Dear friends and fellow caregivers,

As a long-term care nurse, I’m deeply committed to ensuring the safety and well-being of our beloved elders in nursing homes. ?

Families most often request long term care staff to implement side rails because they were used when there loved one was in the hospital. Often they don’t understand why staff are reluctant to implement them even when staff explain the risks involved with their use. This may be due to the fact that they are so upset that their loved one recently had a major injury related to a fall when in a community setting where siderails weren’t used. They then were implemented in the hospital post surgical intervention, and the resident remained free from another fall. Their loved one is then transferred to the nursing home and now are no longer somulent post surgery and attempting to get out of bed once again. In their mind the bedrail is what prevented them from falling but it may have been that they were medicated with pain medicine and did not want to move about.

While it’s true that the use of traditional side rails has decreased over time due to safety concerns, there are still other valuable alternatives and safety measures available to prevent falls. ?

Family members what are your alternatives to Bed rails for your loved ones ?

Did you know that nursing homes are required to implement fall prevention strategies, and there are regulations in place to guide these practices? These measures are essential to protect our elderly residents. ?

In my experience, I’ve seen firsthand how these safety features, including bed alarms and monitors, can make a significant difference in enhancing the quality of care and providing peace of mind for families. ?

I encourage all of you who have loved ones in nursing homes to:

1. Ask the facility about their fall prevention strategies.
2. Share with facility staff what your loved one was doing when the fall happened.
3. Share your loved one’s usual routine such as when they go to bed, wake up, if they attempt to toilet self and usual times they toilet self, If they have pain, If they are restless sleepers, Do they sundown, Do they wander, Do they look for snack at nights, What is the usual position they like to be in to promote a restful sleep pattern, Any assistive device they use to ambulate for example a cane or walker, When was their last fall and how many falls have they had or anything else that you noted that may decrease their fall risk.
4. Inquire about the use of bed alarms and monitors, which are often more widely accepted alternatives to traditional side rails.
5. Familiarize yourselves with regulations to ensure compliance.
   • Side rails may be considered a physical restraint per state operations manual –https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_pp_guidelines_ltcf.pdf
   • “§483.12(a) The facility must—
   • §483.12(a)(2) Ensure that the resident is free from physical or chemical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident’s medical symptoms. When the use of restraints is indicated, the facility must use the least restrictive alternative for the least amount of time and document ongoing re-evaluation of the need for restraints.
   • INTENT
   • The intent of this requirement is for each resident to attain and maintain his/her highest practicable well-being in an environment that:
     • Prohibits the use of physical restraints for discipline or convenience;
     • Prohibits the use of physical restraints to unnecessarily inhibit a resident’s freedom ofmovement or activity; and
     • Limits physical restraint use to circumstances in which the resident has medicalsymptoms that may warrant the use of restraints. When a physical restraint is used, the facility must:
     • Use the least restrictive restraint for the least amount of time; and
     • Provide ongoing re-evaluation of the need for the physical restraint.”
   • “GUIDANCE As described under Definitions, a physical restraint is any manual method, physical or mechanical device/equipment or material that limits a resident’s freedom of movement and cannot be removed by the resident in the same manner as it was applied by staff. The resident’s physical condition and his/her cognitive status may be contributing factors in determining whether the resident has the ability to remove it. For example, a bed rail is considered to be a restraint if the bed rail keeps a resident from voluntarily getting out of bed in a safe manner due to his/her physical or cognitive inability to lower the bed rail independently.“
6. Assessment, Care Planning, and Documentation for the Use of a Physical Restraint
   • “The regulation limits the use of any physical restraint to circumstances in which the resident has medical symptoms that warrant the use of restraints. There must be documentation identifying the medical symptom being treated and an order for the use of the specific type of restraint [See §483.12(a)(2)].”
   • However, the practitioner’s order alone (without supporting clinical documentation) is not sufficient to warrant the use of the restraint. The facility is accountable for the process to meet the minimum requirements of the regulation including appropriate assessment (see § 483.20 – Resident Assessment), care planning by the interdisciplinary team (see § 483.21- Comprehensive Person-Centered Care Planning), and documentation of the medical
   • symptoms and use of the physical restraint for the least amount of time possible and provide ongoing re-evaluation [see §483.12(a)(2)].
   • The resident or resident representative may request the use of a physical restraint; however, the nursing home is responsible for evaluating the appropriateness of the request, and must determine if the resident has a medical symptom that must be treated and must include the practitioner in the review and discussion. If there are no medical symptoms identified that require treatment, the use of the restraint is prohibited. Also, a resident, or the resident representative, has the right to refuse treatment; however, he/she does not have the right to demand a restraint be used when it is not necessary to treat a medical symptom.”
   • NOTE: Falls generally do not constitute self-injurious behavior or a medical symptom that warrants the use of a physical restraint. Although restraints have been traditionally used as a falls prevention approach, they have major, serious drawbacks and can contribute to serious injuries. There is no evidence that the use of physical restraints, including, but not limited to, bed rails and position change alarms, will prevent or reduce falls. Additionally, falls that occur while a person is physically restrained often result in more severe injuries (e.g., strangulation, entrapment).” https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_pp_guidelines_ltcf.pdf
7. Note: To understand why there is such a concern with the use of bedrails review The post in The Federal Register: Safety Standard for Adult Portable Bed Rails https://www.federalregister.gov/d/2023-15189

“Staff identified a total of 332 incident reports for the period January 2003 to December 2021. Of these, 310 were reports of fatalities, and 22 were reports of nonfatal incidents. Most of the incidents were identified from death certificates, medical examiner reports, or coroner reports. Death certificate data often have lag time of approximately two to three years from the initial date of reporting. As the APBR data in CPSRMS are heavily reliant on death certificates, data collection is ongoing and incident data for 2020 and 2021 should be considered incomplete and likely to increase. ” -https://www.federalregister.gov/d/2023-15189/p-38

“The remaining incidents were extracted from various sources including newspaper clippings, consumer reports, and manufacturer and retailer reports to CPSC. These documents contain limited information on incident scenarios. The age range of victims in the 305 fatal incidents for which age was reported was 14 to 103 years. More than 75 percent of the incident victims were age 70 or older, and almost 80 percent of the reported fatalities involved victims 70 or older. Table 1 below presents the distribution of these APBR incidents by age.

Age group (years)	Fatalities	Nonfatalities	Total
13–29	7	0	7
30–59	30	0	30
60–69	22	0	22
70–79	47	2	49
80–89	124	2	126
90 or older	75	1	76
Unknown/Unspecified	5	17	22
Total	310	22	332
Source: CPSRMS (2003–2021).

Approximately 50 percent of all APBR-related incidents and fatalities occurred at home. Other commonly reported locations included nursing homes, assisted living facilities, and residential institutions.^[8] Table 3 below shows the frequency of each location reported.

Location	Fatalities	Nonfatalities	Total
Home	158	6	164
Nursing Home	50	0	50
Assisted Living Facility	40	2	42
Residential Institution	14	0	14
Other ?*	23	0	23
Unknown/Not Reported	25	14	39
Total	310	22	332
Source: CPSRMS (2003–2021).
*?Includes care home/center, foster home, group home, retirement center, adult family home and hospice.

The majority of reports, 58 percent, indicated that the victim suffered from at least one underlying medical condition. Almost 34 percent were reported to have more than one medical condition. Table 4 below summarizes the most common underlying medical conditions reported.

Condition	Fatalities	Nonfatalities	Total
Cardiovascular disease	87	0	87
Alzheimer’s/Dementia/Mental	73	0	73
Mobility/Paralysis/Stroke	20	0	20
Parkinson’s disease	17	1	18
Pulmonary disease	11	0	11
Cancer	7	0	7
Cerebral palsy	6	0	6
Multiple sclerosis	5	0	5
Other ?*	21	0	21
Unknown/Not Reported	123	21	144
Source: Staff briefing memorandum in the staff package for the final rule.

Hazard Patterns noted with the use of bedrails:

“Staff grouped the hazard types into four categories based on the bed rail’s role in the incident. The categories are listed in order of highest to lowest frequency.

• Rail Entrapment: There were 284 fatalities and two not-fatal injuries related to rail entrapment. This category includes incidents in which the victim was caught, stuck, wedged, or trapped between the mattress/bed and the bed rail, between bed rail bars, between a commode and rail, between the floor and rail, between the night table and rail, or between a dresser and rail. Based on the narratives, the most frequently injured body parts were the neck and head.

• Falls: There were 23 deaths, one nonfatal knee fracture, and one non- injury incident related to falls. This category includes incidents in which the victim fell off the bed, fell and hit the bed rail, or hit and fell near the bed rail, and fell after climbing over the bed rail.

• Structural Integrity: There were 11 incidents related to structural component problems (weld of bed rail broke and bed rail not sturdy). This category includes one laceration, one head bump, one bruise, two unspecified injuries, and six non-injury incidents.

• Miscellaneous: There were 10 incidents with miscellaneous problems (hanging on the bed rail after garment got caught, hand, arm, or leg laceration, pinched radial nerve against the bed rail, complaint about a misleading label, complaint about a bed rail that was noncompliant with the ASTM standard, and a claim against a bed rail manufacturer about an unspecified issue). This category includes three deaths, three lacerations, one pinched nerve, one unspecified injury, and two non-injury incidents.

Rail entrapment, the most common hazard pattern among all reported incidents, accounted for more than 90 percent (284 of 310) of the fatal incidents. A review of the In-Depth Investigations (IDIs)?^[10] showed that the victims were typically found with their torso between the product and the mattress frame, with their neck resting on the lower bar. Three other hazard patterns were also reported: (1) chin resting on the bar; (2) slumped backwards, partially suspended with the thorax lodged and compressed in the gap between the rail and mattress; and (3) slumped through the bar opening. The medical examiners in these cases listed the cause of death as “positional asphyxia,” with an additional list of “underlying factors” or “contributory causes.” Staff’s analysis of the data revealed that the head and neck were the body parts most frequently entrapped, with positional asphyxia (neck against rail) identified as the most common cause of death. Neck compression, with or without airway blockage, can result in death, even when the body remains partially supported, because blood vessels taking blood to and from the brain and the carotid sinuses are located in soft tissues of the neck and are relatively unprotected.

The vast majority of nonfatal incident reports (all reports except one) did not list any underlying medical condition. Of the 310 fatal incidents, approximately 34 percent reported the victim to have multiple medical conditions, and approximately 58 percent of incidents reported at least one underlying medical condition. Preexisting chronic medical conditions or disorders included Alzheimer’s disease, dementia, and other mental limitations; Parkinson’s disease; cerebral palsy; multiple sclerosis; Lesch-Nyhan syndrome; amyotrophic lateral sclerosis; cancer; cardiovascular disease; and pulmonary disease. Other conditions included victims with stroke, paralysis, seizures, heavy sedation, and drug ingestion. These factors can limit mobility or mental acuity and contribute to the risk of death by entrapment, because individuals with these conditions are particularly vulnerable and often cannot respond to the danger and free themselves. As discussed in Tab B of the staff’s NPR briefing package, adult aging issues can contribute to entrapments, including age-related declines in muscular strength, muscular power, motor control and coordination, and balance. Consumers 70 years and older, who are the victims in most APBR-related fatalities, are especially vulnerable to such age-related declines.

CPSC staff identified falls as the second most common hazard pattern associated with APBRs, accounting for 25 incidents (8 percent), 23 of which resulted in a fatality. Staff found that most falls associated with APBRs involve the victim falling against or striking the APBR. A minority of fall-related incidents, according to staff’s review, involved the victim deliberately climbing over the APBR.” _https://www.federalregister.gov/d/2023-15189/p-52– 60

Let’s work together to make sure our elders receive the best possible care and protection, taking into account the evolving practices in our industry. Share your experiences and tips below! Together, we can make a difference. ???

The information presented is informative and does not constitute direct legal or regulatory advice

September 2024\Skilled Nursing Support\maria.messina@skillednursingsupport.com

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