The Illinois Department of Health has cited and fined Serenity Estates of Lincolnshire when a 92-year-old resident with dementia became trapped between her bed rail and mattress, resulting in a broken arm. The facility failed to properly assess entrapment risks and obtain required consent before using bed rails as assistive devices.
The resident, who has dementia with agitation and typically requires partial to moderate assistance with transfers, was discovered in distress by nursing staff responding to a call light. However, the call light had been activated by her roommate, not the resident herself, as staff noted that the resident “never calls for help” and doesn’t remember to use her call light despite repeated reminders. When the Licensed Practical Nurse entered the room, she found the resident kneeling on the floor with her wheelchair positioned behind her and her right arm trapped between the mattress and side rail. The resident was complaining of severe pain and was unable to move her right arm.
The facility’s investigation revealed significant gaps in care and safety protocols. Staff members provided conflicting accounts of the resident’s transfer abilities, with some stating she could “safely transfer herself” while others noted she required “one-person extensive assist” and was “weak and does not ambulate.”
The Director of Nursing acknowledged that the resident was “high fall risk” but was uncertain whether proper consent had been obtained for the use of side rails. Multiple staff members noted that the resident “does not use her call light for assistance” and “needs to be supervised” because “if she is left alone, she will attempt to get up.” One nurse stated that “frequent monitoring and supervision could have prevented the incident.”
An inspection of the bed revealed a dangerous gap between the mattress and side rail that was “wide enough for her arm to fall through to get trapped.” This directly violated the facility’s own bed rail policy, which explicitly states that facilities must “ensure the bed frame, bed rail and mattress do not leave a gap wide enough to entrap a resident’s head or body.”
The policy also requires informed consent from the resident or representative before installing bed rails, along with a physician’s order specifying the medical reason for their use. The resident’s care plan indicated she was supposed to use “bilateral half side rails to enhance functional independence,” but staff admitted uncertainty about whether proper consent had been obtained.
X-ray results confirmed the resident suffered a “comminuted fracture of the right humeral neck,” meaning her upper arm bone was broken in multiple places. She was hospitalized for treatment of this serious injury.
The resident’s fall risk assessment had previously identified her as having a “weak gait” and tendency to “overestimate or forget her limits,” yet appropriate preventive measures were not consistently implemented. The facility’s own policies required additional interventions for high-risk residents, including “increased frequency of rounds, sitter if needed, low bed, alternate call system access, and scheduled toileting assistance.” However, staff statements suggest these protocols were not adequately followed, with nursing personnel split between multiple units and the resident left unsupervised despite her documented need for constant monitoring due to her dementia and fall risk status.
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