Description of Event or Problem · 1
RESIDENT WAS BEING TRANSFERRED FROM HER BED TO THE WHEEL CHAIR WITH THE HYDRAULIC HOYER PATIENT LIFT BY TWO NURSING ASSISTANTS. SHE HAD REQUESTED TO BE TRANSFERRED BY THE NON-ELECTRIC LIFT. IN THE PROCESS OF TRANSFERRING WITH ONE NURSE ASSISTANT HANDLING THE HOYER CONTROLS AND GUIDING THE RESIDENT'S SHOULDER'S AND THE OTHER GUIDING HER LEGS A BOLT SNAPPED THAT CONTROLS THE BASE OF THE LIFT, THIS CAUSED THE LEGS OF THE BASE TO FOLD IN AND TIP THE HOYER LIFT OVER. THE RESIDENT ALONG WITH ONE OF THE STAFF WENT TO THE FLOOR. THE RESIDENT HIT THE BACK OF HER HEAD ON THE FLOOR AND HER (R) LOWER LEG ON A DRESSER. NO BRUISED OR BUMPED AREA NOTED ON THE BACK OF HER HEAD. NUERO CHECKS WERE GOOD. SHE COMPLAINED OF MINIMAL PAIN BELOW HER (R) KNEE WITH A SLIGHT SWELLING NOTED. ROM TO OTHER EXTREMITIES CAUSED NO DISCOMFORTS. TAKEN TO THE CLINIC TO SEE DR. GALLAGHER VIA VAN AND X-RAY REVEALED A FX OF TIBIA/FIBULA OF THE (R) LEG. SHE WAS TRANSFERRED TO DAKOTA HOSPITAL IN FARGO, N.D. FOR FURTHER TREATMENT. THE HOYER LIFT WAS EXAMINED AND THE SNAPPED BOLT RETRIEVED FROM THE FLOOR. THIS LIFT WILL NO LONGER BE USEDDEVICE NOT LABELED FOR SINGLE USE. PATIENT MEDICAL STATUS PRIOR TO EVENT: SATISFACTORY CONDITION. THERE WAS NOT MULTIPLE PATIENT INVOLVEMENT.DEVICE SERVICED IN ACCORDANCE WITH SERVICE SCHEDULE. DATE LAST SERVICED: 01-DEC-91. SERVICE PROVIDED BY: OTHER. SERVICE RECORDS 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, VISUAL EXAMINATION. RESULTS OF EVALUATION: COMPONENT FAILURE, TELEMETRY FAILURE, NONE OR UNKNOWN, COMPONENT FAILURE. CONCLUSION: DEVICE FAILURE OCCURRED AND WAS RELATED TO EVENT, DEVICE FAILURE DIRECTLY CONTRIBUTED TO EVENT. CERTAINTY OF DEVICE AS CAUSE OF OR CONTRIBUTOR TO EVENT: YES. CORRECTIVE ACTIONS: DEVICE PERMANENTLY REMOVED FROM SERVICE. INVALID DATA - ON DEVICE DESTROYED/DISPOSED OF STATUS.