An MDH investigation has found neglect of a resident at Assumption Home in Cold Spring related to the resident dying of asphyxiation after the resident's neck became lodged between the bed's mattress and bed rail.

MDH found that the nursing home should be cited for neglect because there was no evidence that the nursing home assessed the risks versus benefits of using a bed rail, sometimes called a grab bar.

"Nursing homes are entrusted with the care of vulnerable adults and a death like this is totally unacceptable," said Commissioner of Health Dr. Ed Ehlinger. "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."

Because bed rails are a known risk for strangulation for some patients, health care providers are required to assess whether the potential benefits of the device outweigh the dangers.

State and federal guidelines require all health settings using bed rails to conduct an individual assessment and evaluation with certain patients, such as those with dementia, to assess the risks of using the devices. MDH could find no evidence that Assumption Home completed the required assessment for bed rails.

The resident in this case suffered from dementia, impaired mobility, chronic pain, and a history of falls out of wheel chairs and beds. MDH is not able to identify the vulnerable adults involved in investigations or other private data in these incidents, according to Minnesota law,

After the incident, Assumption reported the incident to the MDH Office of Health Facility Complaints, which investigates suspected violations of regulations and the Minnesota Vulnerable Adult Protection Act. To get back in compliance, the facility put together a corrective plan that was implemented and confirmed by an MDH site visit.

Bed rails can be used to enhance the mobility of residents by assisting with movement in bed, sitting up or getting out of bed. However, when bed rails prevent a resident from leaving the bed, they are considered a form of physical restraint.

The increased recognition of serious injuries and deaths associated with bed rail use prompted the FDA to issue an alert in 1995. Bed rails can be especially hazardous for demented or agitated individuals. Nationally, between 1985 and 2009, 803 incidents related to bed rails, of which more than half resulted in death, were reported to the U.S. Food and Drug Administration.

"We encourage families and seniors to discuss the issue of bed rails with their care team so that a proper assessment can be done to find the safest option," Ehlinger said.

For more information, visit this FDA site about hospital bed safety:

The investigation report is available at