The Minnesota Department of Health has opened investigations into six separate nursing homes this year due to adverse patient events with bed rails.
This is even after the department published a revised guide on bed rail safety and regulation in February.
In three out of the six investigations, patients reportedly died as a result of some entanglement or entrapment caused by bed rails, reports show.
Since 2023 began, Minnesota has investigated the following bed rail-related adverse events in nursing homes:
- An investigation that concluded Feb. 17 into an incident at Lilydale (Minn.) Senior Living found the facility was at fault after "The facility neglected the resident when a bed rail was placed on the resident's bed without appropriate assessment and follow-up," the report reads. "The resident became entangled in the bed rail and died."
- A separate investigation that concluded April 18 found that Diamond Willow Assisted Living in Baxter, Minn., was at fault after "Facility staff/alleged perpetrators neglected a resident when they left the resident on a bed pan for over three hours," when the individual was found by family members, the resident "was hanging on to the bed rail with both legs off the bed and covered in feces," according to the report. "At the time of the onsite investigation, the resident's bed rails were observed to be very loose and not securely attached to the bed."
- A May 15 investigative report into Suite Living Senior Care in St. Paul, Minn., revealed that the facility was responsible for an incident that left one resident dead. "The facility neglected a resident when they failed to reassess a bed rail consistent with the manufacturer’s recommendations for monitoring and the resident became trapped and died," the report states.
- A June 7 report investigating an incident at Arlington Place in St. Joseph, Minn., found the facility at fault after "The facility neglected a resident when the resident was found on the floor, on his knees in front of the bed with his head stuck between the bed rails and the mattress," according to the repot. "The resident's face was purple in color."
- A state investigation into Edgewood Brainerd (Minn.) Senior Living published July 11 found it responsible for maltreatment of a resident and for failing to ensure safety after they had fallen out of bed, returned 11 hours later only to have the same thing happen again, this time resulting in the resident's death. "The facility failed to reassess the resident and take proper safety measures to prevent harm when the resident returned from the emergency room after he was found entrapped in his bed rail," the report states. Approximately 11 hours later, the resident became entrapped in the bed rail a second time and died."
- An Aug. 19 investigation by the state into Meadows of Wadena (Minn.) found that the assisted living facility was responsible for a resident's death after it failed to "assess the resident’s ability to use bed rails after she experienced a change in condition," according to the report. "The resident became entrapped in a bed rail and died."
The rise in these adverse events is not unique to Minnesota; adverse events related to bed rails is a growing issue nationally. In July, the U.S. Consumer Product Safety Commission published a new federal standard for bed rails and cited safety as a primary concern prompting it to do so.
According to the agency's July 6 statement, it "identified 284 entrapment deaths involving adult portable bed rails between January 2003 and December 2021."
The FDA also updated its guidance on bed rail safety for clinical providers in February 2023.