Failure to Obtain and Follow PICC Line Orders for Two Residents
Summary
The deficiency involves the facility’s failure to ensure safe, appropriate administration and management of PICC lines and IV-related care for two residents in accordance with physician orders and the facility’s own central venous catheter policy. For one resident (R7), who was admitted with a PICC line placed in the left basilic vein for chemotherapy/infusions, the facility did not obtain any physician orders for PICC care or monitoring at the time of admission and did not develop a PICC-related care plan until eight days later. The admission clinical assessment section specific to PICC line care (including PICC care profile, length, solution, location, patency, and site) was left incomplete, and multiple skin assessments and the admission nurse’s note failed to document the presence or condition of the PICC line, despite hospital records clearly indicating its placement and measurements. During interviews, nursing staff could not explain why PICC orders were missing for several days after admission, and the DON later acknowledged that there were no hospital orders for the PICC line and that the PICC should have been identified and documented during the skin assessment. For the second resident (R1), who had complex orthopedic and infectious diagnoses including left total hip and knee arthroplasty with antibiotic spacers and a history of polymicrobial and fungal infection, the facility did not consistently follow existing physician orders for PICC line care and monitoring. R1 had multiple detailed orders, including weekly PICC dressing and injection cap changes, flushing PICC lumens every shift with normal saline, monitoring the PICC site every shift for signs and symptoms of infection, measuring external catheter length weekly, and measuring left arm circumference above the insertion site every shift with notification of the MD for changes. Review of the January and February treatment administration records (TARs) showed multiple dates and shifts where these ordered treatments and assessments were left blank, indicating they were not documented as completed. On several specific dates, required dressing changes, cap changes, external length measurements, arm circumference measurements, site monitoring, and line flushes were not initialed on the TAR. The facility’s own policy on central venous catheter care requires site care and dressing changes at established intervals or when compromised, daily assessment of the entire infusion system and insertion site, evaluation for signs of complications, and measurement of external catheter length and arm circumference for PICCs when indicated. Despite this, for R7, there were no initial orders or care plan elements to operationalize these requirements, and the PICC line was omitted from admission and subsequent skin assessments. For R1, although appropriate orders were in place, the nursing staff did not consistently document completion of the ordered PICC-related treatments and monitoring on multiple dates, and there were no progress notes explaining why the physician orders were not followed. When questioned, a unit manager stated that the expectation is that completed treatments are signed out on the TAR or documented in a note, underscoring that the missing initials represented a failure to carry out or document the ordered PICC care. Interviews with staff further clarified the gaps in practice. R7 reported that staff flushed her PICC line daily and showed the surveyor a dressing dated several days after admission, but this care was not supported by timely physician orders or a care plan at the time of admission. LPNs caring for R7 were unable to explain the delay in obtaining PICC orders. The unit manager indicated that the admitting nurse is responsible for completing orders and that unit managers typically ensure orders are complete, yet the omission of PICC orders persisted for eight days. For R1, review of progress notes on dates where PICC orders were not initialed revealed no documentation explaining missed or omitted treatments. A unit manager confirmed that the expectation is that nurses sign out treatments on the TAR, highlighting that the blank entries represented noncompliance with physician orders for PICC care and monitoring.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
IV access and medication labeling deficiencies: A resident with a PICC line had no documented admission measurement of external catheter length or arm circumference, another resident’s IV tubing was observed without the required date, time, and RN initials, and a third resident’s meropenem IV bag was not labeled with the date, time, and initials. Facility policy required labeling of IV solutions and documentation of PICC measurements.
Failure to Document Baseline Midline IV Measurements: A resident receiving IV antibiotics via a midline IV had no documented baseline external catheter length or arm circumference measurements when admitted from the acute hospital. The resident’s care plan did not address the midline IV, and the IV MAR lacked baseline documentation. RN confirmed staff performed dressing changes and measurements, but could not verify any baseline values from the acute care hospital; the DON verified the findings.
A resident with a PICC line, diabetes, obesity, atrial fibrillation, and CHF had no documented PICC-related care plan interventions, and the PICC dressing was found stained, loosening, and dated well beyond the weekly change schedule. Although the MAR showed the dressing change as completed, staff interviews confirmed it was overdue and should have been changed sooner, with the DON acknowledging it was late and that loose or soiled dressings require more frequent attention.
A resident received IV Cefepime multiple times through a long-term IV catheter, but the MAR lacked documentation that the catheter was flushed before and after administration as required by facility policy. The DON confirmed the nurse should have flushed the IV catheter pre- and post-medication administration.
A resident receiving IV antibiotics through a PICC had no documented baseline or weekly catheter length and arm circumference measurements, despite an order for the RN to record them after each Sunday dressing change. RNs stated the measurements were needed to confirm the catheter remained in position, but the IV MAR showed only dressing changes and no measurements. The DON confirmed the record lacked both admission and weekly measurements, and the complaint noted the catheter had moved, leading to a hospital return, PICC removal, and replacement catheter placement.
PICC Line Removal Not Timely or Fully Documented: A resident with severe cognitive impairment, dependence for all ADLs, and IV antibiotic therapy had a PICC line that was not removed when the antibiotic ended, and nursing documentation showed conflicting removal entries. The chart lacked a physician order for removal, lacked confirmation that the full line including the tip was removed, and lacked documentation of post-removal site inspection or monitoring for complications.
IV access and medication labeling deficiencies
Penalty
Summary
The facility failed to provide the necessary care and services to maintain intravenous access for Resident 23, who had a right upper arm single lumen PICC line and a BIMS score of 12 on admission. The resident’s medical record showed a physician’s order to measure the external catheter length of the PICC and midlines upon admission and with each dressing change, and to include arm circumference for the midline device every seven days and as needed. However, the Nursing Admission/readmission Evaluation/assessment did not document the measurement and assessment of the PICC line, and the record did not show evidence that the length of the catheter above the insertion site or arm circumference were obtained upon admission. The facility also failed to ensure Resident 123’s IV tubing was labeled. During an initial tour, Resident 123 was observed with a peripheral IV in the left hand and a one-liter bag of 0.9% Sodium Chloride infusing at 75 mL per hour. The IV tubing was not labeled with the date, time, and nurse’s initials. The resident’s order summary showed an order to change IV tubing every 24 hours for intermittent IV infusion and TPN and every 72 hours for continuous IV infusion. In addition, the facility failed to ensure Resident 9’s IV medication was correctly labeled. During medication administration observation, Resident 9 was observed with a right upper arm three lumen PICC line and meropenem 1 gram was prepared and administered through the PICC line. The IV tubing was labeled by the RN, but the meropenem medication bag was not labeled with the date, time, and initials of the RN who administered the medication. Facility policy stated that the nurse hanging IV solutions will label the bag with the date, time, and initials.
Failure to Document Baseline Midline IV Measurements
Penalty
Summary
The facility failed to provide the necessary care and services to maintain the intravenous access for Resident 68, who had a midline IV in the left upper arm with two lumens and a transparent dressing. The resident had physician orders for antimicrobial disc use, routine flushing of the midline lumen, monitoring for inflammation or infiltration every shift, measuring arm circumference 5 cm above the insertion site during dressing changes, changing the midline dressing and Stat-lock weekly, and measuring the external catheter length during dressing changes with notification to the MD if the length increased by 2 cm or more. Medical record review showed no baseline documentation of the external catheter length or arm circumference above the insertion site when the resident arrived from the acute hospital where the midline was inserted. The resident’s care plan did not address the midline IV, and the IV Administration Record for April and May 2026 did not show baseline arm circumference or catheter length measurements documented on admission. During interview and record review, RN 1 confirmed the resident was receiving IV antibiotics through the midline and stated nursing staff were responsible for dressing changes and measurements, but could not verify any baseline measurements from the acute care hospital. The DON later reviewed and verified these findings.
PICC Dressing Not Changed as Ordered
Penalty
Summary
The facility failed to ensure parenteral fluids and central venous catheter care were provided in accordance with professional standards of practice and physician orders for one resident with a PICC line. The resident was admitted with diagnoses including cellulitis of the left lower limb, type 2 diabetes mellitus, morbid obesity, unspecified atrial fibrillation, and acute-on-chronic systolic heart failure, and had a BIMS score of 15 indicating intact cognition. The baseline care plan contained no documented interventions, monitoring, or care planning related to the PICC line or IV antibiotic therapy. The order summary included an order to monitor the PICC site every shift for signs and symptoms of infection and an order to change the PICC dressing weekly and every Monday. Although the MAR documented the PICC dressing change as completed on 05/18/26, an observation and interview on 05/19/26 found the PICC dressing visibly stained, loosening around the edges, and dated 05/08/26. The resident stated the dressing had not been changed since admission. Staff interviews confirmed the dressing should have been changed the prior day, that a loose or rough dressing could be changed more frequently under PRN orders, and that the RN charge nurse was going to change it that day. The DON stated PICC lines are to be changed every 7 days and acknowledged the dressing should have been changed the day before.
Failure to Flush IV Catheter During Antibiotic Administration
Penalty
Summary
Professional standards of practice were not followed for the care of a resident's long-term IV catheter. Resident 8 had physician orders for IV Cefepime HCl, including 2 grams every 12 hours for seven days and a one-time 2 gram dose, and the facility's IV catheter policy required flushing the catheter with 5 ml of normal saline before and after infusion. Review of the MARs for April and May 2026 showed that staff administered IV Cefepime 14 times, but there was no documented evidence that the IV catheter was flushed before or after medication administration. The DON confirmed in interview that the nurse should have flushed the IV catheter pre- and post-medication administration.
PICC Line Measurements Not Documented
Penalty
Summary
The facility failed to ensure a PICC line was measured weekly for a resident receiving IV antibiotics for a bone infection. Resident 1 was admitted with diagnoses including an infection in the bone and had a physician order for the RN to change the PICC dressing and securement device every Sunday and to measure the catheter length and arm circumference in centimeters after each dressing change. RN interviews stated that the measurements were important to confirm the catheter remained in the correct position and to monitor for infection, and that the Sunday dressing change process included use of a measuring tape. Record review of the IV MAR for April and May 2026 showed dressing changes were documented on 4/19/26, 4/26/26, and 5/3/26, but no catheter length or arm circumference measurements were recorded. The DON stated the admission measurements should have been obtained from the hospital or measured on arrival to establish a baseline, and that the absence of both admission and weekly measurements meant the facility could not compare values to confirm the catheter remained in place. The complaint also stated the catheter had moved out of its original position, and Resident 1 returned to the hospital with chest pain, had the PICC removed, and received another catheter to complete medication administration.
PICC Line Removal Not Timely or Fully Documented
Penalty
Summary
The facility failed to provide services consistent with the standards of care related to Resident 4’s PICC line when the physician’s order for in-facility removal after completion of IV antibiotic therapy was not followed for three days. Resident 4 had diagnoses including anxiety, diabetes mellitus, aphasia following cerebral infarction, and pressure ulcers to both heels, and the MDS documented severely impaired cognition with a BIMS score of zero, dependence on staff for all ADLs, impairment of both upper and lower extremities, and receipt of IV medications during the observation period. The care plan did not address the PICC line or associated care. The record showed orders for PICC dressing changes, cap changes, and daily saline flushes, and documentation stated to continue Daptomycin/Cerftiax through 05/08/26 and then remove the PICC line. Nursing notes documented the PICC line was removed on 05/12/26 and again on 05/13/26, but the chart lacked a physician order to remove the line and lacked documentation confirming the full removal of the line, including the tip. The record also lacked documentation of inspection of the PICC line after removal to ensure it was fully removed without complications. Administrative nurses stated the order had been sent to department heads, nursing had not done anything with it, and the facility should document the removal and any monitoring or complications.
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