On march 27, 1992 a certified nursing assistant was removing a patient from the whirlpool tub and the hydraulic lift base cracked causing the base to uproot from the floor.
The resident in the lift chair fell from the highest point to the ground.
The resident was not injured.
The nursing assistant operating the lift received bruises to his arm.
Reviewing the situation the maintance department determined the pedestal base had deteriorated from the underside (not visible during routine preventive maintenance) to a point that the hydraulic cylinder completely broke off the base invalid data - regarding single use labeling of device.
Patient medical status prior to event: invalid data.
Invalid data - regarding multiple patient involvement.
Invalid data - on device service/maintenance.
No data - regarding date last serviced.
Service provided by: invalid data.
Invalid data - service records availability.
Invalid data - regarding whether event presents imminent hazard.
Invalid data - whether device used as labeled/intended.
Device was evaluated after the event.
Method of evaluation: invalid data.
Results of evaluation: invalid data.
Conclusion: invalid data.
Certainty of device as cause of or contributor to event: yes.
Corrective actions: no data.
Invalid data - on device destroyed/disposed of status.
|