Description of Event or Problem · 1
AT 12:30 AM ON 2/24/94, A CERTIFIED NURSE AIDE FOUND RESIDENT IN HIS ROOM NOT BREATHING. LICENSED NURSES WERE SUMMONED IMMEDIATELY. OBSERVED BEDRAIL IN DOWN POSITION (HAD BEEN IN UP POSITION PREVIOUSLY), RESIDENT FACE DOWN WITH FACE AND KNEES ON FLOOR WITH MID TORSO SUSPENDED BEING HELD BY WAIST RESTRAINT. NURSES RELEASED RESTRAINT BY CUTTING WITH SCISSORS IMMEDIATELY. NO VITAL SIGNS NOTED, CPR BEGUN IMMEDIATELY. AMBULANCE NOTIFIED OF EMERGENCY, RESIDENT TRANSPORTED TO HOSP. CORONER WAS NOTIFIED, AN AUTOPSY WAS PERFORMED. WE HAVE NOT RECEIVED IN WRITING THE CORONER OR AUTOPSY REPORT BUT VERBALLY THE CORONER TOLD RPTR THE CAUSE OF DEATH WAS COMPRESSION ASPHYXIA. EVALUATION REVEALED THAT THE RESTRAINT WAS PROPERLY APPLIED AND THE BEDRAIL HAD BEEN IN AN UP POSITION. IT APPEARS THE RESIDENT LOWERED THE SIDERAIL AND ATTEMPTED TO GET OUT OF BED. ALSO, THE NURSES CALL LIGHT WAS WITHIN REACH OF THE RESIDENT. THIS PARTICULAR RESTRAINT WAS BEING USED WITH A PHYSICIAN ORDER BUT AT THE SPECIFIC REQUEST OF THE RESIDENT'S WIFE WHO WAS HIS HEALTH CARE SURROGATE. IT WAS HER DESIRE TO ALLOW HIM AS MUCH FREEDOM TO MOVE AS POSSIBLE BUT DID NOT WANT HIM TO FALL. HIS DIAGNOSIS WAS PARKINSONS DISEASE. HE HAD AN UNSTEADY GAIT AND NEEDED ASSISTANCE TO AMBULATE. HE WAS ADMITTED TO THIS FACILITY ON 3/30/93, AND WAS WITHOUT RESTRAINTS UNTIL 9/30/93 WHEN HIS WIFE INSISTED THEY BE USED TO PREVENT HIS FALLING.DEVICE NOT LABELED FOR SINGLE USE. PATIENT MEDICAL STATUS PRIOR TO EVENT: FAIR 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. RESULTS OF EVALUATION: OTHER. CONCLUSION: THERE WAS NO DEVICE FAILURE. CERTAINTY OF DEVICE AS CAUSE OF OR CONTRIBUTOR TO EVENT: YES. CORRECTIVE ACTIONS: USE OF ALL SIMILAR DEVICES STOPPED PERMANENTLY. INVALID DATA - ON DEVICE DESTROYED/DISPOSED OF STATUS.