The Minnesota Department of Health (MDH) has substantiated neglect in the case of a resident who died after becoming trapped between his bed frame and bed rail at an assisted living facility in December 2024. The investigation was concluded on April 8, 2025.
According to the MDH report, on December 28, an unlicensed staff member found the resident on the floor with his arm wedged between the bed and bed rail, and his feet pinned under his electric wheelchair. A law enforcement report indicated officers responded to a 911 call and assisted paramedics in removing the bed rail to free the resident. He told officers he had been trapped for two days and had been unable to use his call pendant.
The resident was transported to the hospital and diagnosed with rhabdomyolysis, caused by prolonged pressure that restricted circulation to his arm, and sepsis from a skin infection. He died four days later. The medical examiner listed the cause of death as complications of prolonged entrapment.
Investigators found the facility did not complete a required assessment of the resident’s bed rail. Although the resident’s service plan indicated he used a bed rail, the associated safety assessment was not performed. Multiple nursing assessments contained outdated or inaccurate information that had been carried over from previous evaluations.
The resident had a history of falls and had initially moved into the facility after a hip fracture. His service plan at the time of the incident included a daily safety check at 10:00 a.m., along with assistance for housekeeping and twice-weekly showers. The MDH noted that safety checks were not consistently documented or conducted.
The investigation included staff interviews, a review of records and policies, and an on-site observation. Based on their findings, the MDH determined the facility was responsible for the resident’s neglect due to failure to assess the bed rail and provide adequate supervision.
Compliance Perspective
Issue
Ensuring the safety of residents who use bed rails is critical to prevent risks such as entrapment or injury. Facilities should assess the need for bed rails and consider alternatives where appropriate, ensuring that any bed rails used are compatible with the bed frame and mattress to avoid dangerous gaps. Regular inspections should be conducted to identify wear, damage, or potential hazards, including entrapment risks. Adequate supervision of residents is also essential to promptly address any issues with mobility or safety. Additionally, whenever there is a change in a resident’s condition or mobility, an updated assessment should be performed to confirm that the bed rails are still appropriate and used safely.
Discussion Points
- Review and update policies and procedures for resident safety, specifically addressing entrapment risks and bed safety checks. Ensure they reflect current best practices and regulatory guidelines. Incorporate protocols for regular resident assessments to determine if bed rails and other safety devices are appropriate based on changes in the resident’s condition.
- Train all appropriate staff on resident safety policies and procedures, with a focus on entrapment risks and the proper use of bed safety checks. Include maintenance staff in training to ensure they understand the correct procedures for assessing bed rails and associated equipment. Emphasize the importance of communication among staff to relay any updates or concerns regarding resident safety.
- Conduct regular audits to verify that bed safety checks are being performed consistently and correctly. Utilize available resources such as the Guidance for Industry and FDA Staff – Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment to assist in conducting thorough entrapment risk assessments for all beds, whether bed rails are in use or not.
*This news alert has been prepared by Med-Net Concepts, Inc. for informational purposes only and is not intended to provide legal advice.*