The Minnesota Department of Health has cited a Cold Spring nursing home with neglect after a resident died of asphyxiation.
The department's investigation of Assumption Home found that the facility didn't assess the risks of using a bed rail for a patient suffering from dementia. The resident, who also had a history of falls, died after becoming lodged between the bed's mattress and bed rail.
Dr. Ed Ehlinger, Minnesota's health commissioner, said bed rails are a known strangulation risk and any facility that uses them should evaluate whether they are necessary. "Even though this doesn't happen a lot, it does happen," he said. "And so every nursing home and every facility that's working with vulnerable adults needs to know about how to do an assessment for the use of the bed rails."
Assumption Home administrator Jan Luthens said the home reported the death to the state when it happened and has responded appropriately.
"We reviewed all our residents and where they were at in their plan of care and made some changes there," Luthens said.
She added the home was not fined.
Between 1985 and 2009 there were 803 incidents related to bed rails in the United States. More than half of those incidents resulted in death.