Bed Rails in a SNF Environment: Physical Restraint or Resident Aid
The subject of bed rails makes up an entire section in the State Operations Manual (SOM) issued by the Centers for Medicare & Medicaid Services (CMS)—and it is important that all SNF staff be fully conversant with the rules and regulations.
A bed rail—the device designed to prevent a resident from falling out of bed—is there as an aid, but, as the regulations point out, it can also be seen as a physical restraint, and should only be introduced after due caution. This is important for compliance purposes: if a bed rail has the effect of a physical restraint, even if it improves the resident’s mobility in bed, the nursing home must code its use as a restraint.
In fact, the only time that a bed rail does not meet the definition of a physical restraint is if the resident is immobile and cannot voluntarily get out of bed because of a physical limitation. Even then, using bed rails is not as straightforward as might be thought. Before they can be used, a full evaluation of the resident and his or her needs must be undertaken. This is particularly relevant for residents with physical limitations or altered mental status, such as dementia or delirium.
The resident assessment must include an overview of his/her medical diagnosis, conditions, symptoms, and/or behavioral symptoms; size and weight; sleep habits; medication; acute medical or surgical interventions, ability to toilet self safely; cognition; and overall mobility (in and out of bed). Other factors which must be considered include the ability to have voluntary and involuntary movements, the possibility of visual barriers, and even the bed rail’s deterrence of physical contact with others.
The greatest issue with involuntary movements is that they can lead to the resident’s body shifting toward the edge of the bed. If bed rails are in place, then this raises the possibility of entrapment, either against the rails or between them, if they are not full length. If this is a possibility, the resident evaluation should include alternatives such as a concave mattress, and frequent monitoring of the resident’s position.
§483.25 of the SOM says that the facility must first attempt to use appropriate alternatives prior to the installation of a bed rail.
According to the SOM, if a bed rail is to be used, the following must be done:
– a full assessment of the risks of entrapment must be made prior to installation
– a full review of the risks and benefits discussed with the resident or his/her representative
– informed consent from the resident or his/her representative obtained prior to installation
– the bed’s dimensions should be appropriate for the resident’s size and weight
– all manufacturers’ recommendations and specifications for installing and maintaining bed rails must be strictly followed
