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When bed rails kill, families go untold

Citations, small fines imposed after state investigations

February 9, 2000


Rose Donajkowski was on vacation when she learned that her 94-year-old mother had died at a Riverview nursing home.

The death certificate said it was a heart attack. With that, Donajkowski went about the sad task of burying her mother, Marie Landry, and dealing with the loss.


  • Dangerous gaps in Michigan, deaths reflect national trend
  • When bed rails kill, families go untold
  • Bed rails are not the only choice

  • "Then the check arrived," Donajkowski recalled.

    It came from the nursing home, Rivergate Terrace, four months after Landry died in March 1998. Donajkowski was baffled at first -- but then found out that the state had investigated the death and cited the home for not protecting her mother from "accident hazards."


  • 1999 bed rail incidents

  • Risks rise with routine use

  • The hazard was a bed rail. Her mother died entangled in it. And the check reflected a state-imposed fine: $100.

    "I was shocked," Donajkowski said. She called the check a slap in the face and refused to cash it. She said she tried to donate it to a nursing home advocacy group, but the group refused, calling it "blood money."


    To report a bed rail incident:

  • The Michigan Department of Consumer and Industry Services regulates nursing homes and investigates bed rail incidents. Call 800-882-6006.

  • The U.S. Food and Drug Administration, Medwatch, collects information about deaths, injuries and life-threatening situations involving medical devices, including bed rails. Call 800-332-1088 or

    For help with a nursing home problem:

    Citizens for Better Care is a nonprofit group that serves as Michigan's nursing home ombudsman agency. In metro Detroit, call 313-832-6387, outstate call 800-292-7852.

    To become involved:

  • Michigan Campaign for Quality Care is a grassroots group that is working for legislation to improve the quality of care in nursing homes. Contact Alison Hirschel at 800-288-5923 or

  • In Michigan, families often are the last to know when their loved ones are involved in nursing home bed rail mishaps. The Free Press reviewed 19 bed rail deaths and injuries from 1999, as well as cases from earlier years, and found that families were often not told about the full circumstances.

    At least five Michigan nursing home residents died in incidents involving bed rails last year. Bed rail dangers have been a stubborn concern nationwide for years. Since 1985, the U.S. Food and Drug Administration has received reports of 370 bed rail entrapments; 227 people died.

    Rivergate Terrace officials did not respond to requests for comment about Landry. But they said in response to a lawsuit filed by Landry's family that she died of natural causes.

    Donajkowski learned the grim details of her mother's last moments only by digging further after the check arrived.

    Nurses at the home discovered Landry's body just before midnight on March 28, 1998. Her head was lodged in a bed rail. Her "face was blue and arms were blue," a nurse wrote. It took two nurses to dislodge her head from the rail. She had a bruise under her chin. And no pulse.

    Dr. David M. Miller, who signed Landry's death certificate and listed a heart attack as the cause, declined comment.

    Donajkowski wept when she learned the full story. "Then I got angry," she said.

    For relatives, the anguish is compounded by the secrecy that they say surrounds the deaths.

    "The family ...should be contacted right away that there's going to be an investigation," said Cathie Wallace of ACTION, a Livonia-based coalition for nursing home reforms. "I'm just horrified."

    Relatives and advocates also complain that Michigan regulators aren't tough enough.

    "Federal law allows for $10,000 per day in fines, yet Michigan officials often fine nursing homes just $100," said Michael Connors, an organizer with the Michigan Campaign for Quality Care, a nursing home advocacy group. "Could they tell us any more clearly that these individuals' lives don't matter to them?"

    Walter Wheeler, who heads nursing home regulation at the Michigan Department of Consumer and Industry Services, said the state takes bed rail deaths seriously. "Any unnecessary death in a nursing home is not acceptable," Wheeler said.

    State regulators rarely impose large federal fines because Michigan nursing homes tie them up in appeals for years.

    He said there is no requirement for family members to be notified of an investigation, if they didn't ask for the investigation. But he said investigators try to keep families informed.

    Under state law, nursing homes are required to alert authorities if a resident dies "suddenly, unexpectedly, accidentally ...or under suspicious circumstances." The law is intended to give county medical examiners a chance to review unusual deaths, and conduct autopsies if needed.

    "If there is any question of entrapment, we are to be notified of that," said Dr. L.J. Dragovic, Oakland County medical examiner.

    In Traverse City, Lucille Kelly's death prompted no autopsy.

    She was found dead Oct. 8 trapped between her mattress and bed rail at Bortz Health Care. The 84-year-old Alzheimer's patient had a bed rail in her mouth, state records show.

    It is unclear how state inspectors found out about it. But Bortz never reported the detail to the state, or the county medical examiner or to Kelly's family.

    Kelly was buried four days after her death. Dr. Thomas Auer, Kelly's physician, signed a death certificate listing her cause of death as Alzheimer's disease.

    Auer said in an interview that he never saw Kelly's body and that Bortz officials never told him anything about the rail.

    He said he was only told "she was found dead in her bed."

    Still, Auer said, he was not troubled by that omission. Even if he had known, he said, he would have have reached the same conclusion about Alzheimer's.

    "It wouldn't have changed it," Auer said. "What is your basic quality of life when you sleep with your mouth open and come in contact with something cold and you don't have the brains to withdraw from it?"

    Brian McCullough, the home's lawyer, said Bortz properly concluded Kelly died a natural death. He noted, for instance, that Kelly's skin color appeared normal when she was found.

    "Even if the bed rail was by her mouth, that in and of itself is not enough to cause suffocation," McCullough explained.

    Helen Rawski's family also was unaware of the complete circumstances surrounding her death.

    Rawski was a 78-year-old Alzheimer's patient at St. Anthony Nursing Healthcare Center in Warren. She was discovered dangling lifeless with her right leg entangled between her bed rail and mattress, and her head -- bleeding from the neck -- in a trash can last October.

    The state investigated the next day, and cited the home for using unsafe bed rails.

    Lucille Arking, the center's administrator, said: "I want to make it very clear that Helen Rawski died of natural causes. There are autopsies to confirm that."

    Macomb County Medical Examiner Werner Spitz, whose office conducted the autopsy, said Rawski died from advanced hardening of the arteries. But the autopsy report also described a faint, two-sided bruise branded across Rawski's chest. That bruise, Spitz concluded, came from Rawski pressing against the bed rail as she tried to get out of bed.

    Rawski's heart gave out from the exertion and stress of trying to escape the bed and bed rails, Spitz said.

    Rawski's daughter, Susan Rawski-Chess, said she was unaware of the full details or that the state investigated, until she was contacted by a reporter.

    "I didn't think at the time it could be bed rail-related at all," she said. "I just assumed they were safe."

    DAVID ZEMAN can be reached at 248-586-2604 or Staff reporters Alison Young and Emilia Askari contributed to this report.

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