Siderail Deaths

Angie Szumlinski
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November 7, 2023
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Shocking title, shocking truth! After years of educating, preaching, citing, and mourning, many centers continue to utilize unapproved, unsafe, devices on resident beds. If this isn’t you, congratulations, you are accepting the responsibility of providing appropriate care for your residents. If this is you, or worse if you aren’t sure, it is time to take action!

In a recent article published in McKnight’s, “there has been an “exponential” increase in the number of deaths and serious injuries tied to bed rails in assisted living communities and other long-term care facilities in Minnesota”. Trust me, Minnesota isn’t alone, we are required to accommodate resident choice (within reason) and sadly, most consumers believe that side rails will “keep mom safe”. However, the lack of knowledge the public has regarding the dangers of side rails does not absolve us of our responsibility, why? Because we DO know the risks and are responsible for following the FDA guidelines regarding side rails.

When I moved my parents to independent living, I found a “portable side rail” in their basement, the type that slide under the mattress. I explained the risks of using this device and disassembled it before putting it out in the trash! What are you doing to “clean house”? In June 2022, the Consumer Product Safety Commission advised consumers to Immediately Stop the Use of Mobility Transfer Systems such as Adult Portable Bed Rails Due to Entrapment and Asphyxia Hazard. Remember, safety first and if we as an industry are identifying a “problem” with side rails, so are plaintiff attorneys! Consider these steps:

  • Perform a complete audit of each bed in your center.
  • REMOVE ALL PORTABLE DEVICES IMMEDIATELY!
  • If there are assist devices on a bed:
    • Perform a thorough resident assessment to identify the risk/benefit of using a device.
    • If the assessment identifies the risk of injury/death outweighs the benefit, educate the resident and/or responsible party on the rationale for removing the device.
    • Don’t remove the device without a plan; consider other options, low beds, fall mats, motion detectors, position of the bed in the room, concave mattress, etc., initiate a trial and document the outcomes.
    • In the event a resident is identified as benefiting from the use of the device, perform the measurements recommended by the FDA and document. This should be done quarterly, with a change in resident condition, or a change in bed/mattress.
    • Provide your team with a cheat sheet of which rooms/beds are equipped with an assist device and the type of device. This will make them aware of any device that is “new”.
    • Educate your management team on performing rounds, look in each room, is there a device on a bed that is “new”? If so, investigate, where did it come from and why?

I could go on and on. Gather your team, review the outcome of your audit, have the QAPI committee initiate a PIP to address any deficient practices and review/update your policy and admission agreement to address the use of assist devices. Meet with your resident and family councils, educate them, share the FDA informational packet; fear is real when it comes to a loved one’s safety. It isn’t going to be easy, nothing is anymore, but if we prevent one death it is worth the effort. Stay well and stay informed!


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