A nursing home resident suffocated after being pinned headfirst behind a grab bar the facility installed without assessing risk factors, a state investigation has found.
The Clarion Wellness and Rehabilitation Center in Wright County, Iowa, was under investigation by the state after the resident died in March, which included a visit to the facility last month.
The resident was getting out of bed in the early hours of March 19 when he fell forward, according to the Iowa Department of Inspections and Appeals (DIA) report obtained by Iowa Capital Dispatch.
Her torso was then pinched between the headboard and the grab bar, which they allegedly installed in June 2021 without the consent of the resident’s family.
It was several hours before a worker found the resident hanging upside down from the edge of the bed.
The resident’s head rested on the floor and his feet hovered in the air above the bed.
Her face was turning purple and black from the pool of blood and rigor mortis, which is the stiffening of joints and muscles that occurs a few hours after death, had already set in, according to inspectors.
A worker said the scene was a “horrible sight”.
According to the coroner, the resident eventually died of positional asphyxiation, which occurs when someone is cut off from oxygen supply from the compression of their chest or because of the angle of their body.
A worker wanted to remove the bed from the resident’s room a few days before the incident.
They suggested placing a mattress on the floor for the resident to sleep on to prevent an increased risk of the resident falling out of bed.
However, the interdisciplinary team at the nursing home rejected the idea.
The director of care later told inspectors it would not have been right to let the resident sleep “like a dog” on the floor.
There is no evidence that the nursing home provided other options to address the risk of the resident falling out of bed.
A Federal Consumer Product Safety Commission official said in March that portable bed rails for adults “have trapped and strangled older adults with an alarming frequency.”
The commission estimated that nearly 197,000 people were injured or killed by the devices between 2003 and 2019.
DIA placed the facility on imminent danger status four and a half months after the resident’s death and said it had been in that state since May 19.
They then had all the beds evaluated by the maintenance manager and administrator, and the staff received bed safety training.
The DIA subsequently lifted the facility’s imminent threat status.
However, the department has fined the suspended nursing home $10,000.
They are waiting to see if federal officials want to impose their own fine on the facility.
The US Sun reached out to the nursing home for comment, but none had been received at the time of publication.
The Iowa Department of Inspections and Appeals was also contacted by The US Sun for the full report but has not yet responded.
https://www.the-sun.com/news/6360188/nursing-home-resident-dies-suffocation-trapped/ Horror details emerge after a nursing home resident suffocates while being hung upside down