Description of Event or Problem · 1
DURING A PT TRANSFER USING A CEILING HOIST, THE OPERATOR PULLED THE RED EMERGENCY LOWERING CORD WHICH RESULTED IN LIFTING THE PT UP. THE OPERATOR PULLED THE CORD A SECOND TIME WHICH RESULTED IN THE ENTIRE STRAP BEING PULLED ALL THE WAY INTO THE LIFT MOTOR CASING. THE OPERATOR PUSHED THE DOWN BUTTON ON THE HAND CONTROLLER AND NOTHING HAPPENED. IN ORDER TO LOWER THE PT, THE CARE GIVER CUT THE STRAPS OF THE SLING AND LOWERED THE PT, HALF INTO A RECLINER AND HALF ONTO THE FLOOR. AN AMBULANCE WAS CALLED WHICH TOOK THE PT TO THE HOSPITAL FOR OBSERVATION. THE CEILING HOIST WAS TAKEN OUT OF SVC AND RETURNED TO HANDICARE FOR ANALYSIS. OUR ANALYSIS SHOWED THAT THE LIFT STRAP HAD BEEN WRAPPED AROUND THE SPOOL IN OPPOSITE DIRECTION TO NORMAL RUNNING. THIS OCCURS WHEN THE EMERGENCY LOWERING CORD IS PULLED UNTIL THE ENTIRE 6 FT LIFTING STRAP IS PAID OUT. WHEN CONTINUING TO PULL THE EMERGENCY LOWERING STRAP, THE SPOOL CONTINUES TO TURN WHICH CAUSES THE LIFTING STRAP TO REWRAP IN THE OPPOSITE DIRECTION. WHEN THIS OCCURS, IF THE EMERGENCY LOWERING STRAP IS CONTINUOUSLY PULLED, THE LIFTING STRAP WILL CONTINUE TO BE PULLED INTO THE LIFT UNTIL IT IS FULLY WOUND INTO THE LIFT MOTOR CASING. WE HAVE THEREFORE CONCLUDED THAT SOMEONE HAD, PRIOR TO THE TRANSFER, PULLED THE EMERGENCY CORD CAUSING THE STRAP TO WRAP AROUND THE SPOOL IN THE OPPOSITE DIRECTION. THE EMERGENCY LOWERING MECHANISM IS DESIGNED TO SAFELY LOWER A PT IN THE EVENT OF A BREAKDOWN AND SHOULD NOT BE USED IN THIS MANNER WHEN ATTEMPTING TO TRANSFER A PT AS STATED IN THE OPERATING MANUAL.