Resident of Iowa Nursing Home Dies After Being Suspended Upside Down Over Bed

State investigators have cited Iowa’s Clarion Wellness and Rehabilitation Center for placing a resident in immediate jeopardy. The resident died on March 19 after a grab bar was installed on a bed and the resident’s upper body got stuck between the headboard and grab bar. The resident was suspended upside down for hours, causing positional asphyxiation.

The resident was trying to climb out of bed in the early morning hours but fell over. The resident’s upper body got trapped – their head was on the floor and their feet were in the air.

When the resident was discovered, their face was purple and black, a side effect of blood pooling in the head. Investigators say the resident’s body already had rigor mortis, the Des Moines Register reports.

The medical examiner said the cause of death was positional asphyxiation, which happens when oxygen gets cut off because of one of two things:

• Compression of the chest
• Positioning of the body

State investigators found the facility did not assess the risks of the grab bar before putting it on the bed. The facility did not ask for consent from the resident’s family before installing the device.

A few days before March 19, the worker who discovered the resident suggested placing the mattress on the floor of the room to prevent the resident falling out of bed. The facility did not want the resident sleeping on the floor, but they did not do anything else to reduce the risk of falling.

In August, the Iowa Department of Inspections and Appeals (DIA) began an investigation of the facility and the resident’s death. They told the medical director of the facility residents had been in danger since March 19, meaning the facility had immediate-jeopardy status. Just one day later, the maintenance director and administrator of the facility checked all the beds and trained staff members about bed safety. The DIA decided to remove immediate jeopardy status from the facility.

Some may question why there was a fourth-month delay before the facility was investigated. However, the DIA has a policy of looking into complaints and other problems when a facility is due to be inspected for recertification.

The DIA proposed a fine of $10,000 for Clarion Wellness, but that fine cannot be imposed until federal officials consider whether they want to impose their own fine. This would be the second year in a row the facility has been fined, as it was also fined in 2021.

Unfortunately, this is not the first time an Iowa nursing home resident’s death has involved a bed rail. A Davenport nursing home was fined $10,000 after a resident who had dementia died from positional asphyxiation. She got tangled in her blankets and was found with her neck on a bed rail.

Staff at the facility were never trained on positioning a bed rail, and the bed rail in this resident’s bed was not installed correctly.

Bed rails caused approximately 197,000 deaths between 2003 and 2019, according to the Consumer Product Safety Commission (CPSC). Just days before the resident of Clarion Wellness died, the CPSC began considering rules to deal with the risks of adult portable bedrails.

Contact PKSD to Discuss a Potential Nursing Home Abuse Claim

If your loved one died at a nursing home due to the negligence or intentional actions of staff members, PKSD’s Wisconsin-based nursing home abuse lawyers may be able to help.

We take nursing home abuse cases in Wisconsin, Iowa and New Mexico, and have a proven track record.  We have obtained millions in compensation on behalf of our clients.

An initial consultation is free of charge and comes with no obligation to hire our firm. We know this is a difficult time for you and your family but contacting an experienced attorney can be an important step.

Call PKSD today to learn more: 414-333-3333 .