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 DAVID P. GILKEY/Detroit Free Press Phyllis Moga worries that her mother, Willene Richardson, could get her head stuck in the rails of her bed at Rivergate Terrace nursing home. But without the rails, Moga said, her bedridden mother "fell out of bed a couple of times."
Dangerous gaps in Michigan, deaths reflect national trend
February 8, 2000
BY ALISON YOUNG
At least five Michigan nursing home residents died last year in incidents involving the safety rails that were supposed to protect them from falling out of bed, according to records obtained by the Free Press. At least 14 other elderly residents were injured as they climbed over or became entangled in the rails.
Some of the cases are horrific: A 78-year-old woman died in Warren with her leg entangled in bed rails, her neck bleeding and her head in a trash can. An 84-year-old woman died in Traverse City -- a bed rail in her mouth. A 79-year-old man in Grandville suffocated when his body became wedged between the mattress and side rail.
Emma Boeling, 93, suffocated in "a death akin to hanging," said Macomb County Medical Examiner Werner Spitz, whose office performed her autopsy.
Boeling became entrapped between the mattress and rail of her bed at Lakepointe Villa in Clinton Township. Home officials are appealing a citation in the case.
"What were we paying these people for?" asked Erwin King, Boeling's nephew. "She had two ribs broken. She had to be thrashing around pretty bad there. So somebody had to be asleep not to hear her."
Such deaths are nothing new in Michigan or across the country. Indeed, hundreds of frail, elderly people have been suffocating and strangling in hospital beds for decades. Federal regulators have long known about the dangers. So have nursing home administrators and bed manufacturers.
But little has been done and people keep dying. Many of Michigan's 50,000 nursing home residents, like 80-year-old Willene Richardson, remain at risk.
"I worry about the danger from her head becoming caught in the side rails," said Phyllis Moga of Lincoln Park, Richardson's daughter. "She couldn't really save herself if that happened."
At the same time Moga fears that her mother, who lives at the Rivergate Terrace nursing home in Riverview, will fall from bed. "She fell out of bed a couple of times without side rails," Moga said.
While federal regulators in the 1970s aggressively took action to close dangerous gaps between the rails of baby cribs, there is still no government regulation of the gaps in hospital beds and bed rails. The U.S. Food and Drug Administration may issue voluntary manufacturer guidelines later this year.
Frustrating position
All this frustrates advocates for the elderly and geriatricians who have published study after study about the dangers of bed side rails, yet continued to watch the death toll rise.
"Used inappropriately or improperly, a seemingly innocent set of bed side rails can turn a nursing home resident's bed into a virtual deathtrap," said Michael Connors, an organizer with the Michigan Campaign for Quality Care. The grassroots advocacy group, which is working to improve care in the state's 450 nursing homes, last week asked state regulators to send out an alert to all Michigan facilities.
"Where are the public warnings and action? How many more people have to die before serious action is taken?" asked Connors, whose monitoring of state records discovered the rash of Michigan bed rail cases.
Nursing home industry officials said homes are aware of the dangers and do their best to protect residents. They said they are often under pressure from residents and their families to use bed rails.
"Most homes try to take steps to see that these things don't happen," said Gary Ellens, director of regulatory services at the Michigan Association of Homes and Services for the Aging. "Obviously from the record you just read to me, they're not always succeeding."
The U.S. Food and Drug Administration has received reports of 370 bed rail entrapment incidents nationwide between January 1985 and December 1999. Of them, 227 resulted in deaths, 90 in injuries, and 53 involved no injury.
But Dr. Larry Kessler, a director at the FDA's Center for Devices, said these numbers represent only a fraction of all bed rail incidents. Even though health care providers are required by law to report all deaths, injuries and life-threatening incidents involving hospital beds, they often don't.
Of 19 death and injury incidents in Michigan in 1999 that were examined by the Free Press, only one had been reported to the FDA, an agency spokeswoman said.
Failing to file reports is punishable by fines and imprisonment.
Bed manufacturers contend deaths and injuries are rare, considering there are more than 1.5 million beds in U.S. nursing homes.
"Whenever there is a loss of life it's a tragedy that merits review," said Chris Feeney, a spokesman for Hill-Rom, one of the nation's leading bed manufacturers. But "the vast majority of these products are being used safely and effectively to benefit the patient."
In August 1995 the FDA issued a safety alert to all of the nation's nursing homes, hospitals, hospices, home health care agencies, biomedical engineers and their industry associations. The alert included a description of the most common ways people become entangled in bed rails.
The incidents often happen in nursing homes, where most frail elderly people are cared for. But they also have been reported in hospitals and home-health care settings, records show.
The FDA advisory warned health care providers that rails shouldn't be used with certain patients and urged them to closely monitor beds for gaps, being especially careful to make sure replacement mattresses fit snugly.
Seeking solutions
Four and a half years and 155 deaths later, the FDA now is holding meetings among regulators, bed manufacturers, health care industry officials and patient advocates. The goal of the task force, convened last April, is to find better ways to reduce the dangers of side rails through education and possibly changes in the ways bed rails are manufactured.
Reaching a consensus can prove tricky, however.
"There are folks within this group who are advocating eliminating side rails," said Jim Utterback, an attorney for Hill-Rom, a bed manufacturer involved in the FDA group. "But what we're finding is that caregiver groups are responding negatively because they perceive an increased risk of falls."
Dr. Steven Miles, a professor of geriatric medicine at the University of Minnesota, author of two studies about bed rail deaths, blames U.S. regulators for not doing more sooner.
"There was a total breakdown at the FDA and the Consumer Product Safety Commission in monitoring over a long period of time a whole series of reports coming into them of these entrapment injuries," Miles said. "They did not respond. They did not bring together the manufacturers. All they did was file the reports away."
FDA officials, bed manufacturers and representatives of the nursing home industry contend the issue is far more complicated and that they have been working to reduce the hazards.
"I would love to tell you it was one thing. If it was one thing, we'd fix it tomorrow," said Kessler.
"It's not that there is any unsafe product on the market," Kessler said. Rather, he said, it's the combination of certain types of patients with certain types of beds, mattresses and bed rails.
Sometimes all these bed components were made by one manufacturer. Often they are an ill-fitting hodgepodge cobbled together from different companies as individual parts -- especially mattresses -- wear out during a bed's 25-year lifespan.
As a result, it is not uncommon to find replacement mattresses that are too small for older bed frames -- leaving gaps that infirm patients can easily roll into.
The equipment issue is further compounded by nursing homes and hospitals that use bed rails for the wrong reasons and with the wrong kinds of patients.
"That's what makes this situation so complicated," Kessler said.
Nursing home regulators at the Michigan Department of Consumer and Industry Services said they regularly look for bed rail dangers when inspecting nursing homes and write up violations.
In the past year, inspectors have identified gaps as large as nine inches on the beds at some nursing homes and ordered the problems fixed.
ALISON YOUNG can be reached at 248-586-2603 or at young@freepress.com. Staff writers David Zeman, Emilia Askari and Patricia Montemurri contributed to this report.
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