Bed rail deaths probed

April 13, 2000|By RICHARD F. BELISLE, Waynesboro

WAYNESBORO, Pa. - Three women at a Quincy Township nursing home died in a recent 13-month period, each after becoming trapped between their mattress and the bed rail, according to the Franklin County coroner.

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The Pennsylvania Department of Health fined the home $2,500 after one of the deaths, a Health Department spokesman said Thursday.

The deaths occurred between June 1998 and July 1999 at Quincy United Methodist Home at 6596 Orchard Road.

Coroner Jeffrey R. Conner identified the three women as Virginia C. Seville, 75, who died on June 2, 1998; Mildred I. Rockwell, 93, who died Sept. 25, 1998; and Florence A. Kipe, 93, who died July 2, 1999.

Quincy Home President and Chief Executive Officer M. Kenneth Bricker declined to comment. He issued a prepared statement Thursday that said the home has cooperated fully with an investigation carried out by local and state authorities.


The statement said Quincy Home had consulted with Hil-Rom, the company that made the Model 860 hospital beds in use there, and repositioned the side rails to prevent future problems.

In each case, the patient slipped between the mattress and side rail and became trapped, then asphyxiated, Conner said.

Pennsylvania State Police began an investigation at the request of nursing home officials following Rockwell's death, Conner said.

The cause of death for Seville and Kipe was originally listed as heart-related, Conner said. "It was believed that they died from heart failure and had slipped under the rails," he said.

Seville and Kipe were found with their chests stuck between the bed frame and the rail, Conner said.

Rockwell was found with her head and neck in the rail opening, and the rail was in the up position at the time, Conner said. Her death was attributed to positional asphyxia. Conner said she suffocated because of her position in the rails.

When nursing home personnel discovered that Seville and Rockwell had been found in the same position, they called police to investigate the possibility of foul play, Conner said.

The investigation produced no evidence of foul play, he said, adding that nursing home administrators cooperated with the investigations.

Conner said his office first realized there was a connection in all three deaths when it compared photographs of the first two women with those taken by state police. Investigators decided that the third death was too similar to ignore, he said.

Investigating agencies included Conner's office, state police and the state Health Department.

Conner said he and state police investigators had showed the results of their investigations to the Pennsylvania Attorney General's Medical and Legal Advisory Board.

The board, which meets quarterly, is made up of coroners, state police officers, physicians, forensic pathologists and prosecutors. They review cases like the ones in Quincy and render advisory opinions on cause of death.

The board's opinions are confidential, said Sean Connolly, spokesman for the Attorney General's Office.

Conner said the advisory board concurred with the findings of the local investigators. He said that on Feb. 14 he issued three new death certificates, which listed the cause of the women's deaths as positional asphyxia.

Conner said he reported the deaths to the federal Consumer Products Safety Commission and was told it could take six to eight months to get a reply.

Richard McGarvey, spokesman for the state Health Department, said Quincy Home was fined in the Rockwell incident because the agency did not believe it properly investigated the cause of her death.

He said the department found no wrongdoing in the deaths of Seville and Kipe. "If the home did anything wrong, we could not determine it," he said.

Jane Sheffield, Virginia C. Seville's daughter, said from her home in McConnellsburg, Pa., that she and her two sisters have hired a Harrisburg, Pa., law firm to look into the matter.

"We don't want what happened to our mother to happen to another family," she said.

Sheffield said that on the day her mother died a doctor called her sister in Hagerstown and told her that her mother had died as the result of an accident. But the death certificate said she died from a heart attack, Sheffield said. The death certificate was changed later to death by asphyxiation, she said.

Seville had Alzheimer's disease and other ailments, her daughter said. She had been a resident of Quincy Home for about a year at the time of her death.

"We used to go in a lot to see her, and the staff always seemed to be attentive to her. She seemed to get good care," Sheffield said.

McGarvey said that bed rails in nursing homes are to be used to enable patients to get in and out of bed. They can be used as patient restraints only with a doctor's permission or that of the patient or the patient's family.

He said fatal bed rail accidents occur occasionally. "We are working with nursing homes on the problem," he said.

There are 795 nursing homes in Pennsylvania, he said.

Chris Feeney, spokesman for Batesville, Ind.-based Hillenbrand Corp., said there are 1.6 million occupied nursing home beds in the country. Hillenbrand is the parent company of Hil-Rom, a leading manufacturer of hospital beds and related health care equipment.

Over a five-year period just ended, there were 334 reported incidents involving patients and bed rails, with 60 percent of them fatal, Feeney said.

"The vast majority are used safely, but incidents do occur, and when they do we look into them," he said.

He said he couldn't discuss the Quincy Home matter because of possible litigation.

Conner said a lawyer for the family of one of the women who died in the home has contacted his office for information.

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