07/14/2022
Survey Tip of the Week: Bed rails
F-tag 689 for accidents is the second highest citation with a scope and severity level of harm and immediate jeopardies for Ohio in CY 2022. It is the fourth most frequently cited f-tag in Ohio at all scope and severity levels. CMS notes that there is no evidence that the use of physical restraints, including, but not limited to bed rails and position change alarms, will prevent or reduce falls. Additionally, falls that occur while a person is physically restrained often result in more severe injuries (e.g., strangulation, entrapment).
Additional guidance on bed rails can be found at F700 §483.25(n). This guidance states that 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.
With the release of phase 3 requirements of participation, CMS notes that facilities must first attempt the use of an appropriate alternative prior to using bed rails. CMS added the following language with the release of phase 3 requirements of participation guidance:
Evidence shows that physical restraints cause more harm than good and seriously infringe upon a person’s autonomy as explained in this article in the Journal of Medical Ethics, “Use of physical restraint in nursing homes: clinical-ethical considerations.”18 The Food and Drug Administration (FDA) also provides guidance on bed rail safety and reducing entrapment:
- 483.25(n) (F700) requires that facilities attempt appropriate alternatives before installing/ using bed rails, and if a bed or side rail is used, the facility must ensure correct installation, use, and maintenance of bed rails.
Appropriate Alternatives Facilities must attempt to use appropriate alternatives prior to installing or using bed rails. CMS encourages facilities to refer to published information from recognized authorities such as the Food and Drug Administration, which has identified the following alternatives to bed rail use: “Alternatives include: roll guards, foam bumpers, lowering the bed and using concave mattresses that can help reduce rolling off the bed.” This and more information may be found at https://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/HomeHealthandC onsumer/ConsumerProducts/BedRailSafety/ucm362843.htm. This webpage was last updated in December, 2017. See also, Clinical Guidance for Assessment and Implementation of Bed Rails in Hospitals, Long Term Care Facilities, and Home Care Settings and Recommendations for Health Care Providers about bed rails
Additionally, alternatives that are attempted should be appropriate for the resident, safe and address the medical conditions, symptoms or behavioral patterns for which a bed rail was considered. For example, a low bed or concave mattress may not be an appropriate alternative to enable movement in bed for a resident receiving therapy for hip-replacement. If no appropriate alternative was identified, the medical record would have to include evidence of the following: • purpose for which the bed rail was intended and evidence that alternatives were tried and were not successful • assessment of the resident, the bed, the mattress, and rail for entrapment risk (which would include ensuring bed dimensions are appropriate for resident size/weight), and • risks and benefits were reviewed with the resident or resident representative, and informed consent was given before installation or use.
CMS recognizes that there are many different types of beds, some with bed rails preinstalled, or bed rails with the call button and lights incorporated into the rail, and others without bed rails pre-installed for which a separate rail could be installed.
Facilities should have a process for determining whether beds, including mattresses and rails, are appropriate and safe for their residents. For beds with rails that are incorporated or pre-installed, the facility must determine whether or not disabling the bed rail poses a risk for the resident. Some considerations would include, but are not limited to the following:
- Could the rail simply be moved to the down position and tucked under the bed
- When in the down position, does it pose a tripping or entrapment hazard?
- Would it have to be physically removed to eliminate a tripping or entrapment hazard?
Facilities should follow manufacturers’ recommendations/instructions regarding disabling or tying rails down. CMS regulations do not specify that bed rails must be removed or disabled when not in use. However, if bed rails are not appropriate for the resident and the facility chooses to keep the bed rail on the bed, but in the down position, raising the rail even for episodic use during care would be considered noncompliance if all of the requirements (assessment, informed consent, appropriateness of bed, and inspection and maintenance) are not met prior to the episodic bedrail use for the resident.
Additional regulatory language on bed rails can be found in Appendix PP. LeadingAge Ohio encourages facilities to utilize Long-Term Care Survey Pathways to monitor for compliance. The survey pathways can be found on the CMS Nursing Home webpage, under the download section, and within the zip file called LTC Survey Pathways.
For more information about the citations occurring in Ohio, please join us on the monthly STAT: Survey Tips and Tactics call. Register now for the August 10 call at 10:00am.
With Ohio’s annual survey restarting in January, LeadingAge Ohio is sharing tips to assist members during the survey process. Send questions you’d like addressed in future Tips of the Week to Stephanie DeWees at sdewees@leadingageohio.org.
