Arjo became aware of the event involving the nimbus 3 system.The customer alleged that the mattress deflation resulted in the patient¿s stage 4 pressure ulcer.The system was returned to the arjo and evaluated.It revealed 3 small holes in the mattress (in the heel guard, in the short cell and in the torso cell) and the small spilt in the compressor tubing.It caused that the mattress did not reach normal operating pressure.However, the revealed air loss did not cause mattress fully deflation and the low pressure alarm activation.The pump alarm was activated while the cpr was used causing the fully mattress deflation.The system was repaired and returned to the customer.
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