Description of Event or Problem · 1
A RESIDENT WAS FOUND DEAD AND THE BODY WAS TRAPPED BETWEEN THE FRAME AND BED RAIL. THERE WAS NO PATIENT FOLLOW-UP OR TREATMENT AS THE PATIENT WAS DEAD. TO OUR KNOWLEDGE THERE WERE NO ENVIRONMENTAL CONDITIONS CONTRIBUTING TO THE INCIDENT. THE CORONER WAS CALLED AND THE RESULTS OF HIS INVESTIGATION INDIRECTLY STATED DEATH BY ASPHYXIATION BY BED RAILS AS THE MOST LIKELY CAUSE OF DEATH. THE BED WAS CHECKED OVER AND A BROKEN TACK WELD WAS FOUND ON THE BED RAIL POST (BOTTOM FOOT). THIS ALLOWED BOUT A QUARTER OF AN INCH PLAY IN THE RAIL MOVEMENT. THE BROKEN TACK WELD WAS REPAIRED AND THE MATTRESS SIZE WAS CHECKED TO ENSURE IT WAS THE PROPER SIZE. IT WAS FOUND TO BE OF THE CORRECT SIZEINVALID DATA - REGARDING SINGLE USE LABELING OF DEVICE. PATIENT MEDICAL STATUS PRIOR TO EVENT: FAIR CONDITION. THERE WAS NOT MULTIPLE PATIENT INVOLVEMENT.DEVICE SERVICED IN ACCORDANCE WITH SERVICE SCHEDULE. DATE LAST SERVICED: 01-NOV-91. SERVICE PROVIDED BY: OTHER. SERVICE RECORDS NOT AVAILABLE.NO IMMINENT HAZARD TO PUBLIC HEALTH CLAIMED. DEVICE USED AS LABELED/INTENDED.DEVICE WAS EVALUATED AFTER THE EVENT. METHOD OF EVALUATION: ACTUAL DEVICE INVOLVED IN INCIDENT WAS EVALUATED, MECHANICAL TESTS PERFORMED, PERFORMANCE TESTS PERFORMED, VISUAL EXAMINATION. RESULTS OF EVALUATION: NONE OR UNKNOWN, NONE OR UNKNOWN, NONE OR UNKNOWN. CONCLUSION: NONE OR UNKNOWN. CERTAINTY OF DEVICE AS CAUSE OF OR CONTRIBUTOR TO EVENT: INVALID DATA. CORRECTIVE ACTIONS: DEVICE REPAIRED AND PUT BACK IN SERVICE. INVALID DATA - ON DEVICE DESTROYED/DISPOSED OF STATUS.