Following information provided by the facility staff, the side rails were raised when the event occurred, however as per the instructions for use dedicated to citadel bed frame system (830.213-en): "side rails and not intended to restrain patients who make a deliberate attempt to exit the bed".The facility staff mentioned also that the exit alarm did not work despite being activated.During device evaluation, this issue was not recreated.The bed exit alarm was working correctly.The alarm detects the patient's movements.The sensitivity level of the detected patient movement can be adjusted using the controls on the foot end split side rails.Depending on the selected level, it can detect even small movements of the patient in bed or larger ones, such as attempts to get the patient out of bed.The activated exit alarm is intended to inform the facility staff about patient movements but is not responsible for preventing falls.To ensure patient safety, the instructions for use dedicated to citadel bed frame system (830.213-en) warns: "to minimize the risk of falls or injury, the bed should always be in the lowest practical position when the patient is unattended." "caregiver should always aid the patient in exiting the bed.Make sure a capable patient knows how to get out of the bed safely." to sum up, no device malfunction was confirmed during the citadel bed frame inspection.The complaint decided to be reportable due to allegation of patient fall.No injury was claimed.
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