses, including Evan's syndrome, systemic lupus erythematosus, hereditary hemolytic anemia, and drug-induced diabetes. The resident was admitted for treatment of a urinary tract infection and required intravenous antibiotics administered through a PICC line in the right upper extremity. Physician orders specified that the PICC line dressing was to be changed weekly on Sundays. Medical record review showed that the Medication Administration Record (MAR) and Treatment Administration Record (TAR) had been signed off by two LPNs for dressing changes on two occasions, but there was no evidence of any dressing changes after those dates, and the order was discontinued later. Progress notes and interviews revealed that the PICC line dressing had not been changed since placement, and the dressing was visibly soiled and dated from the time of insertion when the resident attended a follow-up appointment. The PICC line was removed at the appointment after this was discovered. Staff interviews confirmed that the LPNs had signed off on the dressing changes without actually performing them. One LPN reported not receiving the necessary dressing supplies, while the other believed all assigned dressings had been completed but could not recall specifics. The facility's policy required assessment of the insertion site at each dressing change and labeling of the dressing, but did not specify the frequency of changes. The deficiency was identified through review of records, staff interviews, and facility policy.
Failure to Ensure Physician Orders and Care for PICC Line
Penalty
Summary
The facility failed to ensure that physician orders were in place and care was provided for a resident with a peripherally inserted central catheter (PICC line) used for long-term intravenous access. Medical record review showed that after a hospital visit for a urinary tract infection, the resident was discharged with a new PICC line and an order for IV vancomycin. The care plan indicated the need for IV antibiotics and monitoring of the PICC line, including site evaluation, dressing changes, and tubing management. However, there were no physician orders for monitoring, flushing, or dressing changes for the PICC line from the time it was placed until 15 days later. Review of the Treatment Administration Record (TAR) confirmed that during this period, there was no documentation of PICC line flushing, monitoring, or dressing changes. The Director of Nursing verified that there were no orders for these essential care activities during the specified timeframe, despite facility policy requiring regular flushing, monitoring, and documentation for IV catheters. This lapse was identified during a complaint investigation and affected one resident with a PICC line.
Failure to Maintain Sterile Technique and Timely PICC Line Dressing Changes
Penalty
Summary
The facility failed to ensure the safe and appropriate administration and maintenance of peripherally inserted central catheters (PICC) for two residents. For one resident with multiple complex medical conditions, including diabetes, chronic kidney disease, and pressure ulcers, the PICC line dressing was observed to be peeling and dated well beyond the required weekly change interval. The responsible LPN confirmed the dressing was overdue for change and, during the observed dressing change, did not follow sterile technique as outlined in facility policy. Specific lapses included not establishing a clean field, handling sterile items with non-sterile gloves, and multiple instances of cross-contamination during the procedure. Another resident, also with significant medical issues such as open wounds, cirrhosis, and chronic kidney disease, was found with a PICC line dressing that was dislodged, peeling, and dated beyond the required change interval. The site was observed to have dried blood around the insertion area. The LPN confirmed the dressing was overdue for change and acknowledged the expectation for weekly dressing changes. Review of the facility's policy confirmed that PICC dressings are to be changed weekly or as needed, using a sterile technique to minimize infection risk. The policy details specific steps for maintaining sterility, including hand hygiene, use of masks, establishment of a clean field, and proper handling of sterile supplies. The observed failures to follow these procedures resulted in non-compliance with physician orders and facility policy for PICC line care and dressing changes.
Failure to Maintain and Monitor Central Line Dressing
Penalty
Summary
The facility failed to ensure proper care and management of a central line for a resident who was admitted with multiple diagnoses, including end stage renal disease and diabetes mellitus. The resident had a central line in place, and the plan of care included interventions such as changing the dressing as ordered and per facility policy, and monitoring for signs of infiltration and infection. However, there were no physician orders for monitoring the IV site or for dressing changes, including the type or frequency. Medical record review showed no evidence that the central line dressing had been changed since admission. During observation, the central line dressing was found to be rolled back, discolored, and the line was completely uncovered and exposed, with the date on the dressing illegible. Staff interviews confirmed that there were no orders for dressing changes or site monitoring, and that the dressing had not been changed since admission. Facility policy required sterile dressings to be maintained and changed every five to seven days or when compromised, with documentation of dressing changes and site assessments, but these standards were not met for this resident.
Failure to Change and Document PICC Line Dressing as Ordered
Penalty
Summary
Resident #43, who had diagnoses including acute kidney failure, hypertension, osteoarthritis, and muscle wasting with atrophy, was admitted with a peripherally inserted central catheter (PICC) line for intravenous (IV) therapy, including antibiotics. Physician orders and the resident's care plan required weekly PICC line dressing changes and monitoring for signs of infection or infiltration. Review of the Treatment Administration Record (TAR) showed that the dressing change was not documented as completed for a two-week period, specifically from 03/13/25 to 03/27/25, and there was no documentation that the dressing was changed as ordered on 03/20/25. On observation, the PICC line dressing was found to be loose and peeling, and the date on the dressing indicated it had not been changed as scheduled. An LPN confirmed that she had signed off in the TAR that the dressing was changed, but admitted she had not actually performed the dressing change. The Director of Nursing verified that PICC line dressings were to be changed weekly and that this resident was the only one receiving IV therapy. Facility policy also required dressings to be changed every seven days or sooner if loose, and for nurses to document the procedure and site condition.
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