Description of Event or Problem · 1
ON 3/29/94, AT 7:38 PM THE PT WAS FOUND BY AN LVN IN THE BATHROOM ON THE DORMITORY. HER RIGHT ARM WAS DOWN IN THE TOILET, AND SHE WAS OBSERVED KNEELING ON THE FLOOR. HER COLOR WAS BLUE AND TEMPERATURE WAS COLD. THE STRAP ON THE PROTECTIVE HELMENT SHE WAS WEARING APPEARS TO HAVE BEEN HUNG ON THE FLUSHING HANDLE OF THE TOILET. THE STRAP WAS LOOSENED, PT LAYED ON THE FLOOR, AND CPR BEGAN. EMS ARRIVED AT 7:50 PM, PULSE NOTED AT 8:09 PM. AT 8:15 PM EMS TRANSPORTED HER TO LOCAL HOSP. PT DIED AT HOSP AT 9:40 AM ON 3/30/94.DEVICE LABELED FOR SINGLE USE. PATIENT MEDICAL STATUS PRIOR TO EVENT: SATISFACTORY CONDITION. THERE WAS NOT MULTIPLE PATIENT INVOLVEMENT.INVALID DATA - ON DEVICE SERVICE/MAINTENANCE. NO DATA - REGARDING DATE LAST SERVICED. SERVICE PROVIDED BY: INVALID DATA. INVALID DATA - SERVICE RECORDS AVAILABILITY.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, VISUAL EXAMINATION. RESULTS OF EVALUATION: NONE OR UNKNOWN. CONCLUSION: NONE OR UNKNOWN. CERTAINTY OF DEVICE AS CAUSE OF OR CONTRIBUTOR TO EVENT: INVALID DATA. CORRECTIVE ACTIONS: DEVICE TEMPORARILY REMOVED FROM SERVICE, USER EDUCATION PROVIDED, INSERVICED BY OTHER FACILITY STAFF. THE DEVICE WAS NOT DESTROYED/DISPOSED OF.