D
Patient 1
RESIDENT WAS SLIDING OUT OF HER WHEELCHAIR. S-VEST RESTRAINT WAS TIGHT AGAINST HER NECK. RESIDENT;S FACE AND HANDS WERE PURPLE. THE RESTRAINT HAD TO BE CUT TO REMOVE IT FROM THE RESIDENT. THE RESTRAINT WAS APPLIED INCORRECTLY AND THE RESIDENT WAS IN A RAYON FABRIC HOYER SLING WHICH CONTRIBUTED TO HER SLIDING DOWN IN THE WHEELCHAIR. THE PREVENT REOCCURRENCE, STAFF WAS INSERVICED RE: CORRECT APPLICATION OF THE RESTRATINT. ADDITIONALLY, A NON-SKID PAD WILL BE UTILIZED IN THE WHEELCHAIR AND MESH FABRIC HOYER SLING TO PRENENT SLIPPING.DEVICE NOT LABELED FOR SINGLE USE. PATIENT MEDICAL STATUS PRIOR TO EVENT: SATISFACTORY CONDITION. THERE WAS NOT MULTIPLE PATIENT INVOLVEMENT.DEVICE NOT SERVICED IN ACCORDANCE WITH SERVICE SCHEDULE. NO DATA - REGARDING DATE LAST SERVICED. SERVICE PROVIDED BY: INVALID DATA. SERVICE RECORDS NOT AVAILABLE.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, VISUAL EXAMINATION. RESULTS OF EVALUATION: NONE OR UNKNOWN, NONE OR UNKNOWN, OTHER, MISAPPLICATION OF DEVICE. CONCLUSION: DEVICE DISCARDED - UNABLE TO FOLLOW-UP, THERE WAS NO DEVICE FAILURE, USER ERROR CAUSED EVENT, NONE OR UNKNOWN. CERTAINTY OF DEVICE AS CAUSE OF OR CONTRIBUTOR TO EVENT: YES. CORRECTIVE ACTIONS: DEVICE DISCARDED, INSERVICED BY OTHER FACILITY STAFF. THE DEVICE WAS DESTROYED/DISPOSED OF.