To: Risk Management From: Valerie Elie, sDPT Date: March 15th, 2011 Subject: Investigation on Occurrence Involving MR Patient

Profile Patient is a 75 year old female who is s/p CVA with left hemi paresis. MR s treatment sessions include therapeutic exercise, bed mobility and transfer training, gait training, pain management, patient education and fall prevention following the initial assessment on April 20th, 2010. This patient has a PMH of HTN, DM, PVD Hypercholesterolemia, and ESRD. MR is currently on Hemodialysis. MR s frequency for restorative physical therapy consists of five days a week, 50 minutes per session. MR is tested for sensation on the right knee and receives moist heat on the knee as needed. Account of issue On April 24th 2010, at about 4:15 pm, MN, the charge nurse on staff, observed a blister on the dorsal aspect of the right knee of MR. The patient reported she received the blister after moist heat was placed earlier in the day during her physical therapy session. Chart Reviews Upon reviewing MR s chart, medical records indicate that physical therapy services given to MR on 4/24/10 did not include moist heat. The review also indicates that MR s short term memory is impaired. Interviews An interview was conducted by the Director of Physical therapy (DPT) MR states: While in therapy, MP placed a Moist Heat on my right knee for a period of time, and put an Ace Bandage wrap to support the knee. I didn t know I had a blister until the charge nurse asked me about it . Another interview conducted by the DPT MP states: On April 24, 2010 at approximately 4:15pm, I received a call from the MN about a blister on MR s right knee. MR reported for therapy session at about 1.45 pm. Her therapy session consisted of ace bandage wrap to right knee before ambulation training. MR received wheelchair propulsion training in addition to the ace bandage wrap. The therapy session was ended approximately 2:30 pm. moist heat was not part of the treatment that day. Post-therapy inspection of MR s right knee did not reveal any blister .

it will indeed result in a blister. The in-service included proper application of the ace bandage and if applied too tight for long duration. the DPT suggests the blister was a result of a long duration of tight ace bandaging surrounding the knee. . . Ace bandaging that is applied to the knee for knee support should be applied with minimal pressure. an in-service was given regarding information and proper protocol on ace bandaging. on April 25th 2010.Summaries MR may have confused her moist heat therapy session on April 23rd. 2010. 2010 with the ace bandage wrap of April 24th. Intermittent inspection of the ace-wrapped knee for any signs of tightness is required and inspection of the skin is also required after application of moist heat. Plan of action Due to the occurrence the day prior. This suggests her validity may be questioned. At the end of the interview.

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