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Many on the overnight shift at Edgewood Brainerd sensed the danger of returning a frail resident to a bed with a railing that choked him until his face turned purple.

Workers tried to remove the railing, but couldn't. A manager's email ordered an assessment of the resident and removal of his railing, but a nurse didn't read it in time. Even the resident, who had dementia, was reportedly afraid after being stabilized in a hospital and returned hours later to the same bed.

He was put back in his bed, and this time, the result was fatal. As he slipped off the bed in the early morning of June 11, his head became wedged between the mattress and railing, according to a state investigative report that did not identify the resident.

Eilon Caspi, a national elder-safety advocate, has reviewed hundreds of entrapment reports for his research and was incredulous over the timing: "Eleven hours after the first entrapment, it happens again?"

A cluster of bed-rail entrapments has advocates concerned that the risks are worsening amid staffing shortages and other pressures, particularly in assisted living facilities — which are being pressed to provide more complex care as nursing homes close.

The Minnesota Department of Health issued an alert this fall after documenting five entrapment deaths and one serious injury in state-licensed facilities since December 2022. The state found maltreatment in at least three assisted-living facilities where residents died, including Edgewood.

Investigative reports reveal frustrating circumstances in which facilities traded one problem for another by trying to prevent falls with bed rails that either weren't proper fits or weren't regularly assessed for the potential for entrapment.

Staff at Edgewood had been working for weeks to protect the resident who died — after 11 falls from bed in three months. The man complained that he wasn't comfortable in the donated hospital bed that the facility provided. His wife brought a regular mattress, but it had a tendency to slide off the frame and sat up so high that the bed rails offered no protection, according to the state report.

The state faulted the facility for failing to do a documented reassessment of the bed-rail risk in the pivotal hours after the first entrapment — in violation of assisted-living licensing requirements that have existed in Minnesota since 2021.

"When we fought for licensure, one of the reasons was that nursing assessment was imperative," said Jean Peters, a founding member of Elder Voice Advocates, a nonprofit that works to reduce elder abuse and harm. "Really, it's wrong that it's not being done."

Bed rails are metal or hard plastic frames that are designed to help people sit up and prevent them from rolling out of bed, but a 2021 Canadian review advised them only as a "last resort" because of a lack of evidence that they reduce falls. Their tradeoff risks are well-documented; the Consumer Product Safety Commission updated its guidance this summer on when and how to use bed rails based on 284 entrapment deaths since 2003.

Assisted-living facilities raise unique concerns, because loved ones have more input and control than they do in nursing homes over residents' rooms, including the installation of bed rails, said Patti Cullen, chief executive of Care Providers of Minnesota.

Common scenarios include that "they used one in the hospital and it prevented the fall, they used one at home, (or) they would rather have the bed rail than have their loved one fall," Cullen said. "Sometimes the families are insistent even when we talk to them about the risks."

The trade association created a safety tip sheet, including the need for documented conversations about bed-rail risks with residents or relatives before installing them. Cullen said 116 nursing homes have closed since 2000, which likely leaves assisted-living facilities caring for more patients with complex disabilities and levels of dementia.

Staffing shortages could make matters worse, Caspi said, because caregivers will have to prioritize the immediate physical needs of residents at the expense of risk assessments.

The vacancy rate reached 23% at the height of the COVID-19 pandemic for nursing assistants, who provide much of the care in Minnesota's licensed elder-care facilities. State investments in training and tuition forgiveness helped ease that shortage, but the vacancy rate remained above 17% last year, according to the most recent data.

Caspi said newly proposed federal staffing ratios could increase resident oversight and safety, but they are strongly opposed by Minnesota's nursing home industry, which estimates they will cost $240,000 per year for cash-strapped facilities. The ratios also would only apply to nursing homes.

Assisted living "continues to be disregarded by policy makers and the federal government, essentially giving a green light for continued injurious and deadly neglect," said Caspi, who has faculty appointments at the University of Connecticut and the University of Minnesota.

The state Health Department didn't cite understaffing as a cause of any entrapment deaths, but said in a statement that the cluster is "extremely disheartening" and cause for more safety efforts.

Inspectors "had been citing assisted living facilities for bed-rail safety deficiencies for some time previous to these incidents taking place and it had become a regular point of emphasis for inspectors," the statement said.

An executive vice president of Edgewood Healthcare, which operates the Brainerd facility, declined to comment about the entrapment death.

Maltreatment also was documented at Lilydale Senior Living, where inspectors found that an assessment of bed-rail risks was inconsistent with the model affixed to the bed of a woman dealing with physical weakness and Parkinson's disease. She died after severe entrapment last Christmas Eve day; it took several workers to lift her mattress and free her body.

Inspectors found other beds in the assisted living facility with hazardous gaps between the mattresses and railings.

The Meadows of Wadena has appealed the finding of maltreatment in the July 30 bed-rail death of a woman with Alzheimer's dementia. State inspectors faulted the assisted-living facility for failing to reassess bed-rail risks after the woman's health declined and prevented her from using the bed rails appropriately.

Spokesman Jon Austin called the death an "unforeseeable tragedy and a profound loss" but not proof of maltreatment. "We ... believe an independent examination of the facts will substantiate our position," he said in an email.

Consumers concerned about maltreatment in Minnesota's licensed facilities can search their licensure histories on