Description of Event or Problem · 1
VERY SMALL, FRAIL FEMALE SLID DOWN IN THE SECURE II BED AND HAD HER CHIN AND LOWER FACE IN THE OPENING OF THE TOP SIDE RAIL NEAREST TO THE CENTER OF THE BED.- ON THE SIDERAILS, THERE ARE TWO OPENINGS FOR HAND GRIPS-ONE ON THE TOP OF THE OTHER.-THE PT HAD SLID DOWN IN THE BED AND GOT HER CHIN AND LOWER FACE IN THE LOWER OF THE TWO OPENINGS. HER LEGS AND HIPS THEN SLID OUT OF THE BED OFF MATTRESS AND SHE WAS HANGING IN THE OPENING OF THE UPPER SIDERAIL. THE BED ALARM WENT OFF AND STAFF RESPONDED IMMEDIATELY. THE PT DID RECEIVE A SKIN TEAR ACROSS HER NECK 4 INCHES HORIZONTALLY AND 1 INCH HIGH WHICH WAS TREATED WITH BACITRACIN AND TELFA. THE PT IS COGNIZANT. DISCLOSURE WAS DONE WITH THE FAMILY. THE PT WAS MOVED TO INPATIENT REHAB AS PLANNED PRIOR TO THE EVENT. THIS COULD HAVE BEEN A VERY SERIOUS EVENT INVOLVING THIS SIDERAIL DESIGN.