(Roseville, MN)
On December 28, 2016, 88-year-old Ada Yakal was found asphyxiated between her bed and a transfer pole. The pole had been installed to assist her with getting in and out of bed. Ms. Yakal was reported safe and in bed during a routine staff check at 9:00 PM. Sometime between that time and 12:30 AM, she became trapped between the transfer device and her bed.
The stationary vertical pole attached from the floor to the ceiling was installed at the recommendation of her physical therapist. The pole was installed by the facility’s staff. The pole, which was installed only 8 days prior to Ms. Yakal’s death, was inspected for safety by the facility’s staff. Facility’s staff apparently determined the pole was safe.
According to the report produced by the Minnesota Department of Health Sunrise administrator said there were no specific policies about the use of transfer poles. The physical therapists asserted that there was no distance standard for how close the device should be placed to the bed. However, the pole’s manufacturer warnings stated that the pole should not be placed closer than the user’s ability to safely walk around the pole.
Although facility may have performed an internal safety assessment, it appears that they did not adhere to the manufacturer’s instructions. Even though the facility may not have had any policies in place for such devices, Sunrise, which is a national chain of assisted living facilities, should be familiar with the risks that bed rails and other devices may present to patients’ health and life.
Ms. Yakal’s death certificate indicates that the patient’s cause of death was Alzheimer’s Dementia. Andrew Gross, the family’s attorney, said that death certificates of elderly individuals are often incorrectly labeled as Alzheimer’s Dementia. He is unsure at this point why the doctor considered this to be her cause of death Alzheimer’s Dementia. One of the objectives of this investigation is to determine whether the doctor was correct in her analysis.
In its initial investigation, the Minnesota Department of Health cleared the facility of any blame. However, more information was discovered substantiating the allegations of nursing home abuse and neglect. The fact that the Department initially concluded Sunrise had done nothing wrong may raise some serious questions about the Department’s thoroughness.
A Sunrise Assisted Living spokeswoman said the following, “We were surprised by the Department of Health’s decision on this matter. We disagree with the conclusion and will follow up with the department accordingly.”
At this point, it is uncertain whether Sunrise will appeal the decision made by the Department of Health. The attorney for the family of Ada Yakal stated, “Whether Sunrise appeals the decision—I don’t know. Regardless of that, I hope that Sunrise rethinks its policy of ignoring manufacturer’s safety recommendation. There are a lot of vulnerable adults across the country who are entrusted to Sunrise’s care, and lots of vulnerable adults will be exposed to unacceptable levels of danger if Sunrise acts like this throughout the country.”
Report produced by the Minnesota Department of Health:
http://www.health.state.mn.us/divs/fpc/directory/surveyapp/ohfcfindings/hl22361005.pdf
