The Illinois Department of Health has cited and fined Axiom Healthcare Of Mount Vernon when a resident with dementia and Parkinson’s disease died from positional asphyxiation after his head became trapped between a bed rail and mattress. The facility failed to properly assess bed rail safety, obtain proper physician orders, or implement adequate monitoring for a resident with known history of trying to exit his bed.
The incident involved an 82-year-old male resident with multiple medical conditions including Parkinson’s disease, Type 2 diabetes, morbid obesity, dementia, and hydrocephalus. The resident was described as having severe cognitive impairment and was known to frequently attempt to exit his bed by “throwing his legs out.”
In the early morning hours, a Certified Nursing Assistant (CNA) found the resident in a compromised position with “his head lodged between the mattress and handrail” while his body was sitting on the floor. According to the coroner’s report, the cause of death was determined to be “positional asphyxiation” with the death certificate specifically noting the resident was “found in a seated position on floor beside bed” with “legs straight out and head and neck between mattress and bed rail.”
Investigation revealed numerous failures in the facility’s bed rail assessment and safety protocols. Though the facility had obtained a consent form for half side rails on the day of admission, they failed to complete proper assessments, obtain physician orders, or document the rails in the resident’s care plan. The facility’s own bed rail evaluation forms were incomplete, with the bottom sections where the Interdisciplinary Team makes determinations about bed rails left blank with “no staff signatures, initials or dates.”
Even more concerning, the evaluation incorrectly answered “Y” or yes to two critical questions: “Does the bar prevent resident from exiting bed? (Yes = Restraint)” and “Does the bar interfere with the resident’s access to their own body? (Yes = Restraint),” indicating staff knew the rails were being used as restraints rather than for mobility assistance.
Multiple staff interviews exposed systemic failures in the facility’s bed rail program. The Director of Nursing stated she “wasn’t familiar with Side Rail Assessments” and “was not sure who does them.”
The Maintenance Director admitted he “did not know anything about” checking the gap between the side rail and mattress, had not been routinely inspecting installed bed rails, and discovered an unused inspection log book that “has not been kept up or has not been done for a long time, the last one done was in 2023.”
The Administrator revealed a concerning process for bed rail installation, stating “sometimes the family wants them on so we put them on, and sometimes physical therapy may recommend.” The resident’s family member/Power of Attorney stated she “[doesn’t] ever remember signing a consent for side rails” and “just doesn’t understand why they had the side rails on except to keep him in the bed.”
Physical examination of the bed involved in the incident revealed significant safety hazards. The bed had “an air loss mattress on it with metal 1/2 side rail in place and gaps were observed between the mattress and the side rails.” When measured, the gap was approximately 4 1/4 inches, expanding to 5 inches when someone sat on the mattress. When the surveyor grabbed the rail, “it was loose and moved outward” creating a 7 1/8-inch gap—more than enough space for entrapment to occur. One nurse described the rails as “the old brown metal ones that mount on the bed and were very big” with “at least a 6-inch gap” between the rail and mattress. Another staff member acknowledged that the “side rails were too big, they were just too big for the bed.”
The resident’s death appears to have occurred during an attempt to exit his bed—something staff knew he frequently tried to do. The CNA who found him noted “the resident was really wet, and he was poopy too,” suggesting he may have been trying to get up to use the bathroom. Despite his known history of exit attempts and a recent fall assessment documenting “attempting to sit on side of bed independently,” the facility failed to implement adequate monitoring or safety measures. Staff admitted they had not checked on him between 10:00 PM and 1:00 AM, and while the resident had been ordered to have a “pin alarm to person while awake,” this alarm was not in use while he was in bed.
One of our core beliefs is that nursing homes are built to fail due to the business model they follow and that unnecessary accidental injuries and wrongful deaths of nursing home residents are the inevitable result. Our experienced Chicago nursing home lawyers are ready to help you understand what happened, why, and what your rights are. Contact us to get the help you need.
