Failure to Monitor and Assess Skin Integrity Under Medical Device Resulting in Pressure Wound and Infection
Penalty
Summary
A deficiency occurred when a resident with multiple comorbidities, including a right lower leg fracture, chronic kidney disease, diabetes, and immunodeficiency, developed an unstageable pressure wound on the right foot that was not present upon admission. The resident had been fitted with a fracture boot and ace wrap following an orthopedic visit, but there was no documentation of orders for monitoring the boot or the skin under it from the time it was applied. Nursing staff did not remove the boot or ace wrap for approximately two weeks, and there was no evidence that the facility contacted the orthopedic office for guidance regarding care of the device or the resident’s skin integrity during this period. Weekly skin assessments were not consistently completed or documented, with gaps noted between assessments and missing records for several weeks. The facility’s policy required weekly skin evaluations for residents at risk for pressure injuries, but these were not performed as required. The lack of skin assessments and monitoring allowed the development and progression of a pressure wound on the dorsum of the resident’s right foot, which was first identified during a follow-up orthopedic appointment. At that time, significant skin breakdown, desquamation, and full-thickness dermis loss were observed, and the resident was subsequently ordered to receive daily wound care and antibiotics. Despite new orders for wound care, the resident later reported that dressing changes were not performed as frequently as prescribed, with the last change occurring two days prior to a follow-up visit. Upon examination, the wound had progressed to a necrotic, unstageable ulcer with malodorous, bloody, and purulent drainage, and there was concern for wet gangrene. The lack of timely and appropriate monitoring, assessment, and intervention contributed to the worsening of the pressure wound and the development of infection.