Description of Event or Problem · 1
ON 4/9/94, CNA'S WERE TRANSFERRING PT TO HER CHAIR FROM THE BED VIA A LIFT. BOTH CNA'S STATE THAT PT WAS APPROXIMATELY 6 INCHES OFF THE BED WHEN CNA BEGAN MOVING THE LIFT OFF THE BED TOWARD THE CHAIR. CNA STATES THAT HE HEARD A "PING-PONG" NOISE AND THEN HEARD THE CHAINS RATTLE AND THE PT WAS ON THE FLOOR. BOTH CNA'S STATE THAT IT HAPPENED SO QUICKLY THAT THERE WAS NO TIME TO BREAK HER FALL. THE PT WAS SENT TO THE HOSP ER FOR EVALUATION OF LEG PAIN AND A LACERATION TO THE OCCIPUT. SHE RETURNED A FEW HOURS LATER WITH 2 STAPLES TO A 1.25 CM LACERATION AND NEGATIVE X-RAYS. RESIDENT DEVELOPED ECCHYMOSIS WITH EDEMA OF RIGHT CHEEK, EYE AND NOSE. A COMPLETE INVESTIGATION WAS IMMEDIATELY BEGUN. THE RESULTS WERE AS FOLLOWS: 1) THE PARTICULAR LIFT HAD A DIGITAL SCALE ATTACHED TO IT HELD IN PLACE BY A SCREW. THE SCREW BROKE IN HALF DURING THE INCIDENT ALLOWING THE ENTIRE SCALE AND THE CROSS BAR OF THE LIFT TO FALL WITH THE RESIDENT; 2) THE HYDRAULIC PUMP UNIT ON THIS LIFT HAD BEEN REBUILT AND REPLACED ON 3/9/94; 3) THE LIFT HAD BEEN USED BY THE SAME CNA'S ON THE PTS ROOMMATE WITHOUT PROBLEMS, JUST PRIOR TO THE INCIDENT; 4) AFTER THE INCIDENT, THE LIFT WAS INSPECTED BY MAINTENANCE AND FOUND TO BE SLOWLY DROPPING; 5) AN ENGINEER WAS CONTACTED TO DETERMINE WHAT WOULD CAUSE A HYDRAULIC PUMP TO QUICKLY DROP. HE STATED THAT A SMALL AIR POCKET COULD BE PRESENT AND THAT A QUICK SUDDEN DROP WAS POSSIBLE. CONCLUSION: AFTER MANY HOURS OF INVESTIGATION, ONLY ONE CONCLUSION COULD BE DRAWN: THE HYDRAULIC MECHANISM APPARENTLY DROPPED VERY QUICKLY AND STOPPED ABRUPTLY CAUSING THE SCREW HOLDING THE SCALE IN PLACE TO SNAP. THIS RESULTED IN THE ENTIRE SCALE AND CROSS BAR FALLING WITH THE RESIDENT. THIS APPEARS TO BE DOUBLE EQUIPMENT FAILURE: 1. THE SCREW HOLDING THE SCALE ONTO THE LIFT SNAPPED IN HALF; 2. THE PUMP LOST PRESSURE. HYDRAULIC MECHANISM WAS REBUILT BY ANOTHER CO AND REINSTALLED ON 3/9/94. PUMP SERIAL NUMBER P5811C. (ALSO SEE 1001680.)