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Man dies after allegedly being trapped in bed rail at nursing home

Cristina Howorun | posted Tuesday, Jun 19th, 2018

Danny McNeill died alone, allegedly trapped in his bed rail, his 69-year-old body apparently fighting desperately to escape the very rails that were supposed to protect him. That’s how his son, Kevin, describes his father’s final minutes and death at the Maple Manor Long Term Care Home in Tillsonburg.

According to Health Canada there have been 25 reported incidents involving bed entrapment over the past two years, seven were fatal. Since 2008 Health Canada has issued several safety communications about the use of bed rails as restraints in hospitals and long term care homes — most recently in April 2017 — yet they are still used in most homes and hospitals.

“That’s why I’m here, to let people know that they’re being used. Our family members are using them and getting their heads trapped in them,” Kevin McNeill told CityNews. “I’m disgusted.”

“He got trapped between the bars of his bed rail and mattress. That was the call. They said he had died and that was pretty much it,” McNeill says, recalling the phone call he got from the home last Sunday.

McNeill doesn’t know why the restrains were in use. He says an alarm should’ve sounded when his father fell from the bed.

“If he was to fall off the bed or make a movement, the alarm would go off and notify the nursing station and buzz at the bed as well. In the case of falling, the alarm goes off,” he explains.

“The alarm should have been going off as soon as he probably left the area of the pad. He made it to the floor and got his head trapped for too long. That was the case. We really don’t know how long it took until that alarm was heard. I don’t know if they heard.”

In a statement, Maple Manor’s administrator Marlene Van Ham would only say: “We are deeply saddened by this incident. As this matter is presently under investigation we cannot comment on the specifics.”

Van Ham refused to tell CityNews if the home had set standardized response times for alarms, or if the alarm even sounded.

The home has been cited for safety violations involving both the use of restraints and bed rails in the past — including in 2016 when inspectors found that the “licencee (had) failed to ensure that no resident of the home was restrained by the use of a physical device.”

In 2015, the home was cited for failing to ensure that where bed rails were “used in the home (it) had taken steps to avoid patient entrapment” and later that year, 36 of 108 beds were identified as “failed” — in some cases because of a lack of mattress keepers or rails that required ongoing tightening.

Staff at the home told Ministry of Health inspectors that they had received no training on rail safety.

Van Ham refused to tell CityNews if staff had been trained on bed rail safety recently, both via email and when we visited her office in Tillsonburg.

When asked about this incident and the investigation, Ministry of Health spokesperson David Jensen told CityNews in an emailed statement: “The ministry is aware of the issue and is unable to comment on the specifics of this incidents, as per requirements under the Personal Health Information Act.”

McNeill is still very much grieving the loss of his father but says the practice of using bed rails has to be re-examined.

“Maybe they’ve got to change those rails and make sure we’re not using them as restraints, just using them for getting out of bed. i didn’t know what they were used for until I did some research myself. gotta let people know.”


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