Bed rails are rigid structures attached to the sides of a long-term care bed, historically viewed as standard equipment to prevent residents from falling out. Today, their use in long-term care facilities is heavily regulated by federal standards due to the serious safety risks they pose to vulnerable residents. The current approach focuses on individualized care, recognizing that a device intended to assist one person could restrain or injure another.
Federal Guidelines on Use and Classification
The permissibility of bed rails in nursing homes is governed by comprehensive federal regulations that focus on the intent of their use. A bed rail is generally allowed if it is determined to be an assistive device that helps a resident move, reposition themselves, or get in and out of bed independently. Conversely, a bed rail is classified as a physical restraint if a resident cannot easily remove it and it limits their voluntary movement, such as preventing them from safely leaving the bed.
Federal guidance prohibits the use of any physical restraint, including a bed rail, for the convenience of the staff or as a form of discipline. If a bed rail is deemed necessary, the facility must first demonstrate that less restrictive alternatives were attempted and failed to meet the resident’s needs. Before rails are installed, the facility must conduct a thorough, individualized assessment of the resident’s condition, mobility, and cognitive status. This assessment must justify the rail’s purpose, document the risks considered, and be incorporated into the resident’s specific care plan.
The decision to use a bed rail must be medically indicated, not simply based on staff or family preference. For example, a partial rail used by a resident to pull themselves up may not be a restraint, but a full-length rail preventing a confused resident from exiting the bed is. Facilities must continuously review the necessity of the rail, ensuring that its continued use is the least restrictive option to address a documented medical need. This strict framework ensures that rails are applied only when a specific clinical benefit outweighs the known risks.
Patient Rights and Informed Consent
A fundamental aspect of bed rail use is the patient’s right to self-determination. Before any bed rail is installed, the facility must obtain informed consent from the resident or their legal representative. This process requires a complete disclosure of the device’s potential benefits, the specific risks of injury, and the available alternative safety measures.
A resident retains the right to refuse the use of bed rails, even if facility staff or a physician recommends them. If a resident refuses, the nursing home must respect that decision and cannot impose the rail against their will. The facility is required to document the refusal and implement alternative safety interventions to prevent falls or other injuries. Furthermore, the resident has the right to revoke consent at any time, requiring the facility to immediately remove the rails and adjust the care plan accordingly.
The need for bed rails must be periodically re-evaluated by the care team as part of the overall care plan review process. This reassessment ensures the rail is not used longer than necessary and that the resident’s changing status does not increase the risk of harm. The facility must demonstrate that the continued use of the rail remains the least restrictive intervention available to meet the resident’s current needs.
Recognizing Physical Hazards
The strict regulation of bed rails stems directly from their potential to cause serious physical harm. The two most significant hazards are entrapment and an increase in the severity of fall-related injuries. Entrapment occurs when a resident’s head, neck, chest, or limbs become lodged in one of the seven designated zones around the bed system.
These seven zones of entrapment identify specific gaps where the body can get stuck, such as within the rail bars themselves or the space between split rails. Dangerous areas also include the gap between the bed rail and the mattress, or the space between the mattress end and the headboard or footboard. Entrapment injuries are particularly dangerous for frail, confused, or restless residents, with head and neck entrapment posing a risk of strangulation.
The second primary hazard involves falls, which can become more injurious when a resident attempts to climb over a raised rail. The presence of a rail can trigger an impulse in confused individuals to climb from a greater height than if the rail were absent. This action often results in a more severe fall and greater injury risk, such as hip fractures or head trauma, compared to a simple roll-out from a low bed.
Non-Rail Fall Prevention Strategies
Because of the known risks associated with bed rails, nursing homes must prioritize and implement a variety of non-rail interventions for fall prevention. A common environmental solution is the use of low beds, which are adjustable and can be positioned just a few inches from the floor, significantly reducing the distance of a potential fall. These low beds are often paired with floor mats, which are soft pads placed next to the bed to cushion the impact if a resident rolls out.
Technology plays a large role in proactive safety through the use of pressure-sensitive alarms. Bed and chair alarms alert staff immediately when a resident attempts to get up unassisted, allowing for a rapid response before a fall can occur. Specialized mattresses that feature raised perimeters or side bolsters are also used as an alternative to traditional rails, providing a gentle barrier without the risk of entrapment.
Facilities also implement non-environmental strategies, such as increasing the frequency of staff checks and adjusting staffing levels for closer supervision. Exercise and physical therapy programs are utilized to improve a resident’s strength, balance, and gait stability. Furthermore, routine medication reviews are conducted to identify and modify drugs that may cause dizziness or affect balance.