W/C-IV POLE-ANTI TIPPER-SOFT RESTR BELT

Description of Event or Problem

RESIDENT WITH LATE STAGE DEMENTIA UNABLE TO STAND WITHOUT ASSIST HAS SOFT LAP BELT ORDERED FOR POSITIONING. STRAP FOR SOFT LAP BELT IS TO BE ATTACHED BEHIND W/C TO REAR ANTI-TIP BAR WHICH ATTACHES TO W/C FRAME. REAR ANTI-TIP BAR WAS ATTACHED TO IV POLE TUBE TUBING WHICH DOES NOT SECURE REAR ANTI-TIP CAUSING STRAP TO COME IF ALLOWING RESIDENT TO SLIDE OUT OF CHAIR. FALL RESULTED IN HIP FRACTURE.