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http://www.billingsgazette.com/index.php?display=rednews/2004/02/12/build/local/45-stjohnsdeath.inc State probes patient death at St. John's By ED KEMMICK Of The Gazette Staff A resident of St. John's Lutheran Home in Billings died of strangulation last
month when she became entangled in the "mobility bar" attached to her bed,
sparking an investigation by the state Department of Health and Human Services.
Kent Burgess, president and CEO of St. John's Lutheran Ministries, said an
employee of the health department's Quality Assurance Division conducted an
investigation shortly after the woman died on Jan. 10, and issued a report about
a week ago. St. John's is in the process of filing a "plan of correction" in response to
the department's report, Burgess said, and the whole file will be open to the
public after that plan is formally submitted. He said St. John's plan of correction basically amounted to removing the
mobility bars from the 60 beds that were equipped with them, which it did by
Jan. 21. Burgess said the health department also was advising nursing homes
across the state to stop using the bars. "It fundamentally has devastated this place ... it was just a terrible
accident," Burgess said. Compounding the tragedy was that the woman, who was in her late 80s, was a
founding member of St. John's volunteer auxiliary, going back more than 40
years, and was a lifelong member of one of the Lutheran churches affiliated with
St. John's. Burgess said he had known the woman for years before she came to
live at St. John's. Burgess said the woman, whose name he could not release, was sleeping
peacefully in the skilled nursing unit of St. John's when a nurse checked on her
at 6 a.m. Jan. 10. A hour and a half later, the nurse found the woman partially
out of bed, with her head and one arm entangled in the mobility bar. The bar is
a short steel rod attached to the side of the bed. It is used by residents to
change position or to get out of bed. Several years ago, Burgess said, nursing homes stopped using the traditional
hospital bedside rail after a nursing home resident on the Hi-Line became caught
in such a rail and died of strangulation. The mobility bars were simpler and
supposedly safer, and were often requested by families whose loved ones were in
the nursing home, Burgess said. "Nobody thought these bars were a problem," he said. Burgess said St. John's notified the county coroner and the woman's physician
immediately, and notified the state health department on Monday, Jan. 12. The
state investigation was conducted on Jan. 14. Mary Dalton, administrator for the Quality Assurance Division, said early in
the afternoon on Wednesday that she would review the file and then respond to
inquiries, but she could not be reached for comment later in the day. Ed Kemmick can be reached at 657-1293 or [EMAIL PROTECTED]. Click here to return. |
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