APPENDIX
SPECIAL NOTE
For your convenience, we have provided the January 2008 addition of the FDA’s guide to bed
safety. This information from the FDA’s brochure, published by Hospital Bed Safety Workgroup, is
replicated verbatim; the latest version is available at http://www.fda.gov.
A Guide to Bed Safety Bed Rails in Hospitals, Nursing Homes and Home Health Care: The Facts
Bed Rail Entrapment Statistics
Today there are about 2.5 million hospital and nursing home beds in use in the United States.
Between 1985 and 2008, 772 incidents of residents* caught, trapped, entangled, or strangled in
beds with rails were reported to the U.S. Food and Drug Administration. Of these reports, 460
people died, 136 had a nonfatal injury, and 176 were not injured because staff intervened. Most
residents were frail, elderly or confused.
*NOTE: In this brochure, the term resident refers to a resident of a nursing home, any individual
receiving services in a home care setting, or residents in hospitals.
Resident Safety
Residents who have problems with memory, sleeping, incontinence, pain, uncontrolled body
movement, or who get out of bed and walk unsafely without assistance, must be carefully
assessed for the best ways to keep them from harm, such as falling. Assessment by the resident’s
health care team will help to determine how best to keep the resident safe.
Historically, physical restraints (such as vests, ankle or wrist restraints) were used to try to keep
residents safe in health care facilities. In recent years, the health care community has
recognized that physically restraining residents can be dangerous. Although not indicated for
this use, bed rails are sometimes used as restraints. Regulatory agencies, health care
organizations, product manufactures and advocacy groups encourage hospitals, nursing homes
and home care providers to assess residents’ needs and to provide safe care without restraints.
The Benefits and Risks of Bed Rails
Potential benefits of bed rails include:
• Aiding in turning and repositioning within the bed.
• Providing a hand-hold for getting into or out of bed.
• Providing a feeling of comfort and security.
• Reducing the risk of residents falling out of bed when being transported.
• Providing easy access to bed controls and personal care items.
Potential risks of bed rails may include:
• Strangling, suffocating, bodily injury or death when residents or part of their body are
caught between rails or between the bed rails and mattress.
• More serious injuries from falls when residents climb over rails.
• Skin bruising, cuts, and scrapes.
• Inducing agitated behavior when bed rails are used as a restraint.
• Feeling isolated or unnecessarily restricted.
• Preventing residents, who are able to get out of bed, from performing routine activities
such as going to the bathroom or retrieving something from a closet.