A ‘horrible sight’: Nursing home resident suffocates while suspended upside down

An Iowa nursing home where a resident suffocated after becoming wedged between a bed and a safety device has been cited by the state.

State records indicate the Clarion Wellness and Rehabilitation Center in Wright County was cited for placing its residents in immediate jeopardy. The citation covered the period between the date of a resident’s death on March 19 and the first week of September, when state investigators visited the facility and investigated the matter.

According to the inspectors’ report, Clarion Wellness had installed a grab bar — also known as an assistance handle or bed bar – on a resident’s bed in June 2021. The facility installed the device without first assessing the risk it might pose and without obtaining consent from the resident’s family, the inspector reported.

In the early hours of March 19, that resident began climbing out of bed, and apparently fell forward with their upper body becoming trapped between the headboard and the grab bar. A few hours later, a worker entered the room and found the resident suspended upside down off the side of the bed.

The resident’s torso was wedged between the headboard and the grab bar, with their head resting on the floor and their feet suspended in the air over the bed. The resident’s face had turned purple and black due to the pooling of blood, and rigor mortis had already begun to set in, according to inspectors.

A worker described the scene to inspectors as a “horrible sight,” and said the resident “obviously got caught between the headboard and the grab bar.” A medical examiner determined the resident died of positional asphyxiation – a situation in which an individual’s oxygen supply is cut off due to compression of the chest or the angle of their body.

A few days before the death, a worker had proposed removing the bed from the resident’s room and placing the mattress on the floor to address an increased risk of the resident falling out of the bed.

According to inspectors, the home’s interdisciplinary team rejected that plan, and the director of nursing later told inspectors it wouldn’t have been right to have the resident sleeping on the floor “like a dog.” However, there was no evidence the facility implemented other interventions to address the risk of falling.

Four and a half months later, after initiating an investigation of the death, the Iowa Department of Inspections and Appeals informed the home’s medical director that residents of the facility were in immediate jeopardy and had been since March 19. The next day, the facility had all of the beds in the facility evaluated by the maintenance director and administrator, and the staff was trained on bed safety. DIA then lifted the immediate-jeopardy status.

The four-month delay in investigating the matter appears to be the result of DIA’s policy of investigating complaints and self-reported incidents when a facility is due for a scheduled recertification inspection. In Clarion Wellness’ case, the recertification visit was conducted this month and, while there, the inspectors looked into one self-reported incident and two complaints that were deemed substantiated.

DIA’s $10,000 fine against the home has been held in suspension while federal officials consider imposing a fine of their own. According to the Centers for Medicare and Medicaid Services, the most recent federal fine imposed against the facility was in 2021.

Devices are under federal review 

State records indicate other Iowans have died under similar circumstances involving bed rails.

In 2019, Senior Star at Elmore Place, an assisted living center in Davenport, was fined $10,000 after a resident with dementia was found dead, tangled in her blankets, with her neck resting on a U-shaped bed rail that was intended to help her reposition herself in bed.

An autopsy showed the woman died from positional asphyxiation. The director of nursing later told state inspectors the staff had not received any training on the use or positioning of the bed rail, which appeared to have been incorrectly installed.

The federal Consumer Product Safety Commission has estimated that between 2003 and 2019, almost 197,000 people were injured or killed by portable bed rails for adults.

In March, a few days before the death at Clarion Wellness, the commission began the process of rulemaking to address the risks posed by adult portable bedrails.

At the time, one commissioner stated the devices “have trapped and strangled older adults at alarming rates” and said that between the time various public health groups had petitioned the commission to take action and the commission’s decision to do so, at least 129 people were killed by adult portable bed rails.

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