Failure to Prevent and Manage Pressure Ulcers Associated with Medical Device
Penalty
Summary
The facility failed to develop and implement care and services consistent with professional standards of practice to prevent the development of pressure ulcers in a resident with a right ankle fracture who was immobilized with a T scope brace. The resident, who had multiple diagnoses including respiratory failure, traumatic brain injury, and decreased mobility requiring assistance of two staff for bed mobility, was ordered to wear the brace at all times except for hygiene. Despite this, there was no documentation of skin checks to the right leg for 16 days after the brace was applied, and weekly skin assessments were inconsistently documented, with several missed opportunities noted in the Treatment Administrative Record. As a result of these lapses, the resident developed a Stage I pressure ulcer on the right inner and outer knee, and a Stage III pressure ulcer on the right lateral ankle, both associated with the use of the medical device. The care plan was not updated to reflect the resident's increased risk for pressure ulcers or the need for individualized interventions and skin assessments. Staff interviews confirmed that required interventions to prevent pressure ulcers were not implemented, leading to actual harm for the resident.