Mount Evans Home Health Care & Hospice

“In accordance with current clinical practice CFR(s): 484.105(f)(2) All HHA services must be provided in accordance with current clinical practice guidelines and accepted professional standards of practice. This Element is not met as evidenced by: Based on observations and interviews, the agency failed to ensure that staff provided care in accordance with current clinical practice guidelines and accepted professional standards of practice in 2 of 2 patients, who received peripherally inserted central catheter (PICC) line treatment, reviewed (Patients #1 and #2). Findings include: 1. The clinical record for Patient #1 was reviewed on 10/8/24. Review of the plan of care for the certification period of 8/30/24 to 10/28/24 revealed a start of care date of 8/30/024. Relevant diagnosis include encounter for adjustment and management of vascular access device, infection and inflammatory reaction due to other cardiac and vascular devices ‘implants and grafts’ initial encounter, other Escherichia coli (E. coli) as the cause of diseases classified elsewhere, and long term use of antibiotics. Plan of care (POC) orders included skilled nursing (SN) one time a week for nine weeks with three visits as needed (PRN) for PICC line management, change PICC line dressing weekly, and discontinue PICC line after last dose of antibiotics. a) The agency failed to provide proper PICC line management in accordance with accepted professional standard for Patient #1. During a home health visit on 10/8/24 around 7:30 a.m. registered nurse (RN) #9 was observed to perform a PICC line removal from the right arm of Patient #1. RN #9 was observed washing hands, gathering a sterile PICC line dressing kit, and setting Patient #1 in a comfortable position. RN #9 was observed to wash her hands, open up the sterile kit, put on sterile gloves, set up the sterile field, and remove the PICC line dressing. Following that, RN #9 washed her hands, applied new sterile gloves, cleansed around the PICC line insertion site with antiseptic solution. RN #9 pulled the PICC line out of the Patient #1’s right arm, set the line aside, and applied pressure to the site for approximately 3 minutes. RN #3 applied a sterile dressing and gave Patient #1 instructions on caring for the site over the next 24 hours. RN #9 did not measure the length of the PICC line before pulling it out of Patient #1’s arm. RN #3 did not inspect the tip of the PICC line after it was removed. Patient #1 threw the soiled dressings and PICC line in the garbage at the end of the visit. During an interview on 10/8/24 at approximately 7:45 a.m. at the home visit of Patient #1, RN #9 was unable to verify if she had previously documented a measurement of the length of Patient #1’s PICC line during previous home visits for PICC line dressing changes. Review of RN #9’s skilled visit notes between 8/30/24 and 10/8/24 showed no measurements of the PICC line during dressing changes. There was no documentation on the visit notes dated 9/3/24, 9/10/24, 9/16/24, 9/24/24, and 10/2/24, regarding a measurement between the PICC line skin puncture point and the crease point (where the PICC line bends toward the port) to see if the PICC line had moved. During an interview on 10/10/24 at 11:08 a.m., the director of nursing (DON) explained the agency’s PICC line procedure. The procedure was to measure the PICC line with each dressing change, document the length of the PICC line, hold pressure for 5 to 10 minutes following PICC line removal, and to inspect the tip of the PICC line after it was removed. The DON admitted this was the standard of care for PICC line management. 2. The clinical record for Patient #2 was reviewed on 10/8/24. Review of the plan of care for the certification period of 10/4/24 to 12/2/24 with a start of care date of 10/4/24. Relevant diagnosis include sepsis, unspecified organism and urinary tract infection. Plan of care orders include skilled nursing (SN) one time a week for six weeks with three visits as needed for PICC line management, soiled dressing, and flush PICC. a) The agency failed to provide proper PICC line management in accordance with accepted professional standard for Patient #2. During a home health visit with Patient #2 on 10/8/24 at approximately 10:20 a.m., the SA surveyors observed RN #2 provide a PICC line dressing change treatment. RN #3 performed hand hygiene, gathered supplies, and ensured Patient #2 was comfortable, lying in bed in the supine position with left arm extended. RN #3 set up the PICC line dressing kit, applied sterile gloves and a surgical mask, removed the soiled dressing, cleansed the PICC line port with alcohol swab for 30 seconds, and drew 2 vials of blood to send for testing per standing doctor’s orders. Following, RN #3 cleansed the port with another alcohol swab and capped the port with a sterile cap. RN #3 performed hand hygiene, cleansed the PICC line insertion site, and applied a sterile dressing. RN #3 did not use the measuring tool which was included in the PICC line dressing kit to measure the PICC line skin puncture point and the crease point to verify the line did not shift during the procedures. During an interview with RN #2 on 10/8/24 around 10:30 a.m., RN #3 was asked about measuring the length of the PICC line. RN #3 responded that she “eyeballed it and it was 1 centimeter.” RN #3 added Patient #2’s PICC line was inserted too far to show the measuring lines outside of the insertion site. RN #2 followed up with a statement about her personal nursing experience and “knowing exactly how long a PICC line is without needing to measure it.” During an interview on 10/8/24 at approximately 4:15 p.m., the DON stated RN #3 should not have eyeballed the measurement of the PICC line but should have gotten an actual measurement and documented it. During an interview on 10/10/24 at 11:08 a.m., the director of nursing (DON) explained the agency’s PICC line procedure. The procedure was to measure the PICC line with each dressing change, document the length of the PICC line, hold pressure for 5 to 10 minutes following PICC line removal, and to inspect the tip of the PICC line after it was removed. The DON admitted this was the standard of care for PICC line management.”