Assisted Living FAQs: Resident Record Requirements

To ensure an individual is an appropriate candidate for a bed rail, the licensee must assess the individual's cognitive and physical status as they pertain to the bed rail to determine the intended purpose for the bed rail and whether that person is at high risk for entrapment or falls. This may include assessment of the individual's incontinence needs, pain, uncontrolled body movement or ability to transfer in and out of bed without assistance. The licensee must also consider whether the bed rail has the effect of being an improper restraint.

Additionally, the licensee must ensure the bed rail is securely attached to the bed frame per manufacturer guidelines. This includes consideration of any identified contradictions of use such as height/weight restrictions, age, mattress, bed frame set up, etc.

Per the Uniform Assessment Tool, the need for assistive devices, such as bed rails, must be assessed upon initial installation, with each 90-day assessment and change of condition. (Please refer to Rule 4659.0150 where it directs assessment of mobility, including ambulation, transfers, and assistive devices.) Bed rail assessment should also be conducted whenever the type of bed rail is changed or if the rails is observed to not maintain a consistent secure attachment to the bed frame.

Even when bed rails are used according to manufacturer's guidelines, they can present a hazard. The licensee must ensure the resident and/or resident's responsible party has been educated on the risk for injury up to and including death due to entrapment.

The licensee is responsible for the safety and appropriateness of all portable bed rails in the licensee's facility for residents/clients receiving assisted living/home care services. Licensees should have a process in place for monitoring and unlicensed personnel reporting new bed rails for nurse assessment. This is also true for hospital beds delivered to the licensee's facility (for example, upon a resident's admission to a hospice service).

If a problem is found, both the assisted living facility and the home care or hospice agency can be held responsible if proper protocols are not followed.

The licensee should offer alternatives, discuss and offer interventions to mitigate safety risks, and ensure the portable bed rail is installed and secured per manufacturer's guidelines. If the licensee elects to utilize a negotiated and/or mitigated risk agreement, the licensee must maintain documentation of the offer of alternative, interventions to mitigate safety risks and conduct ongoing reassessment for the appropriate use of a bed rail.

If a licensee is unable to locate manufacturer's guidelines, they are unable to assess and determine if the portable bed rail is being used appropriately and installed properly. This results in an imminent safety risk for the resident/client.

The United States Consumer Product Safety Commission (CSPC) works to save lives and ensure safety by reducing the unreasonable risk of injuries and deaths associated with consumer products, such as portable bed rails. The CSPC posts information on its website related to portable bed rail recalls. Licensees should review the CSPC website regularly for updates on recalled portable bed rails. The opportune time to do this would be with the 90-day assessment due to the requirement included in the uniform assessment tool for assessing assistive devices.

One such element/performance/skill a prudent nurse performs is the documentation of all assessed data. If any aspect of patient care is not documented, it is viewed as not having been completed. Based on the above-mentioned statutes, the nurse must also abide by accepted health care standards, and the use of portable bed rails according to manufacturer's guidelines is one of those accepted standards. Documentation about a resident's bed rails includes, but is not limited to:

• Purpose and intention of the bed rail
• Condition and description (i.e., an area large enough for a resident to become entrapped) of the bed rail
• The resident's bed rail use/need assessment
• Risk vs. benefits discussion (individualized to each resident's risks)
• The resident's preferences
• Installation and use according to manufacturer's guidelines
• Physical inspection of bed rail and mattress for areas of entrapment, stability, and correct installation
• Any necessary information related to interventions to mitigate safety risk or negotiated risk agreements

Ensure that:

• An assessment was completed;
• the bed rails were determined to not act as a restraint;
• the portable bed rails were installed and maintained according to the manufacturer's guidelines;
• the manufacturer's guidelines are accessible upon request (hint: you may need to search the bed rail for identifying manufacture and model number, and/or do a Google search to download the installation and maintenance instructions);
• and the risk vs. benefits were discussed and documented with the resident/responsible party.

To ensure an individual is an appropriate candidate for a bed rail, the licensee must assess the individual's cognitive and physical status as they pertain to the bed rail to determine the intended purpose for the bed rail and whether that person is at high risk for entrapment or falls. This may include assessment of the individual's incontinence needs, pain, uncontrolled body movement or ability to transfer in and out of bed without assistance. The licensee must also consider whether the bed rail has the effect of being an improper restraint.

Additionally, the licensee must ensure the bed rail measurements are documented and that the bed rail has not shifted and is securely attached to the bed frame per manufacturer recommendations.

Per FDA recommendations, the need for bed rails must be assessed on a "frequent, regular basis." At a minimum this would include assessment of the bed rail upon initial installation, with each 90-day assessment, or with a change of condition. (Please refer to Rule 4659.0150 where it directs assessment of mobility, including ambulation, transfers, and assistive devices to be completed as part of the uniform assessment.)

Even when bed rails meet the FDA guidelines and are used appropriately, they can present a hazard. The licensee must ensure the resident and/or resident's responsible party has been educated on the risk for injury up to and including death due to entrapment.

Per the FDA guidelines, "High-risk people include those with pre-existing conditions such as confusion, restlessness, lack of muscle control, or a combination of these factors. Additionally, people who are cognitively impaired from the use of medication or from a medical condition, such as Alzheimer's or dementia, are at a higher risk of entrapment and injury."

The licensee is responsible for the safety and appropriateness of all portable bed rails in the licensee's facility for residents/clients receiving assisted living/home care services. Licensees should have a process in place for monitoring and unlicensed personnel reporting new bed rails for nurse assessment. This is also true for hospital beds delivered to the licensee's facility (for example, upon a resident's admission to a hospice service).

If a problem is found, both the assisted living facility and the home care or hospice agency can be held responsible if proper protocols are not followed.

Per the FDA recommendations, "evaluating the dimensional limits of the gaps in hospital beds is one component of an overall assessment and mitigation strategy to reduce entrapment," and "regardless of mattress width, length, and/or depth, the bed frame, bed side rail, and mattress should leave no gap wide enough to entrap a patient's head or body." The licensee should offer alternatives, discuss and offer interventions to mitigate safety risks, and ensure the bed rail is installed and secured per manufacturer's recommendations. If the licensee elects to utilize a negotiated and/or mitigated risk agreement, the licensee must maintain documentation of the offer of alternative interventions to mitigate safety risks and conduct ongoing reassessment for the appropriate use of a bed rail.

One such element/performance/skill a prudent nurse performs is the documentation of all assessed data. If any aspect of patient care is not documented, it is viewed as not having been completed. Based on the above-mentioned statutes, the nurse must also abide by accepted health care standards, and the FDA requirements related to the safety of bedrails is one of those accepted standards. Best practice for documentation about a resident's bed rails includes, but is not limited to:

• Purpose and intention of the bed rail
• Measurements
• The resident's bed rail use/need assessment
• Risk vs. benefits discussion (individualized to each resident's risks)
• The resident's preferences
• Physical inspection of bed rail and mattress for areas of entrapment, stability, and correct installation
• Any necessary information related to interventions to mitigate safety risk or negotiated risk agreements

Ensure that:

• An assessment was completed;
• measurements were completed and documented;
• the rails were FDA compliant;
• and the risk vs. benefits were discussed and documented with the resident/responsible party.