Highlights Policy Statement
Our facility shall strive to provide a safe sleeping environment for the resident.
Policy Interpretation and Implementation Assessment of Resident 1. The resident’s sleeping environment shall be assessed by the interdisciplinary team, Sleeping Environment considering the resident’s safety, medical conditions, comfort, and freedom of
movement, as well as input from the resident and family regarding previous sleeping
habits and bed environment.
Hospital Bed System 2. To try to prevent deaths/injuries from the beds and related equipment (including the Safety Review frame, mattress, side rails, headboard, footboard, and bed accessories), the facility
shall promote the following approaches:
a. Inspection by maintenance staff of all beds and related equipment as part of our regular bed safety program to identify risks and problems including potential entrapment risks; b. Review that gaps within the bed system are within the dimensions established by the FDA (Note: The review shall consider situations that could be caused by the resident’s weight, movement or bed position.); c. Ensure that when bed system components are worn and need to be replaced, components meet manufacturer specifications; d. Ensure that bed side rails are properly installed using the manufacturer’s instructions and other pertinent safety guidance to ensure proper fit (e.g., avoid bowing, ensure proper distance from the headboard and footboard, etc.); and e. Identify additional safety measures for residents who have been identified as having a higher than usual risk for injury including entrapment (e.g., altered
mental status, restlessness, etc.).
3. The maintenance department shall provide a copy of inspections to the Administrator Review of Inspection
and report results to the QA Committee for appropriate action. Copies of the Results by QA Committee
inspection results and QA Committee recommendations shall be maintained by the
Administrator and/or Safety Committee.
4. The facility’s education and training activities will include instruction about risk Staff Training
factors for resident injury due to beds, and strategies for reducing risk factors for
injury, including entrapment.
5. If side rails are used, there shall be an interdisciplinary assessment of the resident, Side Rail Use
consultation with the Attending Physician, and input from the resident and/or legal Interdisciplinary
6. The staff shall obtain consent for the use of side rails from the resident or the Consent for Use of Side
resident’s legal representative prior to their use. Rails
7. After appropriate review and consent as specified above, side rails may be used at the Resident Request for Side resident’s request to increase the resident’s sense of security (e.g., if he/she has a fear Rails of falling, his/her movement is compromised, or he/she is used to sleeping in a larger bed). continues on next page
? 2001 MED-PASS, Inc. (Revised December 2007)
Side Rails to Support 8. Side rails may be used if assessment and consultation with the Attending Physician Medical Needs has determined that they are needed to help manage a medical symptom or condition,
or to help the resident reposition or move in bed and transfer, and no other reasonable
alternatives can be identified.
Risk-Benefit Assessment 9. Before using side rails for any reason, the staff shall inform the resident and family for Use of Side Rails about the benefits and potential hazards associated with side rails.
Reducing Related Risks 10. When using side rails for any reason, the staff shall take measures to reduce related risks.
11. Side rails shall not be used as protective restraints. Should a protective restraint be Protective Restraint Use used, our facility’s protocol for the use of restraints shall be followed. 12. The use of physical restraints on individuals in bed shall be limited to situations Use of Restraint Devices where they are needed to treat a resident’s medical symptoms, and only after being reviewed by authorized individuals.
Reporting of 13. The staff shall report to the Director of Nursing and Administrator any deaths, serious Injuries/Deaths Resulting illnesses and/or injuries resulting from a problem associated with a bed and related From Bed/Bed Side Rails equipment including the bed frame, bed side rails, and mattresses. The Administrator
shall ensure that reports are made to the Food and Drug Administration or other
appropriate agencies, in accordance with pertinent laws and regulations including the
Safe Medical Devices Act.
483.25(h)(1); 483.25(h)(2); 483.70(c)(2); 483.70(d)(2)
See also FDA’s Hospital Bed System Dimensional and Assessment Guidance to Reduce OBRA Regulatory Entrapment; and The Hospital Bed Safety Workgroup’s Clinical Guidance for the Reference Numbers Assessment and Implementation of Bed Rails in Hospitals, Long Term Care Facilities
and Home Care Settings
F323; F456 Survey Tag Numbers
Clinical Guidance for Bed Rails (Appendix D)
Consent for Use of Side Rails (Appendix D)
Evaluation for Use of Side Rails (Appendix D) Related Documents
Hospital Bed System Guidance to Reduce Entrapment (Appendix D)
Use of Restraints (Resident Behavior and Facility Practices – Restraints)
Date:________________ By:__________________ Policy
Revised Date:________________ By:__________________
? 2001 MED-PASS, Inc. (Revised December 2007)