Description of Event or Problem · 1
DOOR ON TUB FELL DOWN ONTO PT'S FINGER RESULTING IN LACERATION (19 SUTURES) AND A COMMINUTED FRACTURE OF THE DISTAL PHALANX (4TH FINGER). CAREGIVER REPORTS SHE HAD JUST TRANSFERRED (MOVED) PT OUT OF TUB. TUB WAS IN THE DOWN POSITION WHEN THE DOOR CLOSED UNEXPECTEDLY ONTO 4TH DIGIT OF THE PT CAUSING INJURY. I HAVE CONCERNS ABOUT THE DESIGN OF THE DOOR. THE GAS HINGE ALLOWS IT TO CLOSE SLOWLY UNTIL A CERTAIN POINT IS REACHED WHICH VARIES FROM TUB TO TUB (AT LEAST ON THE 5 THAT WE HAVE). ONCE THIS POINT IS REACHED ABOUT HALF WAY DOWN, THE TUB DOOR JUST DROPS THE REST OF THE WAY. THE BOOKLET WITH THE TUB DIRECTS STAFF TO HOLD THE DOOR WHEN CLOSING IT. IN OUR SITUATION, THE STAFF MEMBER HAD GIVEN A BATH TO A RESIDENT, AND THEN MOVED HER TO THE CHAIR ADJACENT TO THE TUB. THE CAREGIVER HAD HER BACK TO THE TUB, WHEN THE TUB DOOR CLOSED ON THE RESIDENT'S FINGER WHICH WAS ON THE LEDGE OF THE TUB. IN INVESTIGATING THIS INCIDENT, I SPOKE WITH OUR CHIEF ENGINEER WHO INFORMED ME THAT HE HAD PREVIOUS INVOLVEMENT WITH THIS SAME TUB IN OCTOBER 2005. AT THAT TIME STAFF HAD REPORTED A PROBLEM WITH STANDING WATER IN THE TUB. IN THE COURSE OF HIS ASSESSMENT OF THE TUB, HE DISCOVERED THAT THE DOOR LATCH WAS NOT PERFORMING CORRECTLY OR SAFELY. TO REMEDY THE PROBLEM, THE GAS HINGE WAS REPLACED. MY ENGINEER INFORMS ME THAT HE PREVIOUSLY HAD DISCOVERED THAT THE COMPANY SOLD ITS TUB DIVISION. THE NEW COMPANY SUPPORTED THE TUB FOR A YEAR OR TWO, BUT NO LONGER SUPPORTS THE TUB AND HAS NOT DONE SO FOR SEVERAL YEARS.