Description of Event or Problem · 1
A NURSING ASSISTANT WAS TRANSPORTING PT FROM BATH AREA BACK TO HIS ROOM, ON THE WHEELED STRETCHER, THE FACILITY USES WHEN GIVING BATHS TO IMMOBILE RESIDENTS. THE STRETCHER TILTED TO THE RIGHT AS THE TRAINEE WAS MAKING A TURN INTO HALLWAY FROM THE BATHING ROOM. AS THE STRETCHER OVERTURNED, THE TRAINEE NOTICED ONE OF THE STRETCHER'S WHEELS HAD SEPARATED FROM THE STRETCHER'S FRAME. THE TRAINEE QUICKLY RESPONDED AND CAUGHT PT BEFORE HE SUFFERED ANY IMPACT WITH ANY OBJECT AND SLOWLY LOWERED HIM TO THE FLOOR. NEVERTHELESS, SOME MINS LATER PT STARTED TO DISPLAY PHYSICAL DISTRESS WHICH APPEARED TO BE CIRCULATORY IN NATURE. PT WAS TRANSPORTED TO THE HOSP BY AMBULANCE WHERE HE DIED. AUTOPSY RESULTS HAVE NOT YET BEEN ISSUED. THE "OTHER CATEGORY" WAS CHECKED IN BOX 2 BECAUSE THE FACILITY DOES NOT KNOW IF THE FAILURE RELATED TO THE DEVICE IN QUESTION-SEPARATION OF A WHEEL FROM A STRETCHER-WAS A CAUSE OF ANY INJURY TO PT WHATSOEVER. DESPITE AN INVESTIGATION, THE FACILITY HAS BEEN UNABLE TO DETERMINE DEFINITELY WHETHER THE WHEEL'S SEPARATION FROM THE STRETCHER WAS THE CAUSE OF THE STRETCHER'S OVERTURNING, OR WHETHER SOME OTHER CAUSE (SUCH AS PT'S UNANTICIPATED SHIFTING OF WEIGHT) CAUSED THE STRETCHER TO OVERTURN, WHICH IN TURN CAUSED THE WHEEL TO SEPARATE. ADDITIONALLY, THE FACILITY HAS BEEN UNABLE TO DETERMINE WHETHER THE WHEEL SEPARATION HAD ANYTHING TO DO WITH PTS SUBSEQUENT DEATH FROM SYMPTOMS THAT SUGGESTED CIRCULATORY DISTRESS (ALTHOUGH NO AUTOPSY REPORT HAS YET BEEN MADE AVAILABLE).