Failure to Monitor and Prevent Pressure Ulcer from Medical Device
Penalty
Summary
A resident with multiple medical conditions, including a recent femur fracture, peripheral vascular disease, and muscle weakness, was admitted and required the use of a knee brace. Physician orders and the care plan indicated the need for skin assessments, monitoring for redness or open areas, and interventions to prevent skin breakdown, especially given the resident's risk factors. Despite these orders, there was no documented evidence that the facility staff consistently removed the brace and checked the skin under and around the device on a daily basis. The resident developed a skin tear on the right calf, which was initially treated with Steristrips and kerlix. Over the following days, the area worsened, becoming open and bleeding, and was later found to be a deep tissue injury that progressed to a stage four pressure ulcer. The wound was attributed to pressure from the knee brace, specifically where the dial of the brace contacted the skin. The wound ultimately required two surgical debridements and ongoing wound care. Interviews with the DON and ADON confirmed that the wound was caused by the brace and that additional padding could have been used to prevent pressure, but this was not done. Review of the facility's documentation and staff interviews revealed a lack of consistent monitoring and documentation regarding removal of the brace and assessment of the skin beneath it. The facility failed to follow best practices for prevention of medical device-related pressure injuries, such as daily inspection of the skin under devices and appropriate cushioning. This failure resulted in actual harm to the resident, who developed a severe pressure injury requiring extensive medical intervention.
Plan Of Correction
F 0686 Lost Creek Nursing and Rehabilitation Center wishes to have this plan of correction submitted as our written allegation of compliance. Preparation and/or execution of this plan of correction does not constitute an admission to nor agreement with, either the existence of, or the scope and severity of, any of the cited deficiencies or conclusions set forth in the statements of deficiencies. This plan is prepared and/or executed to ensure continuing compliance with regulatory requirements. Our alleged date of compliance is 6/27/25. F 0686 Treatment/Services to Prevent/Heal Pressure Ulcer: Resident #9 skin check was completed on 6/23/25 by the Director of Nursing, and no new skin areas of concern were noted. The wound is now improving, currently classified as stage IV, with wound doctor visits weekly. An initial audit was conducted on all residents with braces/splints on 6/23/25 by the Director of Nursing and Assistant Director of Nursing, and no skin issues or areas of concern were noted. An audit was conducted to ensure daily skin checks were listed as a treatment on the TAR by the Director of Nursing on 6/23/25. All clinical staff were educated on the importance of removing any and all braces and/or splints with daily skin checks and performing complete skin checks with hygiene and bathing on 6/23/25 by the Director of Nursing. Education also included daily documentation of braces and/or splints removal and skin checks daily in a progress note and/or TAR. The Director of Nursing will conduct an audit 3 times per week for 4 weeks to observe all residents with splints and/or braces to ensure daily skin checks are being completed. The Director of Nursing will observe brace removal and review nursing documentation (progress notes and/or the TAR) to ensure it is being completed daily. Any unusual findings will be forwarded to the QAPI committee for prompt resolution. The Director of Nursing will monitor this area for compliance on an ongoing basis.