On (b)(6) 2023 arjo became aware of patient, who developed a serious injury while laying on atmosair 9000, which is a hybrid mattress.A patient had stage 2 pressure injury on buttock upon admission which progressed to an unstageable pressure injury.The same facility reported 2 additional serious injuries, which were submitted under importer medwatch numbers 1419652-2023-00011 and 1419652-2023-00012.The investigation, which included an interview with the customer, revealed that several factors may have contributed to the pressure injuries: staff was using the bleach, which may have degraded the cover fabric, the mattress was not checked for wear, the customer's staff did not have protocols in place for moisture and continence reduction; covid changes required changes in hiring new employees who needed education.
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