Description of Event or Problem · 1
THE PATIENT WITH PRE-EXISTING PRESSURE ULCERS WAS LYING IN A RECOVERCARE LOW BED. THE BED ELEVATED AND THEN BEGAN MOVING BY ITSELF INTO A REVERSE TRENDELENBURG POSITION. THE PATIENT WAS ON A CAREMEDEX MATTRESS DUE TO WOUNDS AND WAS ON BEDREST. THE FAMILY WAS IN THE ROOM WHEN THIS HAPPENED AND COULD NOT MAKE THE BED STOP. THEREFORE THEY UNPLUGGED THE BED AND CALLED FOR HELP. WHEN THE RN ARRIVED IN THE ROOM, THE PATIENT WAS ALMOST UPRIGHT AT AN 80 DEGREE ANGLE AND WAS SLIDING HEAD-FIRST TOWARDS THE FLOOR. STAFF USED A HOYER LIFT TO LIFT AND MOVE THE PATIENT INTO A BED WITH A REGULAR BEDFRAME. THE PATIENT'S PRESSURE ULCERS BEGAN BLEEDING WHEN THE HOYER LIFT WAS USED. THE RECOVERCARE BED WAS RETURNED TO THE RENTAL COMPANY, WHO INSPECTED IT AND FOUND NO ELECTRICAL PROBLEMS, WIRING PROBLEMS, OR SHORTS, NO ELECTRICAL CURRENT LEAKS. THIS MODEL OF BED HAS 2 HAND CONTROLLERS, ONE AT THE FOOT OF THE BED AND ONE AT THE HEAD OF THE BED. RECOVERCARE TECHNICIANS WERE ABLE TO RECREATE A SIMILAR SITUATION WITH THE HAND CONTROLLER BETWEEN THE FOOT OF THE MATTRESS AND THE FOOTBOARD THEN APPLYING PRESSURE ON THE MATTRESS, RESULTING IN THE BED OPERATING AND MOVING THE BED UP AND THEN INTO TRENDELENBURG POSITION. A SIMILAR EVENT OCCURRED APPROXIMATELY 2 WEEKS LATER AT THIS HOSPITAL THAT WILL ALSO BE REPORTED. THE HOSPITAL SENT A SAFETY ALERT TO NURSING LEADERSHIP FOLLOWING THESE 2 EPISODES, ADVISING STAFF THAT IF THIS MODEL IS USED, THE LOWER HANDSET SHOULD BE SECURED. ALTHOUGH THE CONTROLLER MAY BE INITIALLY "SECURED", IF VISITORS OR FAMILY MEMBERS USE IT TO OPERATE THE BED, IT MAY NOT END UP BACK IN THE "SECURED" POSITION. THE HOSPITAL HAS REQUESTED THAT THE RENTAL COMPANY DELIVER ONLY BEDS THAT HAVE 1 SET OF HAND CONTROLLERS FOR THE HEAD OF THE BED.======================MANUFACTURER RESPONSE FOR LOW BED, RECOVERCARE ULTRA HI LO BED V RISER (PER SITE REPORTER).======================RESPONSE FROM DISTRIBUTOR IS INCLUDED IN THE EVENT SECTION. DISTRIBUTOR IS WORKING WITH MANUFACTURER.