Eagle Rock Health: PICC Line Safety Failures - ID

Eagle Rock Health and Rehabilitation of Cascadia failed to properly manage a PICC line for Resident #21, who suffers from interstitial lung disease and heart failure. The specialized intravenous line allows long-term medication delivery directly into large blood vessels.

When inspectors arrived on March 30, they found the PICC line dressing on the resident's right arm undated and loose around the edges. The tubing hung unsecured.

The resident had been receiving Ertapenem, a powerful antibiotic, through the line to treat sepsis related to pneumonia. His doctor had ordered the medication to run until March 1 — nearly a month before the inspection.

LPN #2 told inspectors the next day she wasn't working when the PICC line was installed and "was not sure if it was still being used." She acknowledged the dressing should have been dated but wasn't.

RN #4 delivered more troubling news: she couldn't locate any current orders for the PICC line at all.

"The PICC line may have been discontinued but either way the PICC line should of been removed or had orders for it," she told inspectors.

PICC lines require careful maintenance and clear medical orders because they provide direct access to major blood vessels near the heart. Loose dressings can allow bacteria to enter the insertion site, potentially causing dangerous bloodstream infections in patients already fighting serious illness.

The facility's medication management also showed gaps. Nursing staff documented that Resident #3 refused bowel care medications on March 20 and 21, but only noted the refusals on a worksheet. They failed to document the refusals in the official medication administration record or in progress notes, as required.

The Regional Clinical Specialist confirmed during the April 2 inspection that staff "should have" properly documented the medication refusals in the resident's official medical record.

Resident #21's case illustrates the risks when medical devices lack proper oversight. His interstitial lung disease already makes breathing difficult by causing inflammation and scarring in lung tissue between air sacs. The condition prevents oxygen from reaching his bloodstream effectively.

Combined with heart failure, his compromised health status makes him particularly vulnerable to complications from improperly maintained medical equipment.

The inspection found the facility's nursing staff couldn't answer basic questions about active medical devices in their care. When the LPN stated uncertainty about whether the PICC line was "still being used," it revealed a fundamental breakdown in communication about critical patient care.

Federal regulations require nursing homes to ensure residents receive necessary care and services to maintain their highest level of physical well-being. Leaving medical devices in place without orders, or failing to remove discontinued equipment, violates these standards.

The undated, loose dressing on Resident #21's PICC line created multiple infection risks. Proper PICC line maintenance requires sterile dressing changes on schedule, with each dressing clearly marked with the date of application.

Unsecured tubing poses additional dangers, including accidental disconnection or pulling that could damage blood vessels or allow air to enter the line.

The facility's documentation failures extended beyond the PICC line incident. When staff don't record medication refusals in official records, it prevents doctors from making informed decisions about alternative treatments or addressing underlying reasons for refusal.

Resident #21 remains at the facility with his complex medical conditions, dependent on staff who demonstrated they couldn't manage basic aspects of his care. His case shows how administrative failures can directly threaten vulnerable residents who rely on nursing home staff for life-sustaining medical support.

The inspection occurred on April 2, finding violations that had persisted for days while a seriously ill resident received care through medical equipment that lacked proper authorization or maintenance.

Full Inspection Report

The details above represent a summary of key findings. View the complete inspection report for Eagle Rock Health and Rehabilitation of Cascadia from 2026-04-02 including all violations, facility responses, and corrective action plans.

Additional Resources

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