02/12/2026

Survey Tip of the Week: Bed Rails

Bed rail citations have resulted in Immediate Jeopardy when residents have experienced bed rail entrapment, underscoring the high-risk nature of bed rail use when not properly assessed, monitored, and reassessed. The intent of the requirement under F700 is to ensure that prior to the installation or use of bed rails, the facility attempts to use alternatives. Surveyors expect facilities to demonstrate that less restrictive interventions were considered and implemented before bed rails are introduced, and that bed rails are not used for staff convenience or as a substitute for appropriate supervision or care planning. 

Surveyors evaluate whether the facility has identified and mitigated entrapment risks, such as gaps between the mattress and bed rail, between split rails, or between the rail and the headboard or footboard. State Operations Manual (SOM) Appendix PP emphasizes that changes in a resident’s condition, including declines in mobility, cognition, strength, or balance, may significantly alter the safety of bed rails that were previously appropriate. Failure to reassess bed rail use following a change in condition is a common survey finding. 

Surveyors will also review facility policies and procedures related to bed rail assessment, installation, monitoring, and reassessment, as well as staff competency in identifying entrapment hazards and responding to changes in resident condition. Facilities must demonstrate that bed rails are compatible with the bed and mattress system and are installed and maintained in accordance with manufacturer guidance. 

Specialty or therapeutic air-filled mattresses may increase entrapment risk due to their high compressibility, which can widen gaps between the mattress and bed rail and increase the likelihood of sliding or compression against the rail. Surveyors may evaluate if the facility is following manufacturer equipment alerts and recalls. 

State Operations Manual (SOM) Appendix PP references multiple resources related to bed rail safety, including the FDA Recommendations for Consumers and Caregivers about Adult Portable Bed Rails webpage, Clinical Guidance for Assessment and Implementation of Bed Rails in Hospitals, Long Term Care Facilities, and Home Care Settings, FDA Recommendations for Health Care Providers using adult portable bed rails, FDA Hospital Bed System Dimensional and Assessment Guidance Document to Reduce Entrapment, and Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment.