F0686

G

Failure to Follow Knee Immobilizer Orders and Monitor Skin, Leading to Device-Related Pressure Ulcer

Siler City, North Carolina Survey Completed on 03-13-2026

Penalty

Fine: $19,920

Summary

The deficiency involves the facility’s failure to follow physician and hospital discharge orders for a knee immobilizer and to provide adequate skin assessment and monitoring, resulting in a facility-acquired pressure ulcer under the device. The resident was admitted after a left patella fracture with hospital discharge instructions specifying that the knee immobilizer should be worn when bearing weight and could be removed when not bearing weight for comfort. However, when the order was transcribed into the facility’s EMR by a house supervisor, it was entered as “left knee immobilizer in place at all times. May remove for bathing and skin checks every day and night shift,” which did not match the hospital discharge instructions. Neither of the two house supervisors who handled admissions could explain where the “at all times” language originated, and no documentation was produced to support that wording.

The resident was admitted with multiple diagnoses including left patella fracture, A-fib, CHF, hypothyroidism, Alzheimer’s disease, and later-documented moderate protein-calorie malnutrition. On admission, nursing documentation noted a dark spot on the coccyx, an open area on the spine, and redness to the left knee, but these findings were not reflected on the admission MDS, which indicated no pressure ulcers, no other skin problems, and no malnutrition or risk for malnutrition. The care plan identified risk for skin breakdown and nutritional risk but did not include specific interventions related to the knee immobilizer or to the coccyx and spinal skin issues noted on admission. Subsequent Braden and advanced skin checks at various dates documented normal skin findings and, on at least two occasions, incorrectly indicated that the resident did not have an external device, despite the presence of the immobilizer.

Throughout October and early November, the TAR carried the order for the immobilizer to be in place at all times, with removal allowed for bathing and skin checks, and nurses consistently initialed that the order was carried out. Multiple nurses and NAs reported that they either did not fully remove the immobilizer or could not recall doing so, and some stated they believed the order did not require full removal except for baths. One nurse later acknowledged seeing redness and indentations from the brace on the lower leg or back of the thigh on at least two days but did not document or report these findings, considering them not significant. Another staff member documented that the splint was removed and inspected and that no concerning changes were seen, while other staff described only partially opening the brace or being able to see the skin “fine” without fully removing it.

On a follow-up visit, the orthopedic NP recommended that the resident be weight bearing as tolerated with the immobilizer and to continue the immobilizer when sitting and lying, with PT allowed to remove it for range of motion up to 60 degrees of flexion. Later, an NA providing a bed bath observed yellow drainage on the bed sheet and, upon opening the immobilizer and lifting the leg, found an open, dark-colored wound on the back of the left lower leg at the point where the immobilizer ended, with indentations all over the leg from the brace. The nurse who assessed the wound documented it as a new, in-house acquired pressure ulcer and initially mis-located it on the front lateral lower leg due to confusion with directions. The wound was described by staff as open, with red and yellow tissue and “yellowy-red” drainage, and another nurse noted that the immobilizer remained in place and was pushing into the wound. The facility contacted the orthopedic NP days later to ask about removing the immobilizer; the NP gave a verbal order to remove it and requested to see the resident the same day, but the visit was delayed due to transportation issues, and interviews indicated the immobilizer was not actually removed until several days after the verbal order, during which time it potentially continued to exert pressure on the ulcer.