B-COOL
Received Nov 16, 2012 · Event occurred Apr 26, 2012
Report 2842760 · MDR key 2842760
Device
Product problems
- Use of Device Problem
- Improper or Incorrect Procedure or Method
Patient
86 YR
- Pressure Sore/Ulcer
Narrative
Description of Event or Problem
THE TRAUMA PATIENT WAS ADMITTED FOLLOWING A FEMUR FRACTURE. THE PATIENT'S RIGHT LEG WAS SPLINTED WITH A KNEE IMMOBILIZER. THE KNEE IMMOBILIZER WAS ON AT ALL TIMES EXCEPT FOR SKIN CHECKS AND HYGIENE. THE CLINICIAN REMOVED THE MIDDLE METAL ROD FROM THE IMMOBILIZER TO HELP PREVENT PRESSURE ULCERS. SIX DAYS LATER, A NURSE NOTED A NEW BLISTERED AREA TO THE RIGHT POSTERIOR LOWER CALF UNDER THE IMMOBILIZER. TEGADERM WAS APPLIED AND ABD DRESSINGS PLACED ALONG THE METAL BAR OF IMMOBILIZER. THE NEXT DAY, THE WOUND OSTOMY CARE (WOC) NURSE CONSULTED AND STAGED THE PRESSURE ULCER AS A II AND ORDERED SPECIFIC CARES. IMMOBILIZER TO BE USED/APPLIED FOR TRANSFERS ONLY. THE PATIENT WAS DISCHARGED TO A TRANSITIONAL CARE FACILITY. THE RIGHT CALF WOUND WAS STILL PRESENT AT DISCHARGE AND WOC SENT ORDERS TO THE FACILITY RELATED TO PRESSURE ULCER MANAGEMENT.