Failure to Monitor Skin Under Immobilizer Resulting in Pressure Ulcers
Penalty
Summary
A resident with a right femur fracture was admitted and later readmitted to the facility, initially with a cast and subsequently with a leg immobilizer following an orthopedic appointment. The immobilizer was ordered to be worn at all times to stabilize the fracture, and the resident was non-weight bearing. The resident was severely cognitively impaired and required extensive assistance with mobility and transfers. Despite these conditions, there were no physician orders or documentation for routine skin assessments under the immobilizer during the initial period after its application. Nursing staff did not perform or document skin checks under the immobilizer, as they believed the device should not be removed based on the orthopedic provider's instructions. This misunderstanding led to the immobilizer remaining in place without regular inspection of the underlying skin. The lack of skin assessments continued until the resident began complaining of pain, at which point the immobilizer was removed and pressure ulcers were discovered on the resident's right thigh and ankle. The ulcers were subsequently assessed as stage 3 and unstageable, respectively. Interviews with nursing staff, nurse practitioners, and the DON confirmed that the omission of skin checks was due to a failure to clarify or implement appropriate orders for skin monitoring under the immobilizer. The responsible party and multiple clinical staff acknowledged that the immobilizer was not opened or the skin checked until the pressure injuries were identified. The deficiency was attributed to the absence of orders and the staff's misinterpretation of the immobilizer instructions, resulting in the development of significant pressure ulcers.