Rethinking Safety: Will Side Rails Keep a Patient in Bed and Can Decrease the Risk of Falling?

Between 1985 and 2009, the FDA received reports of 803 patient entrapment incidents in beds with rails, including 480 deaths. This raises a critical question: will side rails keep a patient in bed and can decrease the risk of falling, or do they introduce new dangers?

Quick Summary

Contrary to common belief, bed rails can introduce significant dangers, including fatal entrapment and more severe fall injuries. Their effectiveness is highly debated, and they can be considered physical restraints, prompting experts to recommend thorough risk assessments and safer alternatives.

Key Points

• Not a Simple Solution: Contrary to popular belief, bed rails can increase the risk of serious injury from falls or entrapment and are not a universal fall prevention tool.

• Entrapment is a Deadly Risk: The FDA and CPSC have recorded hundreds of deaths due to patients becoming trapped between the rails and the mattress, leading to suffocation.

• Restraint vs. Assist: If a bed rail prevents a person from voluntarily getting out of bed, it is legally and ethically considered a physical restraint, which should be avoided.

• Heightened Fall Danger: A person attempting to climb over a bed rail may fall from a greater height, leading to more severe injuries than a fall from the bed itself.

• Assessment is Crucial: The decision to use a bed rail must be based on a thorough, individual assessment by a healthcare team, weighing the specific benefits against the significant risks.

• Safer Alternatives Exist: Lowering the bed, using floor mats, bed alarms, and foam bolsters are often safer and more effective strategies for fall prevention.

• Distinguish Rail Types: Smaller 'assist handles' are designed to help with mobility and are generally safer than full-length 'bed rails' intended as a barrier.

The Surprising Truth About Bed Rails and Fall Prevention

Many caregivers assume that installing bed rails is a straightforward solution to prevent a loved one from falling out of bed. The logic seems simple: a physical barrier should keep someone safely in place. However, regulatory bodies like the U.S. Food and Drug Administration (FDA) present a much more complex and cautionary picture. While rails can provide a sense of security and assist with repositioning for some, they are not a one-size-fits-all solution and can, paradoxically, lead to more severe injuries. For individuals who are confused, agitated, or have poor muscle control, the presence of a rail might lead them to try climbing over it, resulting in a fall from a greater height. This misunderstanding of their function versus their risks is a critical issue in senior care.

Unpacking the Dangers: Entrapment and Other Risks

The most severe risk associated with bed rails is entrapment. The FDA has documented hundreds of deaths where patients, often frail or elderly, became caught, trapped, or entangled in the spaces within the rail, between the rail and the mattress, or between the rail and the headboard. These incidents can lead to suffocation and strangulation. Between 2003 and 2021, the U.S. Consumer Product Safety Commission (CPSC) identified 284 entrapment deaths involving adult portable bed rails alone.

Beyond entrapment, other risks include:

• Serious Fall Injuries: A determined individual may attempt to climb over the rail, leading to a fall from a higher point and increasing the risk of significant injury.
• Agitation: For individuals with cognitive impairments like dementia, the rails can feel like a cage, increasing agitation, confusion, and anxiety.
• Reduced Independence: Rails can prevent a person who is otherwise capable from safely getting out of bed to use the bathroom or move around, leading to a loss of mobility and dignity.
• Physical Injury: Bruises, cuts, and scrapes can occur from contact with the rails themselves.

When Does a Bed Rail Become a Physical Restraint?

A key legal and ethical consideration is whether a bed rail constitutes a physical restraint. According to guidelines from the Centers for Medicare & Medicaid Services (CMS), a device is considered a restraint if it restricts a person's freedom of movement and cannot be easily removed by the resident. If a patient cannot voluntarily get out of bed because the rails are raised, those rails are functioning as a restraint. Using all four side rails is almost always considered a restraint. However, a partial rail that a patient can use for support to get in and out of bed might not be. The determination is highly individualized and depends on the patient's physical and cognitive ability. Facilities are required to use the least restrictive methods possible, making the routine use of full bed rails problematic.

Comparison: Full Bed Rails vs. Assist Handles

Not all rails are designed for fall prevention. It's crucial to distinguish between full bed rails and smaller bedside assist handles or bars.

Feature	Full Bed Rails	Bedside Assist Handles/Bars
Primary Purpose	To prevent a person from rolling or falling out of bed.	To provide a stable grip for assistance with sitting up, repositioning, and getting in or out of bed.
Size	Typically extend along a significant portion, or the full length, of the bed.	Smaller, localized, and provide a hand-hold rather than a full barrier.
Risk of Entrapment	Higher, especially with gaps between the rail and mattress.	Lower, as they are not designed to enclose the person.
Restraint Potential	High; often considered a physical restraint if the person cannot lower it themselves.	Low; generally considered a mobility aid, not a restraint.
Best Use Case	Rarely recommended; requires a thorough risk assessment. May be used for patients during transport.	Individuals who need support for mobility but are not at high risk of rolling out of bed.

Safer Alternatives for Fall Prevention

Given the risks, healthcare professionals and the FDA encourage exploring alternatives before resorting to bed rails. A comprehensive fall prevention strategy should be person-centered.

Here are several effective alternatives:

1. Lower the Bed: Use a height-adjustable bed and keep it in its lowest position. This reduces the distance to the floor and the severity of a potential fall.
2. Place Mats on the Floor: Placing firm, bevel-edged fall mats next to the bed can cushion an impact if a fall does occur.
3. Use Bed Bumpers or Bolsters: Soft foam bumpers or bolsters can be placed along the sides of the mattress under the fitted sheet to create a gentle reminder of the bed's edge without the risk of entrapment.
4. Concave Mattresses: Some mattresses are designed with raised edges to help keep a person centered and reduce the likelihood of rolling out.
5. Bed Alarms: Pressure-sensitive alarms can alert a caregiver when a person gets out of bed, allowing for timely assistance.
6. Improve Mobility and Strength: Physical and occupational therapy can help improve a person's balance, strength, and ability to move safely.
7. Address Underlying Needs: Often, a person gets out of bed due to pain, hunger, thirst, or the need to use the toilet. Anticipating and meeting these needs can reduce the likelihood of them attempting to get up unassisted. For more authoritative guidance, you can review information from the U.S. Food and Drug Administration on bed safety.

Conclusion: Prioritizing Individual Assessment Over Automatic Solutions

The question of whether side rails decrease the risk of falling is not a simple yes or no. For a small subset of patients, they may offer a degree of safety or mobility assistance. However, for many others—particularly frail seniors or those with cognitive impairments—they introduce severe risks of entrapment, strangulation, and serious fall-related injuries. They are not a substitute for proper monitoring and individualized care. The modern standard of care emphasizes a thorough assessment of the individual's needs, a consideration of their physical and mental state, and the implementation of safer, less restrictive alternatives. The goal should always be to create the safest possible environment, and that often means looking beyond the bars.

Frequently Asked Questions

Are bed rails ever safe to use for seniors?

They can be used safely under very specific circumstances after a thorough assessment by a healthcare provider. They are generally safer for individuals who are cognitively aware and physically able to use them as an assist handle, not as a restraint. However, the risks often outweigh the benefits.

Can I get in trouble for using bed rails in a home care setting?

While regulations are strictest in licensed facilities, the safety risks are the same at home. Improper use that leads to injury or death, such as entrapment, could have serious legal consequences. It's vital to follow FDA and manufacturer guidelines.

What is the main danger of using bed rails?

The single most dangerous risk is entrapment, where a person's head, neck, or chest gets caught in the gaps of the rail or between the rail and the mattress, which can lead to strangulation and death.

Do bed rails actually stop falls?

Not always. They might prevent someone from accidentally rolling out of bed, but they can't stop a determined person from trying to get out. In these cases, they may make a fall worse by forcing the person to climb over, increasing the fall height.

What's the difference between a hospital bed rail and one I buy online?

Hospital bed rails are part of an integrated system regulated by the FDA. Portable bed rails bought separately are regulated by the CPSC and have been subject to numerous recalls due to safety hazards. Compatibility between the rail, bed frame, and mattress is a major concern with portable rails.

Is a partial bed rail considered a restraint?

Not necessarily. If the person can easily and safely get out of bed with the partial rail in place, it's typically considered an assistive device. If it impedes their movement, it would be considered a restraint.

What is the best alternative to bed rails for preventing falls?

A combination of strategies is best. The most recommended alternative is using an adjustable-height bed kept in its lowest position, often paired with a floor mat next to the bed to cushion any potential falls.

Why would someone try to climb over a bed rail?

A person, especially one with dementia or confusion, may not perceive the rail as a safety device. They might feel trapped or simply need to get to the bathroom or address another need, prompting them to try and climb over the barrier.