Harmony Healthcare International (HHI) Blog

Bed Inspections: Risk for Entrapment



Compliance • Audits/Analysis • Reimbursement/Regulatory • Education/Efficiency

Writing on clipboard with patient in background in hospital.jpegBed Inspections in the nursing home setting are on the rise and are being incorporated into life safety and state health inspections.  The focus is not new to healthcare, as the FDA released hospital guidelines back in 2006. As these principles merge into the post-acute continuum, education and tools are essential for your facility. 

As of 2.13.18, Harmony Healthcare International (HHI) has received over 10 calls from facilities across the country stating they received a deficiency in bed assessments for: 

“not completing the assessment while the patient was in the bed.”

In true Harmony Healthcare International (HHI) fashion, we emphasize the importance of the team approach. Input and discussion is required by the Interdisciplinary Team (IDT), including nursing, maintenance and therapies.  The Interdisciplinary Team (IDT) should conduct an initial Bed Assessment (see download) along with annual bed inspections of all: 

  1. Bed Rail Usage
  2. Bed Frames
  3. Bed Accessories 

The intent of this process is to detect the risk of entrapment. 

“Entrapment is defined as an event in which a patient is caught, trapped or entangled in the spaces in or about the bed rail, mattress or hospital bed frame. Entrapment can result in serious injury or death. Solving the problem of patient chest, head or neck entrapment between bed frames, bed rails and mattresses is complex and should include conformance with the dimensional criteria for bed systems, quality improvement efforts, and patient, staff and family education.  A bed system is defined as a bed frame, mattress, bed rails, as well as other accessories that are compatible with each other.” Source FDA 

It is prudent to implement and monitor a regular maintenance program to: 

  • Identify
  • Prevent
  • Correct 

any areas of possible entrapment.  

Download HHI's Bed Assessment Form

The team must confer and problem solve usage of appropriate alternatives prior to installing a bed rail.  A skilled clinical assessment is required to accurately determine the necessity of bed rails. 

  1. Bed Rails

    If the team determines that a Bed Rail is necessary, i.e. to prevent harm from oneself or to aide in bed mobility, then a Bed Rail Assessment is completed and included in the medical record.  In addition, the inclusion of a Released Consent Form is required and maintained in the medical record.

    The State Operations Manual (SOM), (Rev. 168, 03-08-17) Revised Regulations and Tags addressing bed rails specifically, mandating the facility must ensure that the resident’s environment remains as free from accident hazards as is possible; and that each resident receives adequate supervision and assistance devices to prevent accidents.

    483.25(n)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.

    As the industry traverses the treatment progressions via evidenced based healthcare, ongoing assessment of the potential risks and benefits of bed rails.

    Potential Risks of Bed Rails may include:
      • Suffocation, Strangling or Death
      • Falls
      • Skin Injuries
      • Agitated Behavior
      • Feelings of Isolation
      • Restrict Movement

    Potential Benefits of Bed Rails may include:

    • Assist the patient to move (turn, reposition) while in bed.
    • Provide a grab bar when transferring in and out of the bed.
    • Provide a sense of security.
    • Prevent a fall out of bed while the patient is transported via bed. 
  1. Bed Frames

    The seven areas in the bed system where there is a potential for entrapment are identified in Figure 1.
    • Zone 1: Within the Rail
    • Zone 2: Under the Rail, Between the Rail Supports or Next to a Single Rail Support
    • Zone 3: Between the Rail and the Mattress
    • Zone 4: Under the Rail, at the Ends of the Rail
    • Zone 5: Between Split Bed Rails
    • Zone 6: Between the End of the Rail and the Side Edge of the Head or Foot Board
    • Zone 7: Between the Head or Foot 

Figure 1

Bed Assessment.jpg

  •  Entrapment Zones 1-4 account for most of entrapments and deaths from entrapments. 

Source: FDA 

Bed Dimensional Limit

FDA Recommendations for Hospitals 


Dimensional Limit


Within the rail

<120 mm (<4 ¾”)


Under the rail, between rail supports
or next to a single rail support

<120 mm (<4 ¾”)


Between rail and mattress

<120 mm (<4 ¾”)


Under the rail, at the ends of the rail

<60 mm (< 2 3/8”)


>60° angle

Source: FDA 

  1. Bed Accessories

    The Bed Assessment is not limited to bed rails and bed frames.  Other items placed in the bed require evaluation and consideration.  For example, mattresses, pads, wedges, etc. all require attention and identification of risk.

Bed Accessories

Accessories and Devices that Alter the
Openings of Bed Systems

Potential Entrapment Zones

Mattresses with optimal length, width and depth for bed deck, frame and bed rails

2, 3, 4, 7

Gap Fillers

  • Bed Rail Inserts:  Rigid plastic that inserts into the bed rail openings to narrow the openings.
  • Stuff Pads:  Plastic covered pads used to decrease open spaces between bed rails and mattresses and head/foot boards.


4, 7

Pads and Wedges

  • Rail Bumper Wedges:  Elongated pads that address openings between the mattress and bed rail, and cover the openings in bed rails.
  • Rail Pads:  Elongated pads that address openings between the mattress and bed rail, and cover the openings in bed rails.

 1, 4, 5, 6 

1, 4, 5, 6

Drapes, Covers and Shields

  • Rail Covers:  Fabric devices or plastic that slip over the bed rails to close openings.
  • Entrapment Shields:  Rigid plastic device attached to a bed rail which occludes all openings along the side of the bed.

1, 5, 6

1, 2, 3, 4, 5, 6

Source: FDA


Best Practices include the implementation of a Bed Assessment for all new Admissions. Inclusion of this task within the Quarterly Quality of Life Rounding Program. 

Reminder: Citations include bed alarms as they are considered restraints. 

Harmony Healthcare International (HHI) is available to assist with any questions or concerns that you may have. You can contact us by clicking here.  Looking to train your staff?  Join us in person at one of our our upcoming Competency/Certification Courses.  Click here to see the dates and locations.

 Join us November 1st & 2nd, 2018 at Mohegan Sun Resort for harmony18
7th Annual LTPAC Symposium
Click Here to Register
harmony20 October 29-30 2020 Encore Boston Harbor

Topics: Bed Assessment

Kris Mastrangelo, OTR/L, LNHA, MBA


Kris Mastrangelo, OTR/L, LNHA, MBA

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