GUARDIAN SIGNATURE

Description of Event or Problem

PATIENT WAS IMPULSIVE AND NEEDED TO USE THE BATHROOM. PATIENT WAS ASSISTED BY TWO RNS FROM THE CHAIR NEAR THE BATHROOM TO THE BATHROOM WITH THE USE OF A WALKER, FRONT WHEELED. PATIENT WAS CONFUSED AND DID HAVE TROUBLE WITH HIS GAIT. PATIENT LEANED FORWARD WITH WALKER AS HE WAS WALKING TO THE BATHROOM AND THE FRONT WHEEL OF THE WALKER BROKE COMPLETELY OFF. PATIENT LOST BALANCE AND FELL FORWARD AS RN CAUGHT HIM AND, WITH HELP OF THE SECOND RN, LOWERED THE PATIENT TO HIS KNEES. A THIRD RN HELPED LIFT THE PATIENT TO HIS FEET. NO COMPLICATIONS NOTED THROUGH FREQUENT NEURO AND VITALS. PATIENT DENIED PAIN. MD WAS NOTIFIED AND NO FURTHER TESTING OR INTERVENTIONS WERE INDICATED.THIS IS FROM THE PATIENT SAFETY REPORT: PT GOT UP OUT OF CHAIR WITH ASSISTANCE FROM TWO RNS. PT LEANED FORWARD AND THE WALKER BROKE. PT WAS ASSISTED DOWN TO ONE KNEE BY BOTH RNS. NO COMPLICATIONS WERE NOTED. THIS IS THE WALKER SERIAL #: (B)(4).======================MANUFACTURER RESPONSE FOR WALKER, GUARDIAN, W/5IN WHEEL, ADULT (PER SITE REPORTER).======================I HAVE ALREADY RECEIVED A REPLACEMENT AND I HAVE REQUESTED A FOLLOW UP INVESTIGATION LETTER. I WILL FORWARD THAT TO YOU WHEN I GET IT.