State: Nursing home resident suffocated while trapped in bed rails

The NewAldaya Lifescapes nursing home in Cedar Falls, Iowa. (Photo via Google Earth)

A Cedar Falls nursing home has been cited for the death of a resident who suffocated while trapped between her bed rails and a wall.

According to state inspection reports, a registered nurse at NewAldaya Lifescapes entered a female resident’s room shortly after 9 a.m. on June 16 and found the woman face down, wedged between the mattress on her bed and a wall that was about 10 inches away.

The right side of the woman’s neck was pressed up against the bed rail nearest the wall, with her head and neck twisted upward toward the ceiling, according to the reports. The woman’s face was marred by deep, dark bruising caused by broken blood vessels.

There were no signs of respiration or a pulse, and within five minutes she was pronounced dead by the staff, according to inspectors. The cause of death was later declared to be asphyxiation, or suffocation, related to her positioning.

According to the inspectors, the home’s administrator agreed that none of the residents at the home had their required bed-rail risk assessment reviewed since August 2023. Inspectors concluded the 101 residents of the home — 94 of whom used bed rails — had been placed in immediate jeopardy of serious injury or death.

The state has proposed, but held in suspension, a $10,000 fine. The Centers for Medicare and Medicaid Services has yet to impose a federal penalty in the matter.

In addition to the death, NewAldaya Lifescapes was cited by the state for several other violations, including a failure to provide residents with baths twice each week, and a failure to meet the needs of incontinent residents.

A male resident of the home whose call light didn’t work had been given a hand bell to ring so he could try to summon the staff when he needed assistance, inspectors reported. The man allegedly cried as he told inspectors that he had recently been left to sit in his own feces for 90 minutes when the staff didn’t respond to him yelling for help. The man reported that he ultimately used his cell phone to call his daughter who then called the facility and asked the staff to tend to her father’s needs.

The home’s administrator, Crystal Jasper, could not be reached for comment Monday.

The NewAldaya Lifescapes home has a four-star rating, based on CMS’ five-star scale, for health inspection outcomes, staffing levels and quality measures. No federal fines have been imposed against the home in the past three years.

The facility is owned by Cedar Falls Lutheran Home-NewAldaya Lifescapes, a tax-exempt, nonprofit organization. In 2022, the organization reported to the IRS that it paid its then-CEO, Millisa Tierney, a total of $198,856 in salary and benefits. Jasper, the home’s administrator, was paid $153,131 in 2022.

According to tax records, the organization reported revenue of $19.3 million and total spending of $21.4 million in 2022.

The organization also reported to the IRS that it does not make public its governing documents, conflict of interest policy or internal financial statements.

According to state records, the federal Food and Drug Administration fielded roughly 691 reports of bed-rail entrapment nationally between 1985 and 2006. The 691 cases involved 413 deaths and 120 injuries.

In 2022, Clarion Wellness and Rehabilitation Center in Wright County was cited for placing residents in immediate jeopardy by installing a grab bar on a resident’s bed without first conducting a risk assessment.

The resident subsequently tried to climb out of bed and apparently fell forward with their upper body becoming trapped between the headboard and the grab bar. A few hours later, a worker entered the room and found the resident dead, suspended upside down off the side of the bed. A medical examiner determined the resident died of positional asphyxiation.

The state of Iowa proposed, but then held in suspension, a $10,000 fine against the Clarion home. The Centers for Medicare and Medicaid Services later imposed a federal fine of $46,105 for the death.

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