Operators of a nursing home in west-central Minnesota are responsible for a resident getting her head fatally trapped in a bed rail one night last summer, according to results of a state health investigation released Thursday.

Resident Alice Grieger, who had worked as a nurse at Elders' Home in New York Mills for much of the 1980s, died there on Aug. 24, 2013.

"Neglect is substantiated," the report concluded regarding the death of the resident, who had been suffering from late-stage Alzheimer's. "The facility staff failed to complete a thorough assessment for the resident's continued ability to safely use the bilateral side rails following falls from bed, the addition of an air mattress overlay, and the [late-stage Alzheimer's] resident's decrease in functional abilities."

While the home had policies to measure any gap between bed rails and a base mattress, the facility did not require any measurement with additional padding, the report noted.

Two months before Grieger's death, an "air mattress overlay was added to the top of the resident's mattress for comfort," the report noted.

Also, staff members told investigators after the incident that the resident had been unable to use the rails for two weeks before getting trapped, the report continued.

Family members have declined to comment about the report's findings about the operation of the nursing home, where Grieger lived for more than seven years.

Administrator Cal Anderson said the home appealed the findings because "we felt that the death was not attributable" to the resident being trapped by the rail. The state denied the appeal, he said.

Anderson said the injuries noted by police called to the scene were not consistent with asphyxiation. That information was forwarded to the coroner's office, Anderson continued, but no autopsy was ordered.

The state report also noted the absence of an autopsy and added that a death certificate signed by the family's doctor listed osteomyelitis, a bone infection, as the cause of death.

Messages have been left with the coroner's office and the family's doctor seeking elaboration on their actions in the case.

Within a week of the death, the home responded with several changes, the report said. Among them: All bed rails in the home were scrutinized, and those not being used by residents were removed. Inspections of the gap between mattresses and rails were also conducted, including situations where mattress layers were added.

The home also bought new beds to replace those with rails that could not be removed, and staff members received training on the relevant polices and procedures.

A follow-up visit by state officials to the home confirmed that the necessary corrections had been made.

Paul Walsh • 612-673-4482