Assumption Home Cold Spring – Neglect – Entrapment in Bed
In a report concluded on April 18, 2013, MDH cites Assumption Home for neglect of health care entrapment in bed grab bar.
It is alleged that neglect occurred when a resident was found deceased with her head caught in the grab bar.
Entrapment in Bed – Bed Rail – Assumption Home Cold Spring
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. The resident’s neck became entrapped in the grab bar and resident died of positional asphyxiation.
At the time of the resident’s death, the resident was found on the floor by staff with the resident’s head between the left grab bar and the mattress. A staff member indicates that upon discovery of the resident, it appeared the resident’s neck was “stuck between the mattress and the grab bar”. When staff assessed the resident, they were unable to obtain vital signs and the resident was pronounced dead.
The resident’s death certificate listed the cause of death as positional asphyxia and neck entrapment between the mattress and bedrail.
The bed the resident used was observed it was a hi/low bed with grab bars attached to both the right and left side of the bed.
For more information from the Minnesota Department of Health, Office of Health Facility Complaints concerning nursing homes, assisted living and other elder care providers view resolved complaints at the MDH website.