Description of Event or Problem · 1
OBESE PATIENT WITH SKIN BREAKDOWN ISSUES USING KINAIR III SPECIALTY BED WITH A SHEET APPLIED DIRECTLY OVER THE MATTRESS. GETTING OUT OF BED WAS A NEW ACTIVITY FOR PATIENT AS HAD BEEN ON BEDREST PRIOR TO THIS FALL. PRIOR TO THE FALL, THE BOTH OF THE BED'S SIDERAILS WERE UP AND THE HEAD OF THE BED WAS NOT UP TOO HIGH. NURSE HEARD PATIENT YELL OUT FOR HELP. PATIENT WAS ALERT, BUT FORGETFUL AND DID NOT USE NURSE CALL BUTTON APPROPRIATELY. STAFF IMMEDIATELY RESPONDED AND FOUND PATIENT SITTING ON THE FLOOR RIGHT NEXT TO THE BED. PATIENT REPORTED JUST SLIDING OFF OF THE BED PAST THE SIDE RAILS AND ONTO THE FLOOR. NURSE STAFF INDICATED THAT THE MATTRESS ON THIS BED IS SLIPPERY ESPECIALLY WITH A SHEET. IN THIS OCCURRENCE, THE HEAD OF THE BED WAS NOT UP THAT HIGH, BUT SOMETIMES WHEN THE HEAD OF THE BED IS UP HIGH, PATIENTS SLIDE MORE.