LS450 TOILET LIFT

Description of Event or Problem

PATIENT WAS PIVOTING AS A 2 PERSON TRANSFER WITH WALKER AND GAIT BELT TO THE COMMODE. THE COMMODE WAS LOCKED, AND PATIENT WAS SITTING ON THE COMMODE WHEN IT STARTED TO SLIDE OUT FROM UNDER THEM AND THE PATIENT FELL TO THE FLOOR (LS450 TOILET LIFT). UPON INVESTIGATION/TESTING, IT WAS FOUND THAT THE PATIENT RIGHT REAR CASTER BRAKE IS NOT ENGAGING. ALL OTHER CASTERS ENGAGE INTO BRAKE AND WORK PROPERLY. THE SET SCREW ON THE BRAKE ROD THAT RUNS TO THE REAR CASTER IS NO LONGER ATTACHED CAUSING THE BRAKE TO NOT ENGAGE. THERE ARE NO VISUAL CUES THAT LET THE USER KNOW THE CHAIR LOCK IS BROKEN. STAFF WOULD HAVE TO RECOGNIZE THE EQUIPMENT'S MINOR MOVEMENT WHILE IN USE AND KNOW THIS INDICATES AN ISSUE WITH THE BRAKES. THE CHAIR MUST BE FLIPPED UPSIDE DOWN TO CHECK BRAKE FUNCTIONALITY (NOT SOMETHING THE UNIT CAN EASILY DO).