[56928643]
Hme manager states the aid was trying to bring the chair to an upright position and it would not come back up. Hme manager states the aid forced it back up. It appeared to be really hard to close and the staff had to slam it down and her foot may have gotten caught while doing this. The facility nurse stated that the push rail on the back of the geri-chair, when lifted, you have to push on it and that it doesn't close with ease. Hme manager states that it was the next morning approximately that there was a (b)(6) staff member who noticed the patient's leg swollen and bruised and that it when it was checked out by er staff and determined to be a fracture. An x-ray was obtained and confirmed a mildly displaced spiral acute fracture of the distal third of the tibia and acute oblique fracture of the distal third of the fibula with mild angulation at the fracture site. Patient was transported by ambulance to the hospital to obtain a cast to lower left leg and then transported back to long term care facility. Hme manager states there were no witnesses to the incident. Hme manager states they quarantined the chair at their facility and tested it and there are no issues with reclining and bringing the unit upright and that she took video of someone testing it and he could literally recline/decline the chair with a couple of fingers. Hme manager states there is no binding or resistance when doing so. Hme manager states she believes the reason the aid couldn't bring the chair upright was because the patient's foot was caught in the chair footrest. Hme manager states they cannot release the chair to invacare for testing and if we need expanded evaluations done it will have to be on-site. No further information was provided. Initial conclusions show that the event was caused by improper use of the ih6074a/ih61 recliner; operator error. The recliner was quarantined and tested by the facility. Multiple tests demonstrated that the recliner functioned as intended. There was no malfunction or defect associated with the injury allegation. It was reported that the end user's foot was in the chair footrest as the attendant was attempting to raise the recliner. The user manual explicitly warns do not place hands or feet into any openings when adjusting the recliner. Attendant or care provider should always verify placement of user's hands and feet prior to adjusting the recliner. Failure to do so may result in serious bodily injury. A return of the recliner for evaluation is not anticipated at this time, as it was reported that the facility cannot release the recliner to invacare. In conclusion, the underlying cause of the event was that the attendant failed to adhere to the warnings in the user manual. No further investigation will be performed, unless additional information should be provided that indicates an additional underlying cause. 3500a was filed by the facility. (b)(4).
Patient Sequence No: 1, Text Type: D, B5