F700 Guidance—Bedrails
The Phase 2 changes and Phase 3 Requirements of Participation (ROP) that took effect in October 2022 for all nursing homes included clarification and regulatory requirements around a facility’s use of bedrails/siderails. In F700, the Centers for Medicare and Medicaid Services (CMS) spells out that facilities must attempt to use appropriate alternatives prior to installation or the “use” of bedrails. Additional requirements and clarifications are outlined below:
- The facility must assess the resident for risk of entrapment from bed rails prior to installation.
- The risks and benefits of bed rails must be reviewed with the resident or resident’s representative and informed consent obtained prior to installation of the bed rails.
- The facility must also ensure that the bed’s dimensions are appropriate for the resident’s size and weight and must follow the manufacturers’ recommendations and specifications for installation and maintenance of the bed rails.
CMS makes it clear that the intent of F700 is to ensure that prior to the installation or use of bed rails, the facility attempts to use alternatives. If the attempted alternatives are not adequate to meet the resident’s needs, the resident is then assessed for the use of bed rails, which needs to include a review of risks including entrapment. Informed consent must be obtained from the resident or if applicable, the resident representative.
In the guidance, CMS notes that after a facility has first attempted to use appropriate alternatives to bed rails and determined that these alternatives do not meet the resident’s needs, the facility must assess the resident for the risks of entrapment and review possible risks and benefits of bed rails prior to installation or use. In determining whether to use bed rails to meet the needs of a resident, the following components of the resident assessment should be considered including, but not limited to:
- Medical diagnosis, conditions, symptoms, and/or behavioral symptoms.
- Size and weight.
- Sleep habits.
- Medication(s).
- Acute medical or surgical interventions.
- Underlying medical conditions.
- Existence of delirium.
- Ability to toilet self safely.
- Cognition.
- Communication.
- Mobility (in and out of bed)
- Risk of falling.
In addition, the resident assessment must include an evaluation of the alternatives that were attempted prior to the installation or use of a bed rail and how these alternatives failed to meet the resident’s assessed needs. The facility must also assess the resident’s risk from using bed rails. Additional information regarding risks associated with side/bedrails can be found in the F700 Guidance.
The facility is expected to maintain evidence that they have provided sufficient information so that the resident or resident representative was able to make an informed decision. Information that the facility should provide to the resident, or resident representative should include, but is not limited to the following:
- What assessed medical needs would be addressed using bed rails.
- The resident’s benefits from the use of bed rails and the likelihood of these benefits.
- The resident’s risks from the use of bed rails and how these risks will be mitigated.
- Alternatives attempted that failed to meet the resident’s needs and alternatives considered but not attempted because they were inappropriate.
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.” More information and resources with links to alternatives can be found in F700 Guidance. If no appropriate alternative was identified, the medical record must 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).
- Evidence demonstrating that risks and benefits were reviewed with the resident or resident representative, and informed consent was given before installation or use.
CMS places a focus on the correct installation and maintenance of bed rails being an essential component in reducing the risk of injury resulting from entrapment or falls. According to CMS, the FDA, and the United States Consumer Product Safety Commission (CPSC) has recommended the following initial and ongoing actions to prevent deaths and injuries from entrapment and/or falls from bed rails:
Before bed rails are installed, the facility should:
- Check with the manufacturer(s) to make sure the bed rails, mattress, and bed frame are compatible since most bed rails and mattresses are purchased separately from the bed frame.
- Rails should be selected and placed to discourage climbing over rails, which could lead to falling over bed rails.
NOTE: If a facility is unable to identify the manufacturer and access the manufacturer information and guidance for bed rails that they use, they would not meet requirements to follow the manufacturers’ recommendations and specifications for installing and maintaining bed rails.
When installing and using bed rails, the facility should:
- Ensure that the bed’s dimensions are appropriate for the resident.
- Confirm that the bed rails to be installed are appropriate for the size and weight of the resident using the bed.
- Install bed rails using the manufacturer’s instructions and specifications to ensure a proper fit.
- Inspect and regularly check the mattress and bed rails for areas of possible entrapment.
- Regardless of mattress width, length, and/or depth, the bed frame, bed rail and mattress should leave no gap wide enough to entrap a resident’s head or body.
- Check bed rails regularly to make sure they are still installed correctly as rails may shift or loosen over time.
Facilities must also conduct routine preventive maintenance of beds and bed rails to ensure they meet current safety standards and are not in need of repair. CMS expects facilities to have a process for determining whether beds, including mattresses and rails, are appropriate and safe for their residents.
Also, 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, CMS clearly states that 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.
Another component necessary to ensure facility compliance is the expectation of ongoing monitoring and supervision of the resident when bed rails are in use. This should be evidenced in the residents’ records, including their care plan. Information should include, but not limited to the following information:
- The type of specific direct monitoring and supervision provided during the use of the bed rails, including documentation of the monitoring.
- The identification of how needs will be met during use of the bed rails, such as for re-positioning, hydration, meals, use of the bathroom and hygiene.
- Ongoing assessment to assure that the bed rail is used to meet the resident’s needs.
- Ongoing evaluation of risks.
- The identification of who may determine when the bed rail will be discontinued; and
- The identification and interventions to address any residual effects of the bed rail (e.g., generalized weakness, skin breakdown).
SNF Questions?
Please email Elena Madrid, or call her at 1-800-562-6170 extension 105.
Posted in Skilled Nursing Facilities, Survey & Regulatory