DOH Issues DAL for Nursing Homes on Entrapment Risk with Bed Systems and Components
(June 17, 2025) On June 13, 2025, the Department of Health (DOH) issued a Dear Administrator Letter (DAL) on the risk of entrapment with bed systems and components, outlining the following for nursing homes to ensure compliance with the regulation:
Bed rails. The facility must attempt to use appropriate alternatives prior to installing a side or bed rail. If a bed or side rail is used, the facility must ensure correct installation, use, and maintenance of bed rails, including but not limited to the following elements.
1) Assess the resident for risk of entrapment from bed rails prior to installation.
2) Review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation.
3) Ensure that the bed’s dimensions are appropriate for the resident’s size and weight.
4) Follow the manufacturers’ recommendations and specifications for installing and maintaining bed rails.
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The State Operations Manual, at F700, reminds providers: “Even when bed rails are properly designed to reduce the risk of entrapment or falls, are compatible with the bed and mattress, and are used appropriately, they can present a hazard to certain individuals, particularly to people with physical limitations or altered mental status, such as dementia or delirium.” Additionally, the State Operations Manual also outlines several key areas that need to be addressed for consideration of bed rail use, including resident assessment; informed consent; appropriate alternatives, installation, and maintenance and ongoing monitoring and supervision.
It is recommended that the Nursing Home conduct initial and ongoing reviews of beds to ensure that no mattress, side rail, or enabler bar has gaps that are larger than recommended in the Food and Drug Administration (FDA) document "Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment" issued on March 10, 2006. The FDA document details seven potential zones for patient entrapment and provides detailed diagrams and instructions on how to measure the open spaces between bed system components.
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Additionally, it is equally important to assess bed systems already in use. Wear and tear can compromise the integrity and function of bed components, rendering them potentially unsafe. Over time, mattresses become soft and compressed, and side rails and enablers can become loose, wobbly, and improperly positioned.
The DAL includes several resources that facilities should review to reduce the risk of entrapment with bed systems and components.
Facilities should also review F-tag F-604 Physical Restraint prior to installing a bed rail (excerpt on page 116 of the State Operations Manual):
For example, a bed rail is considered to be a restraint if the bed rail keeps a resident from voluntarily getting out of bed in a safe manner due to his/her physical or cognitive inability to lower the bed rail independently.
If the resident does not meet the above criteria and the bed rail remains on the bed, the resident will need to be coded on the Minimum Data Set (MDS) as having a physical restraint. The facility will need to follow their policy and procedure regarding restraints. The policy and procedure should include the following components:
- Documented evidence of interventions trialed prior to applying the bed rail
- A physician’s order for the bed rail
- Signed consent from resident or resident representative
- Education on risks and benefits of bed rail
- A care plan for bed rails
If you have any questions regarding the DAL, please contact the DOH Division of Nursing Home and Intermediate Care Facility for Individuals with Intellectual Disability (ICF/IID) Surveillance via email at nhinfo@health.ny.gov.
Contact: Amy Nelson, anelson@leadingageny.org, 518-867-8383 ext. 146