November 11, 2021

Bed Rail Safety and Assisted Living Surveys

On November 11, 2021 by Bobbie Guidry

The Minnesota Department of Health (MDH) frequently cites the following in assisted living surveys: “The licensee failed to ensure a side rail was assessed for appropriateness and safety.”

Although bed rail monitoring is not a specific requirement within assisted living licensure or rules, it is cited under the Bill of Rights and the Right to Appropriate Care and Services, 144G.91, Subd. 4. This has been similarly addressed during Home Care surveys for several years.

We recommend that staff are trained to watch for and report to the CNS or LALD if a side rail is observed in a resident's apartment. The nurse can then assess the side rail for safety and advise the resident or their representative related to safety concerns, alternative approaches to meeting the resident's needs, and suggest a therapy evaluation to assist in planning safer practices.

Deaths have occurred related to side rails in Minnesota in recent years. A detailed document on side rails is available for the US Food and Drug Administration (FDA). Staff should utilize the guidance below to assess side rails for safety and attempt alternative approaches to meet the needs if possible. Some side rails are devices that are put on a regular bed and, for example, may slip under the mattress for attachment. These devices may not be stable or may have openings that can also cause entrapment. You should assess any side rail or transfer bar for safety.

Information from FDA Regarding Side Rails:

In 2006, the Food and Drug Administration (FDA) released its recommendations for reducing entrapments. The FDA identified seven “zones of entrapment” and recommended maximum dimensions for four of the zones.

In the diagram, zones 1, 2, and 3 are areas where a person’s head can be caught within the side rail or between the side rail and the mattress. Zone 4 is an area where a person’s neck can be caught between the side rail and the mattress.

The FDA recommends that the dimensions in Zones 1-4 be less than:

• Zone 1: Within the Rail (4.75”)
• Zone 2: Under the Rail, Between the Rail Supports or Next to a Single Rail Support (4.75”)
• Zone 3: Between the Rail and the Mattress (4.75”)
• Zone 4: Under the Rail, at the Ends of the Rail (2 and 3/8” and greater than 60° angle)

The FDA has not established recommended maximum dimensions for Zones 5-7:

• Zone 5: Between Split Bed Rails
• Zone 6: Between the End of the Rail and the Side Edge of the Head or Foot Board
• Zone 7: Between the Head or Foot Board and the Mattress End

Side rails can be very helpful in assisting individuals in transferring out of bed or repositioning in bed. It is essential to recognize that the dangers exist regardless of the purpose of using the side rails. Nursing staff should assess an individual's capabilities for using side rails safely.

In care centers, the facility is responsible for the bed, side rails, and mattress and complying with the FDA recommended dimensional limits. A mattress that does not fit properly against the side rails poses a risk (Zone 3 in the diagram), and loose side rails make the zones more dangerous because they increase the distances.

In assisted living, the property will belong to the resident, but the provider must assess its safety and advise the resident or their representative.