This week, we are rounding out our “Ftag of the Week” for F700 Bed Rails on the CMSCG Blog. Once you have completed the necessary assessments and received informed consent for the use of bed rails, then the facility can start thinking about installation. The facility is expected to check with the manufacturer(s) of the bed frame, mattress and bed rails to ensure that they are compatible. If not, then an alternate plan should be considered. If the installation is going ahead, there are multiple items to be addressed:
- The bed’s dimensions need to be appropriate for the resident’s size
- Confirmation that the bed rails are appropriate for the resident’s size/weight
- The bed rails that are selected should be placed to discourage climbing over the rails to get into the bed or out of bed, which could lead to falls
- The manufacturer’s instructions for installation of the bed rails need to be followed to ensure a proper fit
Mind the Gap
Check for gaps! The Interpretive Guidance (IG) states that regardless of the length/ width/ depth of the mattress, there should be no gap that is wide enough to entrap a resident’s head or body part. There should be no gap between the bed frame, bed rail and mattress.
The gaps are one of the most significant hazards that can increase the risk of entrapment or death. It is important to remember that gaps can be created when a resident moves, including through compression of the mattress which can be caused by the resident’s weight or position in bed.
Specialty Mattresses
Another important area to be aware of is when a specialty mattress is in use, such as with an air mattress/ pressure relieving mattress. Air-filled mattresses compress differently than traditional mattresses, so this can result in a resident sliding off the mattress or against the bed rail because the compression has widened the space between the mattress and rail. Once the resident’s weight is no longer on the mattress, there is a lack of compression from the mattress, and it can potentially entrap the resident as it expands again.
These mattresses can also create an entrapment risk that is different from bed rail entrapment when bed rails and a regular mattress are utilized. This means that extra precautions should be in place to reduce the risk of entrapment, including following manufacturer recommendations and increasing supervision for residents using specialty mattresses and bed rails.
Complaint Survey Citation – F700 S/S: D
A facility was cited for failure to assess the use of bed rails when used with a specialized mattress for one resident, resulting in the potential for risk of entrapment, injury and/or death. The resident was observed lying in bed, and there was a 13 cm gap between the air mattress and half rail. The mattress appeared to be smaller in size than the bed frame. Facility staff was interviewed and stated that the mattress had recently been replaced by the maintenance staff, at which time, she had expressed her concern that the mattress was too small for the bed and created a gap, but her concern was not addressed.
Inspection & Maintenance
Providers are expected to regularly inspect the mattress and bed rails for areas of possible entrapment, and also ensure that the bed rails are routinely checked to ensure they have not shifted or loosened and are no longer installed correctly. The regulation at F700 states that providers must conduct routine preventative maintenance of beds and bed rails to ensure that they are not in need of repair and meet current safety standards. When is the last time someone audited your facility’s bed rail use to ensure all rails are appropriately installed, and maintained? What is the process that is followed when a decision is made that a resident would benefit from the use of a specialty mattress? Is someone checking to ensure that the specialty mattress is compatible with the rest of the bed each time someone needs a different type of mattress?
The regulation at F700 states that providers must conduct routine preventative maintenance of beds and bed rails to ensure that they are not in need of repair and meet current safety standards.
Supervision & Monitoring
After the bed rails have been installed and a preventative maintenance plan is in place, that is not where facilities can consider the bed rail process complete. CMS also requires that the facility will identify, complete, and document the following:
- Type of specific direct monitoring and supervision that will be provided during the use of the bed rails
- How the resident’s needs will be met when the bed rails are being used, including as it relates to using the bathroom, maintaining hygiene, positioning/re-positioning, as well as meals and hydration
- Identification of who may determine when the bed rail use will be discontinued
Facilities are also expected to conduct on-going assessments to ensure that the bed rail is used to meet the resident’s needs, conduct on-going risk evaluations, and identify any interventions needed to address “residual effects” of bed rail use, such as skin breakdown or increasing weakness. Don’t forget that there is an expectation that monitoring documentation will be completed as part of bed rail use.
On Survey
During survey, a resident whose MDS is coded with a bed/side rail in use will be included in the sample. However, if a surveyor observes a bed rail in place during the survey, he/she can conduct an investigation. It’s also wise to remember that once surveyors identify an issue at one facility, they will often investigate the same concern at another. Here’s two back-to-back Immediate Jeopardy citations from the same area – occurring 1 day apart:
Standard Survey Citation – F700 S/S: L
A facility was placed in Immediate Jeopardy after it was identified that the facility failed to perform risk for entrapment from bed rail assessments prior to installation, failed to follow manufacturer’s recommendations and specifications for installing and maintaining bed rails for approximately 50% of residents with bed rails in use. During the initial tour, it was observed that multiple resident beds had a space between the mattress and bed rails that was 3 inches wide and space between the mattress and head/foot boards that was 7 inches wide. The facility was unable to provide:
- Documentation related to resident assessment/ re-assessment for risk of entrapment from mattress and bed rails
- Documentation related to bed manufacturer recommendations and specifications
- Bed certifications from Biomed provider
Standard Survey Citation – F700 S/S: L
Another facility in the same area was placed into Immediate Jeopardy the day after the facility above for failure to use appropriate alternatives prior to using siderails for resident beds for approximately 80% of residents with bed rails in use. It was observed during the initial tour that multiple resident beds had 3 side rails in the up position. The surveyors were not able to find evidence that:
- Facility re-assessed residents for the risks and benefits of side rail use
- Facility re-assessed the risk of entrapment from bed rail use
- Facility follows manufacturer’s recommendations and specifications
- Beds were certified by Biomed provider
Don’t forget that many bed rail citations are associated with Complaint investigations or Facility-Reported Incidents (FRIs) – do what you can proactively to prevent the potential for negative outcomes and carefully decide if using side rails is worth all the associated risks.
