The resident was fine when Sunrise Assisted Living staff checked in around 9 p.m. When staff returned around 12:30 a.m., the resident’s neck was wedged between a bed and a transfer pole, and the resident was no longer breathing, according to a report by the Minnesota Department of Health.
The department determined earlier this month that the Roseville facility was at fault for neglect, having placed the pole too close to the bed.
A Sunrise Assisted Living spokeswoman said they weren’t expecting the blame.
“We were surprised by the Department of Health’s decision on this matter,” a Sunrise spokeswoman said in a statement. “We disagree with the conclusion and will follow up with the department accordingly.”
The stationary, vertical pole was meant to increase the resident’s independence by enabling the resident to rise from a bed or chair. Physical therapy staff had recommended the pole because the resident didn’t like using mechanical devices for helping getting up, the report said.
Physical therapy staff had determined the client could safely use the pole. They reported there was no standard distance for placement of transfer poles, but suggested a fist-width distance, the health department’s report said.
But a manufacturer’s warning said the pole shouldn’t be “closer than the user’s ability to safely walk around the pole or there may be a possibility of becoming entrapped between the pole and the side of any objects adjacent to the pole,” the health department report said.
And that is what appears to have happened to this resident.
“The EMS care report states that the client was wedged and pinned with her/his neck pushed up against the transfer pole. The report also reflects that the client had ecchymosis (blood under the skin) on her/his face and bleeding from the mouth,” the report said.
When staff found the resident, they called 911, moved the bed to free the client, and began CPR until emergency medical services could take over, according to the report.
The client had rolled out of bed at a previous facility as well, the report said.
STATEMENT FROM SUNRISE
The name, gender, age, and date of death of the resident were not included in the report. Sunrise declined to disclose additional information about the resident’s identity. State regulators visited the care center on Jan. 4 on the complaint.
“The safety and well-being of our residents is always our top priority. As we work to resolve this with the Department and due to privacy considerations, we have no additional details to share.”
Sunrise was originally cleared of the blame in March, but after the Department of Health received more information, the report was revised in October to say neglect was substantiated.
A Sunrise spokeswoman said they are following up with the local health department, but did not say whether or not they plan to appeal the decision.
