FLEXICAIR MC3
Received Apr 3, 1997 · Event occurred Mar 29, 1997
Report 81918 · MDR key 81918
Device
Generic name
Wound Care Bed
Manufacturer
Hill-rom., A Hillen Brand IndustryModel number
MC3Catalog number
NA
Lot number
NA
Product problems
- Side rails, failure of
Patient
76 YR
- Airflow, restricted
- Fall
- Asphyxia
Narrative
Description of Event or Problem
AT 7:45AM A RESIDENT WAS SEEN IN BED SLEEPING BY RN SUPERVISOR. AT 8:00AM NA ENTERED ROOM TO SET UP BREAKFAST TRAY. SHE NOTED RESIDENT'S HEAD, LEFT ARM AND CHEST TO BE IN SIDE RAIL. RESIDENT'S LEGS WERE FOLDED UNDERNEATH IN A KNEELING POSITION. NA WENT TO DESK FOR ASSISTANCE. R.N. SUPERVISOR, CHARGE RN 11-7 SHIFT AND TWO OTHER NURSES HELPED RESIDENT TO BED. RESIDENT WAS A D.N.R. NURSES WERE UNABLE TO OBTAIN BLOOD PRESSURE AND NO PULSE. NO MOTTLING NOTED. RESIDENT NOTED TO HAVE INDENT FROM SIDE RAIL ON LEFT CHIN AREA, LEFT FOREHEAD AND CHEST AREA UNDER LEFT BREAST. PHYSICIAN WAS NOTIFIED AT 8:05AM. HE CALLED CORONER'S OFFICE. FAMILY NOTIFIED. FACILITY CALLED CORONER'S OFFICE FOR FINDINGS ON 4/1/97.