Healthcare Compliance Perspective:
The inappropriate use of restraints constitutes substandard quality of care, thereby increasing the potential for allegations of fraud, waste and abuse.
Last September, an 89-year-old resident, with Alzheimer’s disease and limited mobility in a Pittsburgh nursing and rehabilitation center, died after he got his neck trapped in the bed rails. The medical examiner ruled the man’s death an accident “due to compression of the neck” that restricted his breathing and caused the man to suffocate.
The details of the incident became public when the Department of Health recently posted a report on its website about the facility being cited for deficiencies related to the death of the resident. According to the report, the use of side bed rails created a hazard that the facility did not identify after the resident’s condition changed, and he could no longer use his left hand to grasp the side rails and assist in his repositioning in the bed. The use of the side rails was initially suggested by the resident’s physician to allow the resident to assist in repositioning himself.
Side rails are not supposed to be used except in situations where they can assist a resident with repositioning, and when that purpose is no longer applicable, they should not be used. They also have sometimes been used to prevent a resident from falling out of their bed.
Officials at the nursing home removed any bed rails being used throughout the facility within 12 hours after the resident’s death, and are now a side rail free facility. This information is being included in the facility’s literature and new admission packets, and new incoming residents and their families are being informed about the side rail free status by mail.
The resident’s death is under review by the county’s district attorney’s office; but, it was noted that in accidental deaths occurring in nursing homes, there are usually no criminal charges filed.
