Skip to content Skip to navigation

Side-tracked by side rails

July 21, 2015
by Alan C. Horowitz, RN, JD
| Reprints

When the alarm clock rings, most of us can enjoy those last remnants of sleep, choosing whether or not to hit the snooze alarm. We can decide when and how to get out of bed and start the day. But, how do nursing home residents feel when they awaken to see cold, impersonal side rails? Like a prisoner? Like a burrito? And, what dangers are lurking in the use of those seemingly innocuous bed rails? The use of side rails can indeed be a double-edged sword.

Both the U.S. Consumer Product Safety Commission (CPSC) and the Food and Drug Administration (FDA) have received many death and injury reports related to side rails. (The terms “side rails” and “bed rails” are used interchangeably.) According to the FDA, 803 incidents were reported where patients/residents were caught, trapped, entangled or strangled in beds with rails between 1985 and January 1, 2009. The FDA notes that of those 803 incidents, 480 people died while 138 sustained nonfatal injuries. An additional 185 patients were not injured because staff intervened. Most of the deaths and injuries occurred to fairly typical residents who were frail, elderly or confused.

After years of safety alerts issued by the FDA, resident deaths and injuries related to side rails remain a concern. Because of the ongoing problems associated with side rails, the FDA, the CPSC and the Administration for Community Living (ACL) posted new guidances related to side rail safety in 2014.

Lessons Learned

A recent case where a resident died after his head became “wedged” between his side rails illustrates the many lessons facilities can learn. [Disclaimer: the author represented CMS in that case and a further appeal, which upheld CMS’ determination of immediate jeopardy.] In the case of Laurelwood Care Center v. CMS, CR1796, a resident was found without pulse or respirations with his head literally “wedged” between the side rails of his bed. The 64-year-old resident was severely cognitively impaired and had a seizure disorder. He was 4’10”, weighed 120 pounds and required complete care. According to his medical records, he was incapable of voluntary movement. Yet, the physician, who was also the medical director, ordered side rails. [Editor's note: The Laurelwood Care Center involved in the above case is located in Johnstown, Pa.]

On cross-examination, the physician admitted that he did not participate in any risk/benefit analysis regarding the use of side rails for this particular resident. Nor could he recall any discussions with the staff regarding the resident’s need for side rails.

The physician testified that the placement of side rails in this instance was “within the standard of care.” Yet, no appropriate risk/benefit analyses or individualized safety risk assessments regarding the use of side rails had been done for any of the 54 residents. Neither the administrative law judge (ALJ) nor the judges on a further appeal accepted the physician’s assertion.

Going From Bad to Worse

When the surveyors went to the facility to investigate the entrapment-related death, they made some stunning observations.



Alan C. Horowitz

Partner at Arnall Golden Gregory

Alan C. Horowitz

Alan C. Horowitz, Esq., is a partner at...