Cold Spring nursing home cited in suffocation death caused by bed rail


A nursing home in Cold Spring has been cited by the Minnesota Department of Health after discovering that a woman there died in January, suffocating when her neck became lodged between a mattress and a bed rail.

The Star Tribune reports that the Assumption Nursing Home failed to conduct an assessment of the patient and whether a bed rail was needed, the MDH said Wednesday.

According to KARE 11, citing a 29-page report issued by the health department, the resident was a woman who suffered from dementia, impaired mobility, chronic pain, and a history of falls out of wheel chairs and beds.

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

KMSP-TV quotes Commissioner of Health Dr. Ed Ehlinger as saying, "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."

According to the Strib, the health department acknowledges the home has taken steps to ensure against future incidents.

KSTP-TV says Assumption reported the incident to the MDH Office of Health Facility Complaints, which investigates suspected violations of the Minnesota Vulnerable Adult Protection Act. Channel 5 and the others also report that nationally, between 1985 and 2009, 803 bed rail incidents were reported, with more than half ending in death.

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