State cites bed rails as cause of death
11:30 p.m. on Sept. 17, “a nurse aide was performing first rounds to check on the residents and found Resident R1 (Health Department inspection reports do not identify individuals by name) pulseless and without respirations, lying with his body on the floor and his neck between the air mattress and the side rail.” A nursing supervisor pronounced him dead at 11:40.
The inspection report faulted the nursing home for failure to evaluate whether Mr. Frankel had continued need for side rails after developing the pain that disabled use of his left hand. The department stated that side rails are to be used only to help a resident reposition himself or manage a condition when “no reasonable alternatives can be identified. When using side rails for any reason staff will take measures to reduce related risks.”
In their response to the inspection report, Charles Morris officials said any side rails in use at the facility were removed within 12 hours after Mr. Frankel’s death. It said the therapy staff was notified about the need to assist four residents concerned about removal of the rails.
“Therapy referrals will continue to be made for any residents with bed mobility and/or transfer concerns,” according to the response from Charles Morris, a 159bed nonprofit facility owned by the Jewish Association on Aging. “A letter was written announcing to all incoming residents and families that we are now a side rail free center and is placed in the new admission packet.”
Phil Ricci, administrator of Charles Morris, issued a statement Thursday referring to Mr. Frankel’s death as a “tragic accident,” which led to removal of all bed rails “out of an abundance of caution.”
“The well-being of both our residents and their families has always been — and always will be — our top priority,” Mr. Ricci said. “We remain focused on constant improvements to deliver on this promise, which is why we are introducing new approaches aimed at helping our residents to remain mobile and safe.”
Mr. Frankel’s death is under review by the Allegheny County’s District Attorney’s office after it received an investigative report from city police, a district attorney’s spokesman said. Criminal charges are rarely filed, however, in nursing home deaths that have been deemed accidental.
Mr. Frankel’s son, Dan, issued a statement in which he declined to comment on details of the findings or the nursing home’s actions.
“I have spoken at length with Charles Morris administrators,” the legislator said, “and I believe we all agree on the importance of moving forward with the safety and quality of life for current and future residents of the facility topmost in mind.”