Failure to Prevent Pressure Injury Under Orthopedic Device
Penalty
Summary
A deficiency was identified when a resident developed a pressure injury on the right lateral knee, attributed to the use of a knee brace. The resident had an order to wear a right hinge-knee brace locked in extension at all times, with no range of motion allowed. Although there was an initial order to assess the skin under the brace and report abnormalities, this order was discontinued after a few days, and no further documentation of skin assessments was found in the progress notes or treatment administration record for over a month. The care plan included an intervention to check the right knee skin under the immobilizer every shift and notify the medical provider of any abnormalities, but there was no evidence that this intervention was consistently implemented during the period in question. Staff interviews revealed that the standard practice was to assess the skin before and after placement of orthopedic devices, ideally every two to four hours, regardless of whether there was a specific order. However, in this case, the lack of documented skin checks and the absence of ongoing assessment orders contributed to the development of an avoidable pressure injury. The wound was first identified during a skin and wound evaluation, at which point recommendations were made to check the skin daily, consult orthopedics, and consider alternative bracing or additional padding.