[63625]
On 19 aug 1996, the fluidotherapy unit, in occupational therapy caught on fire. The henley int'l fluidotherapy unit is a therapy unit designed to blow cellex particles, a sand like material, over the pts hands which are inserted into gloves giving the pt the feeling of a "fluidized bed". Heaters, which are controlled by the operator, are incorporated into the therapy. The initial check out found that the power cord was not damaged and both the air and temperature fuses (15 amp) located on the control panel had not blown. The temperature setting for the heater was set on medium (113 degree - 117 degree f). After the control panel was removed, large quantities of cellex particles were discovered in the blower motors indicating that they had seeped into the plenum chamber. The mfr's literature indicates that air flows from the blower up through a foam distributor which is designed to stop the cellex particles from leaking into the plenum chamber. Upon disassembly of the unit, burn marks were found at the right glove and the bottom of the cellex chamber along the wood supports and perforated metal plates. When the foam distributor was investigated, it was found to be burnt and largely deteriorated. It appears that when parts of the foam distributor fell off and came in direct contact with heater they caught fire & were then blown around in the unit by the blower motor setting fire to right glove and wood supports. Admin research indicates that the unit had scheduled svs performed on it on 17 jun 1996. The medical maintenance technician who performed svs at that time found no deficiencies or indications of problems. It is the finding of this office that the fire was a unforeseen incident. Because the unit's rivets must be removed to get to foam distributor & the literature states that "fiberglass units should be returned to factory for heater replacement", the foam distributor could not be inspected during routine scheduled services.
Patient Sequence No: 1, Text Type: D, B5