MDH presents bed side rail education

By Doug Beardsley  |  February 24, 2023  |  All providers

On Friday, February 17, 2023, representatives from the Minnesota Department of Health (MDH) presented a one-hour training covering their current regulatory expectations regarding the use of bed side rails in nursing facilities, assisted living facilities, home care, and hospice. The training was requested by Care Providers of Minnesota as there have been a significant number of survey licensing orders issued in the assisted living environment, each coming with a $3,000 fine. 

Over 900 people participated in the training, which was presented primarily by Matt Heffron and Kathy Lucas from MDH and led by Daphne Ponds.

The training slides focused on documentation expectations when side rails (include “grab bars”) are used in these various care settings, noting the differences between the following:
  1. Side rails installed on hospital-type of beds, overseen by the FDA
  2. Portable side rails installed on consumer-types of beds—with no regulatory guidance

Common expectations for both types of side rails include the following:
  1. Resident has  been assessed for side rail entrapment risk (cognitive status, physical strength, mobility, history of falls, incontinence and toileting needs, etc.)
  2. Purpose of the side rail is documented
  3. Side rail has been determined it is not acting as a restraint
  4. Resident (and when appropriate, family) has been educated regarding the benefits and risks of using the side rail(s)
  5. Physical inspection of the stability and condition of the side rail—side rail is secure and not wobbly

Additional documentation requirements for side rails installed on hospital-style beds include the following:
  • Measurements for Zones 1, 2, 3, and 4 should be documented to verify they meet the dimensional requirements
    • Zone 1—Spaces within the rails (not to exceed 4.75”)
    • Zone 2—Under the bottom of the rail, between the rail supports (not to exceed 4.75 “)
    • Zone 3—Between the rail and the mattress (not to exceed 4.75”)
    • Zone 4—Under the rail at the end of the rail (not to exceed 2 3/8”)
  • Nursing facilities must obtain informed consent prior to the use of side rails

Additional requirements for portable side rails installed on consumer-style beds include the following:
  1. The facility must determine the make and model of the portable side rail
  2. The facility must document it checked the Consumer Product Safety Commission to verify the specific portable side rail in use has not been recalled by the CPSC
  3. The facility must verify the portable side rail was installed /attached according to  the manufacturer’s recommendations (may need to download the instructions for the make and model of portable side rail in use) 
  4. The facility should visually verify and document the side rail does not appear to be an entrapment risk, particularly the spaces within the rail and the space between the rail and the mattress (are there areas big large enough for a body part to be trapped?)
  5. The facility should include and reference the use of the portable side rail in each assessment conducted (a required assessment element is “assistive devices”)—this includes, when appropriate, the initial assessment and subsequent assessments (change of condition and every 90-days)
  6. If the portable side rail appears unsafe to use, consider using a negotiated risk agreement, or, in extreme situations, contact MAARC

If you conclude the side rail in use is not safe for the resident, do the following: 
  • Offer alternatives, and discuss and offer interventions to mitigate safety risks 
  • Document your assessment and all interventions discussed, offered, or attempted 
  • If you use a negotiated risk agreement or similar, you must: maintain documentation of the offer of alternatives, implement interventions to mitigate safety risks, and conduct ongoing reassessment for the appropriate use of a bed rail

Care Providers of Minnesota has created audit forms for facilities to use to verify they are in compliance:
  • Side-rails on hospital-style beds audit tool
  • Portable side-rails installed on consumer-type beds audit tool 


Doug Beardsley
Doug Beardsley  |  Vice President of Member Services  |   dbeardsl@careproviders.org  |  952-851-2489