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In the investigated complaint the circumstances under which the equipment was damaged remain unknown.However, based on the analysis of the previous complaints and the conducted investigation, it is believed, that the most likely scenario is that the side rail detached (screws holding the panel were ripped off) due to excessive external force applied.According to the instructions for use for citadel plus bed (ifu 831.374 rev.14), the operation of the sides rails should be checked daily."if the result of any of these actions in unsatisfactory, contact arjo or qualified service personnel." to sum up, the side rail was partially detached from the bed's frame, therefore the arjo device did not meet the specification.The complaint was assessed as reportable due to the side rail panel partial detachment from the bed which may result in the patient fall from the bed.There was no patient involvement.
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During the quality control inspection of the citadel plus bed frame upon its return from the customer, it was found that two of the four screws holding the panel to the metal plate started to pulling out.There was no indication of patient involvement, and no injuries were reported.
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