MALIBU/SOVEREIGN (INCL. DIGNITY)

Description of Event or Problem

INITIALLY IT WAS REPORTED BY ARJOHUNTLEIGH REPRESENTATIVE THAT CHAIR CAME AWAY FROM LOCKING CATCH DURING PATIENT TRANSFER. THE SEAT AND FRAME ASSEMBLY WERE ATTACHED TO THE LIFT ARM OF THE BATH IN PREPARATION FOR BATHING. THE LIFT ARM WAS RAISED SLIGHTLY TO ALLOW FOR THE REMOVAL OF THE SUB-CHASSIS. THE CHASSIS WAS PROVING DIFFICULT TO REMOVE BUT WAS EVENTUALLY FREED. IMMEDIATELY UPON REMOVING THE CHASSIS, THE SEAT FRAME STARTED TO TILT TO THE LEFT AND BECAME UNSTABLE. THE CARE STAFF ATTEMPTED TO SUPPORT THE BATHER BY APPLYING HER OWN BODY WEIGHT AS A COUNTERBALANCE TO THE TILTING MOTION. UNFORTUNATELY THE SEAT WAS COMPLETELY DETACHED FROM THE LIFT ARM AND FELL TO THE FLOOR." FROM THE INFORMATION RECEIVED, RESIDENT SUFFERED SHOCK AND TENDERNESS IN BUTTOCK REGION AS A RESULT OF THIS INCIDENT. PLEASE REFER MFR REPORT # 9611530-2013-00159.