TIP OF THE WEEK
Is a side rail (a.k.a. bed rail) a physical restraint?
The use of rails on the side of a bed and their relation to restraints can sometimes spur a heated debate. The Centers for Medicare & Medicaid Services (CMS) and the Ohio Department of Health (ODH) provide specific direction, including the following:
CMS FEDERAL REGULATIONS
According to the federal regulations:
Side rails sometimes restrain residents. The use of side rails as restraints is prohibited unless they are necessary to treat a resident’s medical symptoms. Residents who attempt to exit a bed through, between, over or around side rails are at risk of injury or death. The potential for serious injury is more likely from a fall from a bed with raised side rails than from a fall from a bed where side rails are not used. They also potentially increase the likelihood that the resident will spend more time in bed and fall when attempting to transfer from the bed.
As with other restraints, for residents who are restrained by side rails, it is expected that the process facilities employ to reduce the use of side rails as restraints is systematic and gradual to ensure the resident’s safety while treating the resident’s medical symptom.
The same device may have the effect of restraining one individual but not another, depending on the individual resident’s condition and circumstances. For example, partial rails may assist one resident to enter and exit the bed independently while acting as a restraint for another.1
OHIO DEPARTMENT OF HEALTH STATE REGULATIONS
A May 2007 publication from the ODH prohibits the use of bed rails unless they are “necessary to treat a resident’s medical symptoms.” It states:
Bed rails used as restraints increase the risk of more significant injury from falling from a bed with raised bed rails than without bed rails. They also increase the likelihood that the resident will spend more time in bed and fall when attempting to transfer from bed. Entrapment between the bed rail and the bed can lead to death. Therefore, rigorous assessment should tend to avoid using a bed rail as a restraint.
Other interventions that might be incorporated in the care plan include (but are not limited to):
- Providing frequent staff monitoring at night with periodic assisted toileting for residents attempting to rise to use the bathroom.
- Providing restorative care to enhance abilities to stand safely and to walk.
- A trapeze to increase bed mobility.
- Placing the bed lower to the floor and surrounding the bed with a soft mat.
- Equipping the resident with a device that monitors attempts to rise.
- Furnishing visual and verbal reminders to use the call bell for residents who are able to comprehend this information.
Assessments should also include a review of the resident's:
- Bed mobility (Ex. Would the use of the bed rail assist the resident to turn from side to side, or, is the resident totally immobile and unable to shift without assistance?).
- Ability to transfer between positions, to and from bed or chair, to stand and toilet (Ex. Can the resident transfer safely with no risk of falling? Moderate risk? High risk? Would using a bed rail add to or detract from that risk?).
It is expected that the restraint reduction process be done in a systematic, individualized and gradual manner. (Ex. Lessening the time the bed rail is used while increasing visual and verbal reminders to use the call bell.) Bed rails can create a barrier and decrease socialization and interaction with others, especially when padded. The plan of care for a resident using bed rails should address these issues. The same device may have the affect of restraining one individual but not another, depending on the individual resident’s condition and circumstances. For example, partial rails may assist one resident to enter and exit the bed independently, but act as a restraint for another. As a general practice, facilities should consider adding bed rails only when a resident’s assessment indicates that a rail or rails would assist with mobility and transfers; bed rails should not automatically be applied to all beds. When bed rails are used, an assessment of the mattress and bed frame for gaps must be completed.2
THREE KEY POINTS IN FEDERAL AND STATE REGULATIONS
For those nursing homes that are still using physical restraints, it is important to adhere to all federal and state guidelines.
The following points were explicitly stated in both the federal and state guidelines:
- Side (or “bed”) rails may be a restraint for some residents, but not for all.
- Side rails that are used for the purpose of restraining residents have the potential of serious injury and even death.
- Facilities are expected to have a plan in place to reduce restraint use.
RESOURCE SPOTLIGHT
Framework for Reducing Physical Restraints in Nursing Home Facilities (PDF)
(MedQIC) Transformational change occurs through collaboration, partnership, and commitment to a paradigm shift, in this case, an individualized care (IDC) approach to quality improvement. The foundation of transformational change rests on a positive organizational culture that is directed and supported by the administrator, director of nursing, and countless other leaders in today’s nursing home.
The IDC model is an innovative approach in long-term care, enhancing residents’ quality of life by supporting an environment that promotes residents’ freedom, independence, and autonomy.
The purpose of this framework is to provide the foundation necessary for staff to reduce and/or eliminate physical restraints in their facility.
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