HospitalInspections.org

Based on record review and interview, the facility staff failed to complete PICC (Peripherally Inserted Central Catheter) insertion site dressing changes weekly per policy for 3 of 5 Patients (Patient #1, 4, and 7) with PICC access in a total universe of 10 records reviewed.

Findings include:

A review of facility policy titled, "IV (intravenous) Access, Care and Maintenance, Blood Sampling" #7.851 last revised 07/2019 revealed, "Dressing changes with...Chlorhexidine impregnated patch (e.g. Bio Patch) and transparent dressing every 7 days or more frequently as needed."

A review of Patient #1's medical record revealed a History and Physical completed on 06/19/2021 at 3:02 PM by Physician H. An admission date of 06/18/2021 for "diagnosis of endocarditis" (inflammation of the heart valve). Documentation revealed "patient is here for long-term IV (intravenous) antibiotics and for rehab for physical deconditioning...Medications: Cefazolin Sodium/Dextrose 2 gram, infuse 2 gm over 30 minutes intraveneously every 8 hours, rate 100 mL/hour. Last dose on 07/21/2021."

A review of the "Treatment Administration" record for Patient #1 had no documentation of a dressing change being completed weekly from admission on 06/18/2021 through discharge on 07/01/2021. Dressing changes were not documented for 06/20/2021 or 06/27/2021.

A review of Patient #4's medical record revealed a History and Physical completed on 05/05/2021 at 4:38 PM by Physician I. An admission date of 05/04/2021 for "history of paraplegia (paralysis of the legs) since 1982 and has a chronic buttock wound since past several years...Per ID (Infectious Disease) recommended patient...complete a course of Zosyn (antibiotic) 4.5 g (grams) every 6 hours until 06/05/05/2021 for subacute osteomyelitis (infection of the bone) at right ischium (pelvis bone)...Medications: Piperacillin/Tazobactam (also known as Zosyn) 4.5 gm over 4 hours intraveneously every 6 hours, rate 25 mL/hour."

A review of the "Treatment Administration" record for Patient #4 had no documentation of a dressing change being completed weekly from admission on 05/04/2021 through discharge on 06/05/2021. Dressing changes were not documented for 05/09/2021, 05/16/2021, 05/23/2021, or 05/30/2021.

A review of Patient #7's medical record revealed a History and Physical completed on 08/11/2021 at 10:04 AM by Physician J. An admission date of 08/10/2021 for "diagnosis of endocarditis (inflammation of the heart valve)...admitted for IV antibiotics." Documentation revealed "Medications: Vancomycin 1 gram, infuse over 60 minutes intraveneously every 8 hours, rate 200 mL/hour."

A review of the "Treatment Administration" record for Patient #7 had documentation of a dressing change being completed weekly on 08/11/2021. There was no documentation of a dressing change being completed from 08/15/2021 through discharge on 08/24/2021. Dressing changes were not documented for 08/15/2021 or 08/22/2021.

These findings were discussed with and confirmed by interview on 03/22/2022 at 2:33 PM with Quality Coordinator B who stated the staff should be completing dressing changes one time a week on Sundays, and it looks like there is no documentation of that being done for some of the patients.