The use of bed rails in healthcare settings presents a complex challenge, balancing fall prevention with the patient’s right to freedom of movement. Regulatory bodies approach this practice with caution, despite the common assumption that raising a bed rail promotes safety. The classification of a bed rail as a medical restraint is determined by its effect on the individual patient, not the number of rails raised. This regulatory nuance, especially concerning partial use like three side rails, impacts patient care and safety protocols in hospitals and long-term care facilities.
Defining Medical Restraint in Healthcare
In the United States, the Centers for Medicare & Medicaid Services (CMS) provides the regulatory definition for a physical restraint in certified facilities. A physical restraint is defined as any device, material, or equipment that restricts a person’s freedom of movement or normal access to their own body. The determination of whether a device functions as a restraint hinges entirely on its effect on the individual, not the intent of the staff applying it.
If a side rail prevents a patient from voluntarily getting out of bed, it is considered a physical restraint under CMS guidelines. This definition includes equipment adjacent to the person, such as bed rails. Once classified as a restraint, its use is strictly regulated, requiring a physician’s order, specific documentation, and a treatment plan addressing the patient’s underlying medical symptoms.
The Food and Drug Administration (FDA) regulates the bed rail devices themselves, focusing on safety and performance. CMS focuses on the regulatory requirements for patient care within a facility. The distinction between an “assistive device” or “enabler” and a “restraint” is determined by whether the patient can easily move past the device to exit the bed safely.
Regulatory Interpretation of Partial Bed Rails
The classification of three side rails as a medical restraint requires an individualized patient assessment focusing on the patient’s ability to exit the bed. Raising all four side rails is generally considered a restraint because it prevents voluntary exit, restricting egress from all sides. This full enclosure creates a barrier that increases the risk of injury if the patient attempts to climb over it.
When two or three rails are raised, leaving a section open for exit, they are often reclassified as an “enabler” or assistive device. A patient may use a partial rail as a grab bar to reposition themselves or assist with transferring out. This use supports the patient’s mobility and independence.
The regulatory interpretation depends heavily on the patient’s physical and cognitive status. A partial rail that is an enabler for a strong patient may function as a restraint for a frail, confused, or cognitively impaired individual who cannot understand the clear exit path. Facilities must document that the patient can easily and safely exit the bed, or that the rails are used to treat a medical condition, not for staff convenience.
If a patient is physically unable to get out of bed, the raised side rails do not restrict their freedom of movement and are not considered a restraint. However, if a mobile patient’s preferred or safest exit is blocked by the three rails, they are functionally restricting movement. The patient’s care plan must clearly define the purpose of the rails and ensure an alternative, understood exit route remains available.
Safety Risks and Alternatives to Rail Use
Bed rails, despite being intended for fall prevention, introduce serious physical hazards, primarily patient entrapment. Entrapment occurs when a patient gets caught or entangled in the spaces around the bed rail, mattress, or bed frame, potentially resulting in serious injury or death. The FDA has identified seven specific zones where entrapment can occur in a hospital bed system.
Entrapment Zones
These zones include spaces:
- Within the rail.
- Under the rail.
- Between the rail and the mattress.
- Between the split rails.
Zones 1 through 4, related to gaps between the rail and the mattress or supports, account for approximately 80 percent of reported incidents. Additionally, patients attempting to climb over a raised rail fall from a greater height, substantially increasing the likelihood of serious injury, such as fractures or head trauma.
Alternatives to Bed Rails
Healthcare providers must explore less restrictive alternatives before implementing bed rails due to these inherent dangers. Effective alternatives focus on fall prevention without physical restriction.
These include using low beds that position the mattress close to the floor, often combined with soft floor mats to cushion an accidental fall. Other non-restraint interventions involve technology and environmental adaptations.
Examples of non-restraint interventions include bed exit alarms or pressure sensors that alert staff when a patient attempts to leave the bed. Specialized equipment, such as trapeze bars to assist with repositioning and transfer, or concave mattresses with raised foam edges, can also be utilized. The safest approach involves a comprehensive, individualized care plan addressing the root cause of the fall risk rather than relying on physical barriers.