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FEDERAL GUIDELINES FOR BED RAILS
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§483.25(n) Bed Rails. The facility must attempt to use appropriate alternatives prior to installing a side or bed rail. If a bed or side rail is used, the facility must ensure correct installation, use, and maintenance of bed rails, including but not limited to the following elements.
§483.25(n)(1) Assess the resident for risk of entrapment from bed rails prior to installation.
§483.25(n)(2) Review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation.
§483.25(n)(3) Ensure that the bed’s dimensions are appropriate for the resident’s size and weight.
§483.25(n)(4) Follow the manufacturers’ recommendations and specifications for installing and maintaining bed rails.
INTENT 483.25(n) The intent of this requirement is to ensure that prior to the installation of bed rails, the facility has attempted to use alternatives; if the alternatives that were attempted were not adequate to meet the resident’s needs, the resident is assessed for the use of bed rails, which includes a review of risks including entrapment; and informed consent is obtained from the resident or if applicable, the resident representative. The facility must ensure the bed is appropriate for the resident and that bed rails are properly installed and maintained.
DEFINITIONS §483.25(n) "Entrapment" is an event in which a resident is caught, trapped, or entangled in the space in or about the bed rail.
“Bed rails” are adjustable metal or rigid plastic bars that attach to the bed. They are available in a variety of types, shapes, and sizes ranging from full to one-half, one-quarter, or one-eighth lengths. Also, some bed rails are not designed as part of the bed by the manufacturer and may be installed on or used along the side of a bed.
Excerpted from State Operations Manual, Appendix PP - Guidance to Surveyors for Long Term Care Facilities (Rev. 173, 11-22-17), https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/ downloads/som107ap_pp_guidelines_ltcf.pdf.
Examples of bed rails include, but are not limited to:
- Side rails, bed side rails, and safety rails; and
- Grab bars and assist bars.
GUIDANCE §483.25(n) Even when bed rails are properly designed to reduce the risk of entrapment or falls, are compatible with the bed and mattress, and are used appropriately, they can present a hazard to certain individuals, particularly to people with physical limitations or altered mental status, such as dementia or delirium.
Resident Assessment After a facility has attempted alternatives to bed rails and determined that these alternatives do not meet the resident’s needs, the facility must assess the resident for the risks of entrapment and possible benefits of bed rails. In determining whether to use bed rails to meet the needs of a resident, the following components of the resident assessment should be considered including, but not limited to:
- Medical diagnosis, conditions, symptoms, and/or behavioral symptoms;
- Size and weight
- Sleep habits
- Medication(s)
- Acute medical or surgical interventions
- Underlying medical conditions
- Existence of delirium
- Ability to toilet self safely
- Cognition
- Communication
- Mobility (in and out of bed)
- Risk of falling.
In addition, the resident assessment must include an evaluation of the alternatives to the use of a bed rail that were attempted and how these alternatives failed to meet the resident’s assessed needs.
The facility must also assess the resident’s risk from using bed rails. The following includes potential risks regarding the use of bed rails as identified by the Food and Drug Administration’s Hospital Bed Safety Workgroup Clinical Guidance For the Assessment and Implementation of Bed Rails In Hospitals, Long Term Care Facilities, and Home Care Settings (April 2003) and have been adapted for surveyor guidance:
- Accident hazards o The resident could attempt to climb over, around, between, or through the rails, or over the foot board, o A resident or part of his/her body could be caught between rails, the openings of the rails, or between the bed rails and mattress.
- Barrier to residents from safely getting out of bed
Installation and Maintenance of Bed Rails Assuring the correct installation and maintenance of bed rails is an essential component in reducing the risk of injury resulting from entrapment or falls. The FDA and the United States Consumer Product Safety Commission (CPSC) has recommended the following initial and ongoing actions to prevent deaths and injuries from entrapment and/or falls from bed rails:
- Before bed rails are installed, the facility should: o Check with the manufacturer(s) to make sure the bed rails, mattress, and bed frame are compatible, since most bed rails and mattresses are purchased separately from the bed frame.
NOTE : The FDA has published (1) the Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment as a resource to reduce entrapments resulting from hospital beds and (2) Practice Hospital Bed Safety as to the proper dimensions and distance of various parts of the beds (i.e.; distance between bed frames and mattresses, bed rails and mattresses, etc.)
o Rails should be selected and placed to discourage climbing over rails to get in and out of bed, which could lead to falling over bed rails.
- When installing and using bed rails, the facility should: o Ensure that the bed’s dimensions are appropriate for the resident. o Confirm that the bed rails to be installed are appropriate for the size and weight of the resident using the bed. o Install bed rails using the manufacturer's instructions to ensure a proper fit. o Inspect and regularly check the mattress and bed rails for areas of possible entrapment. o Regardless of mattress width, length, and/or depth, the bed frame, bed rail and mattress should leave no gap wide enough to entrap a resident’s head or body. Gaps can be created by movement or compression of the mattress which may be caused by resident weight, resident movement or bed position, or by using a specialty mattress, such as an air mattress, mattress pad or water bed. o Check bed rails regularly to make sure they are still installed correctly as rails may shift or loosen over time.
In addition, ongoing precautions may include following manufacturer equipment alerts and recalls and increasing resident supervision.
The use of a specialty air-filled mattress or a therapeutic air-filled bed may also present an entrapment risk that is different from rail entrapment with a regular mattress. The high compressibility of an air-filled mattress compared to a regular conventional mattress requires appropriate precautions when used for a resident at risk for entrapment. An air-filled mattress compresses on the side to which a person moves, thus raising the center of the mattress and lowering the side. This may make it easier for a resident to slide off the mattress or against the rail. Mattress compression widens the space between the mattress and rail. When a resident is between the mattress and rail, the mattress can re-expand and press the chest, neck, or head against the rail. While using air therapy to prevent and treat pressure injuries, facilities should
also take precautions to reduce the risk of entrapment. Precautions may include following manufacturer equipment alerts and increasing supervision.
Facilities must also conduct routine preventive maintenance of beds and bed rails to ensure they meet current safety standards and are not in need of repair. For concerns regarding installation and maintenance of the beds or bed rails, see guidance for 42 CFR 483.90(d)(3), F909.
Ongoing Monitoring and Supervision Assuring the correct use of an installed bed rail, and maintenance of bed rails is an essential component in reducing the risk of injury. After the installation of bed rails, it is expected that the facility will continue to provide necessary treatment and care, in accordance with professional standards of practice and the resident’s choices. This should be evidenced in the resident’s record, and include the following components, but are not limited to:
- The type of specific direct monitoring and supervision provided during the use of the bed rails, including documentation of the monitoring;
- The identification of how needs will be met during use of the bed rails, such as for re positioning, hydration, meals, use of the bathroom and hygiene;
- Ongoing assessment to assure that the bed rail is used to meet the resident’s needs;
- Ongoing evaluation of risks;
- The identification of who may determine when the bed rail will be discontinued; and
- The identification and interventions to address any residual effects of the bed rail (e.g., generalized weakness, skin breakdown).
KEY ELEMENTS OF NONCOMPLIANCE To cite deficient practice at F700, the surveyor's investigation will generally show that the facility failed to do one or more of the following:
- Identify and use appropriate alternative(s) prior to installing a bed rail;
- Assess the resident for risk of entrapment prior to installing a bed rail;
- Assess the risk versus benefits of using a bed rail and review them with the resident or if applicable, the resident’s representative;
- Obtain informed consent for the installation and use of bed rails prior to the installation.
- Ensure appropriate dimensions of the bed, based on the resident’s size and weight;
- Ensure correct installation of bed rails, including adherence to manufacturer’s recommendations and/or specifications;
- Ensure correct use of an installed bed or side rail; and/or
- Ensure scheduled maintenance of any bed rail in use according to manufacturer’s recommendations and specifications.
INVESTIGATIVE PROTOCOL Use this protocol for:
- A sampled resident who has MDS data that indicates a bed/side rail is used;
- Surveyor observation of the use of a bed/side rail for a resident; and/or
- An allegation of inappropriate use of a bed/side rail received by the State Survey Agency.
- What is the resident’s functional ability, such as bed mobility and ability to transfer between positions, to and from bed or chair, to toilet and to ability to stand.;
- Whether there have been any physical and/or psychosocial changes related to the use of the bed rail, such as increased incontinence, decline in ADLs or ROM, increased confusion, agitation, and depression;
- Whether other interventions have been attempted to minimize or eliminate the use of the bed rails; and
- Whether there are facility guidelines/protocols for the use of bed rails.
Interview the charge nurse, to gather the following additional information:
- How the implementation of the use of bed rails is monitored and who is responsible for the monitoring;
- Who evaluates and assesses the resident to determine the ongoing need for bed rails;
- Whether bed rail use should be gradually decreased; and
- How the modifications for the interventions are evaluated for effectiveness in discontinuing the use of the bed rails.
Record Review Review the MDS, assessments, physician orders, therapy and nursing notes and other progress notes that may have assessment information related to use of the bed rail. Determine whether identified decline can be attributed to a disease progression or use of bed rails. Determine whether the assessment information accurately and comprehensively reflects the status of the resident for:
- The identification of specific medical symptom(s) for which the bed rail is used;
- Functional ability, including strength and balance (such as bed mobility and ability to transfer between positions, to and from bed or chair, and to stand and the ability to toilet);
- Identification of the resident’s risks such as physical/functional decline and psychosocial changes, and benefits, if any, due to the use of the bed rails;
- Attempts at using alternatives to bed rails, including how the alternatives did not meet the resident’s medical or safety need or were inappropriate;
- Identification of any injuries, or potential injuries, that occurred during the use of bed rails.
When the interdisciplinary team has determined that a resident may benefit from the use of a device for mobility or transfer, whether the assessment includes a review of the resident’s:
- Bed mobility; and
- Ability to transfer between positions, to and from bed or chair, to stand and the ability to toilet.
Review the resident’s care plan to determine if it is consistent with the resident’s specific conditions, risks, needs, behaviors, preferences, current professional standards of practice, and included measurable objectives and timetables, with specific interventions/services for use of the bed rail. The care plan may include:
- Which medical need would be met through the use of bed rails;
- How often the bed rail is applied, duration of use, and the circumstances for when it is to be used;
- How monitoring is provided, and when and how often the bed rail is to be released and assistance provided for use of the bathroom, walking and range of motion;
- What the resident’s functional ability is, such as bed mobility and ability to transfer between positions, to and from bed or chair, and to stand and toilet and staff required for each function that requires assistance;
- Identification of interventions to address any potential complications such as physical and/or psychosocial changes related to the use of the bed rails, such as increased incontinence, decline in ADLs or ROM, increased confusion, agitation, and depression;
- Identification of interventions to minimize or eliminate the use of the bed rails; and
- Who monitors for the implementation of the use of the bed rails, and who evaluates and assesses the resident to determine the ongoing need for bed rails, whether the bed rail use should be gradually decreased, and how the modifications for the interventions are evaluated for effectiveness in discontinuing the use of the bed rail.
DEFICIENCY CATEGORIZATION Examples of Severity Level 4 Noncompliance Immediate Jeopardy to Resident Health or Safety include, but are not limited to:
- A facility failed to attempt to use alternatives to bed rails and assess a resident for risk of entrapment. The resident was assessed to be at risk of falls when she made repeated attempts to self-transfer off of her bed. All of the falls occurred when a half side rail was in use. According to a facility accident report, the resident was found on the floor with her back against the bed, holding onto one of the half side rails with both hands, with her neck wedged between the half side rails. The resident was able to remove herself from between the mattress and the bed rail, and did not sustain any injuries from the fall. After this incident, the facility performed a bed rail assessment, which did not indicate the risks/benefits of using bed rails. However, no changes were made to the resident’s care plan, nor was there any documentation that the facility considered discontinuing use of the bed rails. Nine months later, the resident was found dead on the floor next to her bed, with her head wedged between the half side rail and the mattress. The resident’s death certificate listed the cause to be asphyxiation-positional, extrinsic compression of the neck, and neck trapped under the bed rail.
- The facility failed to assess the resident for use of a bed rail, and failed to ensure that the bed rails did not pose a risk of entrapment or injury from falls. A moderately cognitively impaired resident was admitted to the facility who required extensive assistance with bed mobility and transfer, and was not ambulatory. The nursing assessment completed on admission indicated that the resident was at high risk for falls and full bed rails were used on all open sides of the bed. No assessment related to the use of bed rails was completed. A facility investigation report revealed that the resident crawled to the foot of his bed with the full bed rails in a raised position, tried to stand and ambulate, and fell off the right side of the bed. The resident sustained a femoral neck fracture and was hospitalized.
- A facility failed to attempt to use alternatives to bed rails and assess a resident for risk of entrapment. A bed rail assessment indicated that two half side rails would be used for the resident to promote independence. There was no evidence that the facility
