Description of Event or Problem · 1
THE FACILITY REPORTS THE LIFTER WAS BEING USED WITH THE LARGE DPS WITH A PT. IT HAD BEEN IN USE FOR APPROXIMATELY FIVE WEEKS WITHOUT A PROBLEM. THE HOIST IS ONLY USED TO LIFT THE PT OFF THE BED TO CHANGE BEDCLOTHES, ETC. THE HOIST IS NOT MOVED WHILE SHE IS OFF THE BED. THE HOIST WAS IN POSITION AND HER RIGHT LEG HAD BEEN CLIPPED TO THE HANGER BAR. WHILE THE NURSE WAS STARTING ON HER LEFT LEG, THE PT NOTICED THAT THE HANGER BAR DID NOT LOOK RIGHT, BUT BEFORE SHE COULD SAY ANYTHING, THE HANGER BAR DROPPED STRAIGHT DOWN. THE PT WAS LIGHTLY HOLDING THE HANGER BAR BY THE UPRIGHTS. SHE STEADIED IT AND THE TWO NURSES TOOK IT OFF HER. THE HANGER BAR WAS APPROXIMATELY 2 INCHES ABOVE THE PT AT ITS LOWEST POINT. THE PT SUSTAINED BRUISES TO THE RIGHT LEG AND HER KNEE WAS HURTING. (B) (4).