Description of Event or Problem · 1
THE PATIENT WAS USING THE SHOWER CHAIR. HE REACHED FORWARD TO SOAP HIS LEGS AND THE CHAIR TIPPED OVER. HE HIT HIS HEAD AND REQUIRED SUTURING. NO FURTHER TREATMENT WAS NEEDED. STAFF LATER MENTIONED THAT THE CHAIR HAD BEEN WOBBLY AND THAT THE SHOWER FLOOR WAS UNEVEN SO THIS FALL SHOULD HAVE BEEN AVOIDABLE.THE PATIENT WAS BEING EVALUATED TO SEE IF HE WAS SAFE TO RETURN HOME WITH HIS SON. HE IS INDEPENDENT AND DID NOT LIKE FOLLOWING INSTRUCTIONS GIVEN TO HIM. HE WAS ASKED TO SIT IN CHAIR IN SHOWER TO CLEAN UP AND NOT LEAN FORWARD IN CHAIR. HE WAS LEANING FORWARD AND DOWN IN CHAIR TO WASH HIS LEGS. IN THIS PARTICULAR INCIDENT, INSPECTION OF THE CHAIR WAS NOT POSSIBLE. SHORTLY AFTER THE FALL, THE EMPLOYEE STARTED CHECKING THE CHAIR AND TOUCHING BOLTS, ETC WHICH MADE IT IMPOSSIBLE TO KNOW IF ANYTHING WAS LOOSE ON THE CHAIR. THE EMPLOYEE MENTIONED THAT IN RETROSPECT THE CHAIR WAS MAYBE WOBBLY, BUT WE COULD NOT VERIFY THIS SINCE THE CHAIRS BOLTS HAD BEEN TAMPERED WITH PRIOR TO THE REPORT BEING FILED. IN NO WAY ARE WE BLAMING THE PATIENT; JUST STATING THAT THE PATIENT'S LIMITED CAPACITY TO FOLLOW DIRECTIONS FACTORED INTO THE EVENT.AFTER THE DEVICE BEING LOOKED AT AND THEN SENT TO RISK MANAGEMENT DEPARTMENT, IT WAS DISCARDED.