Many on the overnight shift at Edgewood Brainerd sensed the danger of returning a frail resident to a bed with a railing that choked him until his face turned purple. Workers tried to remove the railing, but couldn’t. A manager’s email ordered an assessment of the resident and removal of his railing, but a nurse didn’t read it in time. Even the resident, who had dementia, was reportedly afraid after being stabilized in a hospital and returned hours later to the same bed.
He was put back in his bed, and this time, the result was fatal. As he slipped off the bed in the early morning of June 11, his head became wedged between the mattress and railing, according to a state investigative report that did not identify the resident.
Eilon Caspi, a national elder-safety advocate, has reviewed hundreds of entrapment reports for his research and was incredulous over the timing, saying “Eleven hours after the first entrapment, it happens again?”
A cluster of bed-rail entrapments has advocates concerned that the risks are worsening amid staffing shortages and other pressures, particularly in assisted living facilities — which are being pressed to provide more complex care as nursing homes close.
The Minnesota Department of Health issued an alert this fall after documenting five entrapment deaths and one serious injury in state-licensed facilities since December 2022. The state found maltreatment in at least three assisted-living facilities where residents died, including Edgewood.
Investigative reports reveal frustrating circumstances in which facilities traded one problem for another by trying to prevent falls with bed rails that either weren’t proper fits or weren’t regularly assessed for the potential for entrapment.
Staff at Edgewood had been working for weeks to protect the resident who died — after 11 falls from bed in three months. The state faulted the facility for failing to do a documented reassessment of the bed-rail risk in the pivotal hours after the first entrapment — in violation of assisted-living licensing requirements that have existed in Minnesota since 2021.
Bed rails are metal or hard plastic frames that are designed to help people sit up and prevent them from rolling out of bed, but a 2021 Canadian review advised them only as a “last resort” because of a lack of evidence that they reduce falls. Their tradeoff risks are well-documented; the Consumer Product Safety Commission updated its guidance this summer on when and how to use bed rails based on 284 entrapment deaths since 2003.
Assisted-living facilities raise unique concerns, because loved ones have more input and control than they do in nursing homes over residents’ rooms, including the installation of bed rails, said Patti Cullen, chief executive of Care Providers of Minnesota.
The trade association created a safety tip sheet, including the need for documented conversations about bed-rail risks with residents or relatives before installing them. Cullen said 116 nursing homes have closed since 2000, which likely leaves assisted-living facilities caring for more patients with complex disabilities and levels of dementia.
Staffing shortages could make matters worse, Caspi said, because caregivers will have to prioritize the immediate physical needs of residents at the expense of risk assessments.
Consumers concerned about maltreatment in Minnesota’s licensed facilities can search their licensure histories on EldercareIQ.org.
(Source: Star Tribune)
