MDS Alert

Is that bedrail just a mobility aid - or also a restraint and accident hazard? The answer could surprise you.

Bedrails can derail patient safety - and your survey - if you don't properly assess, code and protect residents who use them.

In fact, your MDS coding may be what gives away the fact you're unwittingly using a bedrail as a mobility aid that also qualifies as a restraint. "If you code the resident as using bedrails for bed mobility (G6b) and then code him as dependent for bed mobility, surveyors will look at that contradiction as a red flag," cautions Cheryl Field, MSN, RN, a consultant with LTCQ Inc. in Lexington, MA.

How so? "To be dependent in bed mobility, the resident has to require total assistance 24/7. So if the resident puts his hand on the bedrail and squeezes his bicep at all to help move in bed, he has participated in bed mobility," Field notes.

Thus, if you code bedrails when the resident is truly dependent in bed mobility, surveyors may be more quick to view the bedrails as a restraint - and you better be able to show you've followed the RAI user manual's restraint policy and procedure.

To determine whether the bedrail is restraining the resident, look at its effect on the resident, advises Field. "For example, if the resident can't assist at all in bed mobility, she may not be able to see the TV or her roommate if the bedrail is at eye level," she says. "Or the bedrail might frighten the resident or make him feel like he's trapped."

Coding compliance tip: If you determine the rail is acting as a restraint, the facility must document a medical reason for its use - and attempt restraint reduction. "While restraints may serve more than one purpose," states the RAI manual, "code items P4a or b when the bedrails meet the definition of a restraint. When a bedrail acts as both a restraint and a transfer or mobility aide, code it at P4 (a or b) and G6b (bedrails used for mobility or transfer)."

For example, Royal Manor Healthcare uses very few full siderails, but when staff do consider using them, they go through the full restraint assessment provided by the Ohio Department of Health, reports Treva Boydelatour, RN, LNC, corporate compliance nurse with the Middlebrook Heights, OH-based nursing facility organization. "Staff does the [restraint assessment] monthly and on the quarterly MDS," she adds.

Boydelatour found that a bedrail actually helped one resident with longstanding documented paranoia feel more secure. "The resident developed severe behaviors when staff tried to eliminate the bedrails," she says. "So we have medical documentation to validate why the siderail is required in that case - and to show that the facility tried various alternatives to using the bedrail."

Care plan tip: "If you're going to use bedrails for bed mobility, document a therapeutic rationale and include goals for their use in the care plan," advises Daniel Sheridan, PhD, RN, a consultant and nursing professor at Johns Hopkins University School of Nursing (see the example of a care plan goal below).

If the bedrail is also acting as a restraint in a particular case, "look for potential alternatives to assist the resident with bed mobility," adds Sheridan. "Could you hook up an overhead device that the resident could use to pull himself up?"

Think out of the box: Sometimes staff has to get creative to figure out alternatives to bedrails to keep a resident from falling from bed. For example, one facility cared for a gentleman who has both cerebral palsy and multiple sclerosis, Boydelatour reports.

"With his permission, we talked to some of his neighbors who told us he used to do everything on the floor," she says. So staff put mats in his room in lieu of a bed. This tack provided the resident the type of environment he has experience navigating - and it completely eliminates the risk of him falling from even a low bed.

Safeguard Residents

If your facility uses bedrails in a particular case, make sure the care plan includes individualized interventions designed to prevent the resident from trying to climb over the rails - or becoming entrapped. A resident can get trapped in gaps between the mattress and headboard or footboard or between the siderail and the mattress. Residents can even get their head caught in some of the older-style siderails, Boydelatour cautions.

For pictures of potential zones of entrapment, see the U.S. Food & Drug Administration's draft proposal for hospital/SNF bed system dimensional guidelines at www.fda.gov/cdrh/ocer/guidance/1537.pdf.

Safety tip: If you use the older siderails, make a pillowcase-type covering to slip over the siderail to prevent the resident from putting his head through the rail, Boydelatour suggests. "Facilities with older beds may need to purchase special mattress extenders to fill out the regular mattress (some of these even fit under the mattress), as manufacturers no longer make mattresses to fit the older beds."

Consider these three interventions to safeguard residents with bedrails: