Resident Trapped in Bed Rails At Oak Park Senior Living
According to a report from the Minnesota Department of Health, Oak Park Senior Living neglected a resident when the staff failed to provide supervision, as a result, the resident remained pinned between the bed frame and side rail for two days and sustained injuries.
The Minnesota Department of Health determined neglect was substantiated. The facility was responsible for the maltreatment. The facility failed to assess the resident’s mobility devices, including the bed rail he used because nurses did not complete assessments in the resident’s room and did not verify information “carried over” from a previous assessment was still accurate and current. The resident fell, became entrapped in the device, unable to use his call pendant and was stuck for a prolonged amount of time that ceased circulation to his arm and caused rhabdomyolysis (a life-threatening condition from muscle tissue breakdown by being in a position for a prolonged period of time and release of body toxins into the bloodstream). The resident died of complications from entrapment.
MDH Substanitated Neglect Against Oak Park Senior Living
The report goes on to state that the investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigator contacted home care agencies and an emergency responder. The investigation included review of the resident records, death record, hospital records, facility internal investigation, facility incident reports, personnel files, and related facility policy and procedures. Also, the investigator toured the facility and observed staff providing safety checks and observed resident rooms. The resident resided in an assisted living facility.
The resident’s diagnoses included diabetes, asthma, and high blood pressure. The resident had a history of falling. Initially the resident moved into the facility after he fell and sustained a hip fracture. During this time, he required extensive help from staff. The resident recovered from his injury and required less help so he moved to a different apartment within the facility.
The resident’s service plan included assistance with weekly housekeeping, twice weekly showers, and one daily safety check scheduled at 10:00 a.m. The resident’s nursing assessment indicated he was independent with mobility but required an electric wheelchair. The resident was alert and orientated, but forgetful.
During an interview, a family member said the resident’s assistive devices included use of a walker, manual wheelchair, electric wheelchair, over-the toilet commode, a bath bench and a four wheeled walker with a seat. The family member stated he thought the resident had the bed rail for over a year. The resident used the bed rail to hold his wedge pillow in place to keep him in an upright position for better breathing while sleeping. The family member said staff were in the resident’s room daily and did not tell him he could not use the bed rail. The family member said they were concerned the resident did not receive his morning safety check.
In conclusion, the Minnesota Department of Health determined neglect was substantiated.
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