APOLLO WHIRLPOOL BATH
Received Oct 7, 2016 · Event occurred May 23, 2016
Report 2182947-2016-00001 · MDR key 6012045
Device
Product problems
- Adverse Event Without Identified Device or Use Problem
Patient
Not reported
- Contusion
- Fall
- Skin Tears
- Contusion
- Fall
- Skin Tears
Narrative
Additional Manufacturer Narrative
THROUGH INVESTIGATING THE INCIDENT IT WAS DETERMINED THAT THE DEVICE WAS USED BY INDIVIDUALS WITHOUT PROPER TRAINING PRIOR TO THE EVENT. THE CHAIR WAS LIKELY REMOVED FROM THE REST OF THE DEVICE FOR CLEANING AND PLACED ON TOP OF THE LOWER SECTION OF THE CARRIER AS OPPOSED TO INTERFACING THE CHAIR'S BEARINGS WITH THE RAILS PROPERLY. DUE TO THIS THE CHAIR'S GUARDS LOCATED UNDER THE BEARINGS WERE RESTING ON THE RAILS INSTEAD OF UNDER THEM WHERE THEY WOULD HAVE WORKED WITH THE BEARINGS TO SECURE THE CHAIR IN PLACE. THE INCIDENT OCCURRED AS THE PATIENT SHIFTED TO THE SIDE AND THUS CAUSED THE CHAIR TO SHIFT AND FALL BETWEEN THE RAILS.
Description of Event or Problem
PATIENT FELL FROM TRANSFER DEVICE CHAIR AND SUFFERED CONTUSION REQUIRING STITCHES.