The resident's PICC line eventually clogged and required removal.
Federal inspectors found The Citadel at Saint Anne Place failed to ensure sterile catheter dressing changes for the resident, who had the peripherally inserted central catheter placed in her left upper arm on September 16 to treat a knee infection.
During a November 21 inspection, the resident explained that staff were not changing her PICC line dressing weekly as required. When she informed them of the need for weekly changes, nursing staff told her they couldn't perform the procedure because they weren't registered nurses.
The facility's own policy, revised in 2016, requires central venous catheter dressings to be changed every 5-7 days to prevent infections. The policy states dressings "must stay clean, dry and intact" and specifies that transparent dressings should be changed "at least every 5-7 days and PRN when wet, soiled or not intact."
An RN at the facility confirmed to inspectors that PICC line dressings should be changed once a week and that only registered nurses can perform the procedure. The RN also said there should be an order specifying when to change the dressing.
The Director of Nursing acknowledged that residents with PICC lines should receive weekly dressing changes and that nursing staff should enter orders to ensure the changes occur. However, she confirmed the resident did not have orders entered for weekly PICC line dressing changes and that the dressings were not performed.
Medical records show the resident's physician order sheets from October 2025 contain no order to change her PICC line dressing. The resident's medication administration record indicates her PICC line and IV antibiotics were discontinued on October 21 following treatment of a wound infection.
The facility's central venous catheter policy requires specific documentation in residents' medical records, including the date and time dressings were changed, location and condition of the insertion site, and the signature and title of the person performing the procedure.
PICC lines provide direct access to major blood vessels for patients requiring long-term IV medications or those with difficult vascular access. The catheters can remain in place for weeks or months but require careful maintenance to prevent serious complications including bloodstream infections.
The inspection found this violation affected one of three residents with central lines among the 18 residents reviewed. Inspectors classified the harm level as minimal harm or potential for actual harm.
The resident's case illustrates how basic nursing protocols can break down when staff lack proper training or when facilities fail to establish clear procedures for specialized medical equipment. Her repeated attempts to advocate for her own care went unheeded until the device failed entirely.
The facility is required to submit a plan of correction detailing how it will prevent similar incidents and ensure proper care for residents requiring central venous access devices.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for The Citadel At Saint Anne Place from 2025-11-25 including all violations, facility responses, and corrective action plans.
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