A resident of St. John's Lutheran Home in Billings died of
strangulation last month when she became entangled in the "mobility bar"
attached to her bed, sparking an investigation by the state Department of
Health and Human Services.
Kent Burgess, president and CEO of St. John's Lutheran Ministries, said
an employee of the health department's Quality Assurance Division
conducted an investigation shortly after the woman died on Jan. 10, and
issued a report about a week ago.
St. John's is in the process of filing a "plan of correction" in
response to the department's report, Burgess said, and the whole file will
be open to the public after that plan is formally submitted.
He said St. John's plan of correction basically amounted to removing
the mobility bars from the 60 beds that were equipped with them, which it
did by Jan. 21. Burgess said the health department also was advising
nursing homes across the state to stop using the bars.
"It fundamentally has devastated this place ... it was just a terrible
accident," Burgess said.
Compounding the tragedy was that the woman, who was in her late 80s,
was a founding member of St. John's volunteer auxiliary, going back more
than 40 years, and was a lifelong member of one of the Lutheran churches
affiliated with St. John's. Burgess said he had known the woman for years
before she came to live at St. John's.
Burgess said the woman, whose name he could not release, was sleeping
peacefully in the skilled nursing unit of St. John's when a nurse checked
on her at 6 a.m. Jan. 10. A hour and a half later, the nurse found the
woman partially out of bed, with her head and one arm entangled in the
mobility bar. The bar is a short steel rod attached to the side of the
bed. It is used by residents to change position or to get out of bed.
Several years ago, Burgess said, nursing homes stopped using the
traditional hospital bedside rail after a nursing home resident on the
Hi-Line became caught in such a rail and died of strangulation. The
mobility bars were simpler and supposedly safer, and were often requested
by families whose loved ones were in the nursing home, Burgess said.
"Nobody thought these bars were a problem," he said.
Burgess said St. John's notified the county coroner and the woman's
physician immediately, and notified the state health department on Monday,
Jan. 12. The state investigation was conducted on Jan. 14.
Mary Dalton, administrator for the Quality Assurance Division, said
early in the afternoon on Wednesday that she would review the file and
then respond to inquiries, but she could not be reached for comment later
in the day.
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