inforMED
InjuryCAN

ROSCOE

Received Oct 3, 2019

Report 3012316249-2019-00028 · MDR key 9152520

Device

Generic name

Regulator 0-15 Lpm

Model number

RMI-15MINI

Product problems

  • Fire
  • Fire

Patient

Not reported

  • Superficial (First Degree) Burn
  • Superficial (First Degree) Burn

Narrative

Description of Event or Problem

COMPANY HAD A SITUATION AT A NURSING HOME WHERE THERE WAS A FIRE INVOLVING A REGULATOR. IT WAS ABOUT A 2 FOOT FLAME THAT WENT OUT IN A SECOND. THEY NOTICED THE GAUGE WAS BENT, BUT NOT SURE IF THAT HAPPENED BEFORE OR AS A RESULT OF THE FIRE. THE WASHER WAS DAMAGED IN THE FIRE. A CNA WAS HANDLING THE TANK, SHE RECEIVED FIRST DEGREE BURNS TO HER HANDS. SHE WENT TO EMERGENCY ROOM AND THEY GAVE HER SOME CREAM AND SENT HER HOME SAME DAY. FROM WHAT THEY WERE TOLD BY EYEWITNESS IT SEEMS THE FLAME CAME OUT ON TOP FROM WHERE THE REGULATOR MEETS THE OUTLET ON THE CYLINDER. THE REGULATOR HAD BEEN USED BEFORE. NOT KNOWN WHEN WASHER WAS LAST REPLACED, ITS NOT SOMETHING THAT TYPICALLY GETS DOCUMENTED. THEY ARE SUPPOSED TO INSPECT BEFORE EVERY USE AND REPLACE AS NECESSARY. THE BOTTOM OF REGULATOR RECEIVED THE MOST DAMAGE. THERE WAS A CHUNK OF METAL MISSING THERE.