Failure to Monitor and Manage Knee Immobilizer Resulting in Skin Breakdown
Penalty
Summary
The deficiency involves the facility’s failure to provide care consistent with professional standards to prevent pressure ulcers and skin breakdown related to a right knee immobilizer for one resident. The resident was admitted with a fragile right knee that had been reset by an orthopedic surgeon and stabilized with a knee immobilizer, and she was non–weight bearing with the brace intended to prevent dislocation. At admission and throughout the review period, there were no physician orders specifying care instructions for the knee immobilizer, including how and when to remove it, how to monitor its fit, or how to assess the skin under and around it. The only order present was a late entry directing that the right knee immobilizer be applied to restrict movement, and there were no new orders when skin breakdown was later identified. The resident’s care plan contained no focus, goals, or interventions related to the knee immobilizer, and weekly skin assessments repeatedly documented that the resident did not have a brace, despite her wearing a right knee immobilizer and having an existing right heel pressure ulcer. These assessments did not include evaluation of the skin under the immobilizer. Nursing documentation noted the presence of the immobilizer at admission but did not reflect ongoing monitoring or care of the device. The medication administration records for the relevant month showed no evidence of monitoring of the immobilizer and no wound care for the newly identified thigh wounds until several days after they were first documented. The resident reported that staff did not remove the brace to check her skin, did not wash the brace, and instead wrapped it in plastic during bathing, and she believed staff did not know how to care for it. She became concerned when the brace developed a foul smell, and her representative eventually replaced the original brace with one from home. The treatment nurse stated he recognized the brace from the start but did not remove it because the resident would not allow it; he only gently peeled back the edges weeks later, at which time he observed two new areas of skin breakdown on the right thigh attributed to rubbing from the brace. A nurse practitioner later assessed stable skin breakdown and a potentially resolved deep tissue injury under the thigh and expressed concern that the brace was ill-fitting and possibly too tight. Medical providers interviewed stated they expected periodic removal of the immobilizer for hygiene and skin assessment and that the facility had not contacted them for clarification or care instructions, and the DON acknowledged there were no orders or care plan interventions for the immobilizer and could not provide a policy for orthotic device care.
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