Minnesota Department of Health investigators found neglect of a Cold Spring, Minn. nursing home resident led to a suffocation death after the resident's neck became lodged between a mattress and bed rail.
The resident in this case suffered from dementia, impaired mobility, chronic pain and a history of falls out of wheel chairs and beds.
Because bed rails are a known risk for strangulation for some patients, including those with dementia, health care providers are required by state and federal law to weigh the potential benefits of the device against the dangers.
MDH found no evidence that Assumption Home completed the required assessment for bed rails.
"Nursing homes are entrusted with the care of vulnerable adults and a death like this is totally unacceptable," said Commissioner of Health Dr. Ed Ehlinger. "As a result of this death, we want all health settings where bed rails are used to take immediate steps to make sure they are following the correct guidelines around bed rails, grab bars and other devices."
After the death, Assumption self-reported the incident to the health department. To get back in compliance, the nursing home implemented a corrective plan that was confirmed by an MDH site visit.
Between 1985 and 2009, 803 incidents related to bed rails, of which more than half resulted in death, were reported nationwide. Recognizing the serious injuries and deaths associated with bed rail use, the FDA issued an alert in 1995.
HOSPITAL BED SAFETY GUIDE: http://www.fda.gov/downloads/ForConsumers/ConsumerUpdates/UCM164395.pdf