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A Minnesota assisted living and memory care provider is appealing a state finding of maltreatment over a resident’s death, which investigators said occurred after she became trapped by a bed rail.

An investigation by the Minnesota Department of Health concluded that the Meadows of Wadena, Wadena, MN, was responsible for maltreatment in the death of the resident because staff members did not reassess her ability to use bed rails after a change in condition. 

The resident, in whom Alzheimer’s and anxiety had been diagnosed, was found entrapped in the bed rail on July 30. A preliminary autopsy indicated probable asphyxia as the cause of death.

In a statement to McKnight’s Senior Living, the senior living provider offered its “deepest sympathies” and called the resident’s death a “tragic loss for their family and friends and for those who cared for our resident.” The company said that it reported the event to the state and worked with health department personnel during the investigation.

“While we have deep respect for the department’s role and responsibility, we believe the facts do not match the conclusion the department reached in this matter and are appealing its findings,” the statement read. “We have every expectation that an independent examination of the facts will substantiate our position.”

According to the state’s report, the resident required assistance with all activities of daily living, and her condition declined in the month leading up to her death. A resident assessment document noted the resident was at high risk for injury if a side rail was in use due to her state of cognition/Alzheimer’s.

The assessment document further noted that a registered nurse determined that the side rails were appropriate because the resident was able to grab on if staff members placed her hand on the rail to help with repositioning in bed. The document also confirmed that the resident could not independently use the bed rails to get in and out of bed.

No action was taken against the community.