Long-Term Care Survey Alert

The Joint Commission on Accreditation of Healthcare Organizations released a sentinel event alert on Sept. 6 providing new guidance and caveats about bed rail use. JCAHO says that since 1995 it has received reports of seven injuries or deaths related to bed rail use, two of which were in long-term care facilities. The sentinel alert recommends that healthcare organizations take these six precautions:

1. Provide orientation and training to staff about entrapment dangers with bed rails and assessment of patients/residents for entrapment risk.

2. Assess patients/residents for risk of entrapment, including confusion, sedation, restlessness, lack of muscle control and size.

3. Re-evaluate beds for entrapment potential, including "gap" measurement and appropriate sizing of mattresses for bed frames. The alert advises modifying or replacing side rails with gaps greater than five inches;

4. For individual patients/residents at risk for entrapment, implement appropriate changes to beds (for example, the use of retrofit kits, bed rail netting, clear padding and/or Velcro or anti-skid mats) to reduce the risk of entrapment.

5. Where possible, keep patients/residents with risk factors for entrapment under more frequent observation.

6. Educate the patient or resident and/or his or her family about the purpose and potential dangers of bed rails.

The JCAHO alert also suggests use of low beds in lieu of side rails as one redesign option "Low beds are a good intervention for many residents" to prevent falls, says Joanne Rader, an associate professor at the Oregon Health and Science University in Portland.

"But you have to go through a problem solving process to see if they'll work for an individual resident." For example, a low bed with a mat placed next to it can help prevent injuries if the resident falls out of bed. But it can also cause falls if the resident tries to walk on it.

"So you have to know the individual resident and his behavior and abilities," Rader says. She recommends getting occupational and physical therapy involved in assessing the resident's bed environment and safety, especially in difficult cases.

Editor's Note: The Sept. 6 JCAHO sentinel event alert can be read at http://www.jcaho.org. Click on "Sentinel Event Alert" under the newsletter category on the home page. For additional information, see A Guide to Bed Safety brochure at www.fda.gov/cdrh/beds.