Failure to Implement Pressure Ulcer Prevention for Resident with Knee Immobilizer
Penalty
Summary
A deficiency occurred when the facility failed to implement appropriate interventions to promote skin integrity for a resident who was ordered to wear a knee immobilizer at all times. The resident, who had multiple complex medical conditions including a recent left below-knee amputation, hemiplegia, dementia, and was at risk for skin breakdown as indicated by a Braden Scale score of 17, required assistance with bed mobility and turning. Despite physician orders and care plans specifying frequent turning and repositioning to prevent skin breakdown, there was no documentation that the resident refused to be turned, and observations repeatedly found the resident lying on the same side in bed. Physical therapy staff identified skin breakdown under the knee immobilizer and alerted nursing staff, but no immediate assessment or treatment was implemented on the day the wound was discovered. The wound, later assessed as a deep tissue injury (DTI) to the front left thigh, was not measured or treated until the following day, in accordance with the facility's routine wound measurement schedule. Additional documentation revealed the development of an unstageable wound in the left popliteal fossa. Throughout the period in question, there was minimal documentation of the resident refusing repositioning, and staff interviews confirmed the resident did not refuse care and required assistance to be turned. Facility policy required a turning schedule and offloading care for residents at risk of pressure ulcers, but the plan of care and physician orders were not consistently followed. The lack of timely intervention and documentation regarding turning, repositioning, and wound assessment contributed to the development of facility-acquired pressure injuries for this resident.