MN nursing home cited after bed-rail asphyxiation

OK, what all do the rest of you think or have to say about this story? Out here, bed rails are considered resstrains..... http://www.twincities.com/politics/c...bed?source=rss


The Minnesota Department of Health called for health facilities across the state to do safety checks on patient bed rails after finding neglect in the case of a nursing home resident who died at a care facility in Cold Spring.

The resident died of asphyxiation after her neck became lodged between her bed's mattress and bed rail, according to a Health Department inspection report released Wednesday.

Bed rails are a known risk for strangulation of some patients, according to the department, so health care providers are required to assess whether the potential benefits of the device outweigh the dangers.

In the Cold Spring case, there was no evidence that the nursing home had assessed the risks versus benefits of using a bed rail, the department said in a prepared statement.

"Nursing homes are entrusted with the care of vulnerable adults and a death like this is totally unacceptable," said Dr. Ed Ehlinger, the state health commissioner, in a statement. "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."

The nursing home resident, who was not identified, suffered from dementia, impaired mobility, chronic pain and a history of falls from wheelchairs and beds.

"A preponderance of evidence indicates that neglect occurred when a resident was not assessed for the need to use a grab bar, and the grab bar was left on the bed after the resident had falls from the bed," Health Department inspectors wrote in the report. Grab bar is another name for bed rail.

"The resident's neck became entrapped in the grab bar, and the resident died of positional asphyxiation," inspectors wrote.

After the incident, Assumption Home reported the situation to the Health Department and put together a corrective plan to get back in compliance with state and federal regulations. The department has since confirmed that the corrective plan was implemented.

"We deeply regret this incident and have expressed our condolences to the family," said Jan Luthens, the nursing home administrator, in a statement. "Since that time we have had a survey by the health department, which was very good."

Nursing home residents use bed rails for assistance with moving in bed, sitting up or getting out of bed, according to the Health Department. Back in 1995, the U.S. Food and Drug Administration issued an alert about the potential for injury and death with bed-rail use.
Between 1985 and 2009, there were 803 bed-rail incidents reported to the FDA, and more than half of the cases resulted in death.