SANTA ANA, CA - Federal inspectors cited St Edna Subacute and Rehabilitation Center for serious failures in monitoring a resident's PICC line, resulting in the development of a deep vein thrombosis and subsequent hospitalization for pulmonary embolism.
Critical PICC Line Assessment Failures
The August 22, 2024 inspection revealed that nursing staff failed to follow their own protocols for PICC line care. According to the facility's policy, staff should assess the insertion site every shift, measure arm circumference regularly, monitor external catheter length, and flush unused lumens every 12 hours.
However, inspectors found no documentation of these critical safety measures in the resident's medical record. The resident had been admitted with a PICC line in his right upper arm, but staff failed to establish baseline measurements or conduct required assessments.
A registered nurse interviewed by inspectors confirmed the facility's protocol but acknowledged that none of the required documentation existed for this resident's PICC line care.
Resident Developed Life-Threatening Complications
The consequences of these failures became apparent when the resident developed concerning symptoms. On July 5, 2024, a family member reported that the resident's right arm was swollen and he was experiencing pain at the PICC site. An LVN obtained an order for a Doppler ultrasound but failed to conduct or document a change-of-condition assessment.
By July 7, the resident's condition had deteriorated significantly. An alert note documented that his arm had "tripled in size" with notable swelling and redness. The resident reported pain when his arm was moved and appeared tender to touch. His respiratory rate had increased to 30 breaths per minute.
The Doppler ultrasound revealed an occlusive right axillary deep vein thrombosis - a complete blockage of blood flow in a major vein. The resident was transferred to an acute care hospital and subsequently diagnosed with pulmonary embolism.
Medical Significance of PICC Line Monitoring
PICC lines (Peripherally Inserted Central Catheters) require careful monitoring because they pose significant risks when not properly maintained. Arm circumference measurements serve as an early warning system for developing blood clots, as swelling often indicates impaired circulation.
Regular flushing of unused lumens prevents blood from clotting inside the catheter, which can lead to both catheter dysfunction and clot formation. When these protocols are ignored, residents face increased risk of deep vein thrombosis, pulmonary embolism, and potentially fatal complications.
The facility's own policy recognized these risks, requiring documentation of arm circumference measurements 8-10 centimeters above the antecubital area and comparison to baseline measurements to detect possible catheter-associated venous thrombosis.
Staff Acknowledged Protocol Violations
During the inspection, the Director of Nursing confirmed that the facility had failed to implement its own PICC line care protocols. She verified that the resident's medical record contained no documentation of arm circumference measurements, external catheter length assessments, shift-by-shift insertion site evaluations, or unused lumen flushing.
The LVN who cared for the resident acknowledged that a change-of-condition assessment should have been conducted and documented when the family reported arm swelling and pain. This assessment could have identified the developing thrombosis earlier and potentially prevented the progression to pulmonary embolism.
Industry Standards and Prevention
Standard PICC line care requires systematic monitoring to prevent complications. Healthcare facilities must establish baseline measurements upon insertion and conduct regular comparisons to detect changes. Signs of complications include arm swelling, pain, redness, or changes in catheter position.
Early identification of these warning signs allows for prompt intervention, which may include anticoagulation therapy, catheter removal, or other treatments to prevent life-threatening complications like pulmonary embolism.
The resident's hospitalization with pulmonary embolism demonstrates the serious consequences when these monitoring protocols are abandoned. What should have been preventable through proper nursing assessment became a medical emergency requiring acute care intervention.
Federal regulations require nursing homes to provide safe administration of IV fluids and appropriate monitoring of central access devices. This case illustrates how failures in basic nursing protocols can lead to serious harm for vulnerable residents requiring complex medical care.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for St Edna Subacute and Rehabilitation Center from 2024-08-22 including all violations, facility responses, and corrective action plans.
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