The September asphyxiation of prominent Pittsburgh businessman Robert Frankel came from an incident in which his neck was trapped in bed rails, and the Charles Morris Nursing and Rehabilitation Center has discontinued using such railings in response, according to a Pennsylvania Department of Health report.
Mr. Frankel, 89, a leading arts patron who was the father of state Rep. Dan Frankel, died late Sept. 17 at the Squirrel Hill nursing home from what the medical examiner deemed at the time accidental asphyxiation, “due to compression of the neck.”
Details of the incident were unavailable until the Health Department posted an inspection report on its website this week in which it cited the Charles Morris center for deficiencies related to the death.
“Based on review of facility policy and documentation, clinical records and staff interview, it was determined that the facility failed to identify a hazard created by the use of side rails resulting in the death,” the report said. The Health Department has not yet indicated if any punitive action, such as a fine or provisional license, was planned against the facility.
The report noted that Mr. Frankel had severe cognitive impairment from Alzheimer’s disease as well as mobility limitations and other physical problems. A physician had recommended that two side rails be used on the upper half of his bed to assist him with his positioning. During the course of several months in the nursing home, Mr. Frankel also developed severe pain and sensitivity in his left hand that made it difficult to use.
The report said that at 11:30 pm. on Sept. 17, “a nurse aide was performing first rounds to check on the residents and found Resident R1 (Health Department inspection reports do not identify individuals by name) pulseless and without respirations, lying with his body on the floor and his neck between the air mattress and the side rail.” A nursing supervisor pronounced him dead at 11:40.
The inspection report faulted the nursing home for failure to evaluate whether Mr. Frankel had continued need for side rails after developing the pain that disabled use of his left hand. The department stated that side rails are only to be used to help a resident reposition himself or manage a condition when “no reasonable alternatives can be identified. When using side rails for any reason staff will take measures to reduce related risks.”
In their response to the inspection report, Charles Morris officials said any side rails in use at the facility were removed within 12 hours after Mr. Frankel’s death. It said the therapy staff was notified about the need to assist four residents concerned about removal of the rails, which are sometimes used to help prevent people from falling out of bed.
“Therapy referrals will continue to be made for any residents with bed mobility and/or transfer concerns,” according to the response from Charles Morris, a 159-bed nonprofit facility owned by the Jewish Association on Aging. “A letter was written announcing to all incoming residents and families that we are now a side rail free center and is placed in the new admission packet.”
Phil Ricci, administrator of Charles Morris, issued a statement Thursday referring to Mr. Frankel’s death as a “tragic accident,” which led to removal of all bed rails “out of an abundance of caution.”
“The well-being of both our residents and their families has always been — and always will be — our top priority,” Mr. Ricci said. “We remain focused on constant improvements to deliver on this promise, which is why we are introducing new approaches aimed at helping our residents to remain mobile and safe at the same time.”
Mr. Frankel’s death is under review by the Allegheny County’s district attorney’s office after it received an investigative report from city police, a district attorney’s spokesman said. Criminal charges are rarely filed, however, in nursing home deaths that have been deemed accidental.
Mr. Frankel’s son, Dan, issued a statement in which he declined to comment on details of the findings or the nursing home’s actions.
“I have spoken at length with Charles Morris administrators,” the legislator said, “and I believe we all agree on the importance of moving forward with the safety and quality of life for current and future residents of the facility topmost in mind.”
Gary Rotstein: grotstein@post-gazette.com or 412-263-1255.
First Published: November 9, 2017, 11:04 p.m.