[17177329]
Patient placed in posey vest and soft wrist restraints. Patient found by nurse in cortorted position between bed and siderails without pulse or respirations. Patient had do not resuscitate order on chart due to terminal status. Medical examiner notified and determined cause of death to be positional aphyxiadevice 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 not used as labeled/indended. Device was evaluated after the event. Method of evaluation: actual device involved in incident was evaluated, other, other, invalid data. Results of evaluation: invalid data, invalid data, invalid data, invalid data. Conclusion: invalid data, device failed during assembly. Certainty of device as cause of or contributor to event: invalid data. Corrective actions: invalid data. The device was destroyed/disposed of.
Patient Sequence No: 1, Text Type: D, B5