[1274]
On 11/4/92, client was placed in her wheelchair at approximately 6:20 a. M. This is a special made wheelchair for this clients needs, as recommended by the physical therapist and her physician. At approximately 6:40 a. M. , the staff on duty found this client in her wheelchair, but had slipped down in the chair and the buterfly breast plate attached to this chair for proper support and alignment, was under the client's neck. She was immediately removed from the chair and cpr and emergency procedures administered without respone from the client. The staff followed all procedures and directives as they had in the past in applying this breast plate. The body was sent to the medical examiner's office, as requested by the physician and they reported back to this facility that the cause of death was positional asphyxiation. This was reported to the state health department and all other agencies concerneddevice 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: performance tests performed, visual examination. Results of evaluation: none or unknown. Conclusion: there was no device failure. Certainty of device as cause of or contributor to event: yes. Corrective actions: inserviced by other facility staff. Invalid data - on device destroyed/disposed of status.
Patient Sequence No: 1, Text Type: D, B5