DAL NH 15-05: Entrapment Risk with Bed Systems and Components

June 19, 2015

Subject: DAL NH 15-05 - Entrapment Risk with Bed Systems and Components

Dear Administrator:

Many facilities are in the process of purchasing new beds to replace old ones. Please remind your staff to be especially diligent in evaluating the risk of entrapment with bed rails and enabler bars on all beds in your nursing home.

It is recommended that initial and ongoing reviews be conducted of your facility's beds to ensure that no mattress, side rail, or enabler bar has gaps that are larger than recommended in the Federal Drug Administration (FDA) document "Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment" issued on March 10, 2006. The FDA document details seven potential zones for patient entrapment and provides detailed diagrams and instructions on how to measure the open spaces between bed system components.

The designation of "entrapment free", "entrapment proof" or "design does not allow entrapment" by a bed system manufacturer or distributor does not remove the facility's responsibility for diligent monitoring of the system for the duration of each beds use.

Please re-examine your systems to ensure that adequate safeguards are in place for all aspects of bed safety encompassing the function of the bed's use. Special attention should be given to the following:

  • Assessing healthcare bed systems and components—bed frames, mattresses, and side rails/enablers. Those whose open spaces are larger than the dimensions advised by the FDA safety guidance are a potential safety hazard for patient and resident entrapment.
  • Reviewing facility policies and procedures for assessing the function and safety of bed systems and their components for both new and used bed systems.
  • Review the FDA's Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment and use it as a resource for assessing bed systems safety.

While new bed systems need to be assessed for safety to assure components are compatible and installed correctly, it is equally important to assess bed systems already in use. Wear and tear can compromise the integrity and function of bed components, rendering them potentially unsafe. Over time, mattresses become soft and compressed and side rails and enablers can become loose, wobbly, and improperly positioned.

Facilities must also evaluate bed components based on the characteristics of their population. For example, tall and/or bariatric individuals need bed system equipment that is designed to accommodate their unique physical characteristics, such as adequate length of bed and mattress and/or density of mattress to support their body weight adequately and comfortably.

It is important that your facility remains attentive to prevent negative resident outcomes associated with entrapment. ALL staff should be aware of the facility's systems, policies and procedures for identifying, managing, preventing, and responding to entrapment risk. Please consider posting this letter at all nursing stations and staff rooms.

The Department acknowledges and appreciates the progress made in reducing entrapment risk for your residents. We encourage your efforts to provide our residents with a safe environment that allows them to enjoy a meaningful and satisfying quality of life. If you have any questions, please contact my office at (518) 408-1267.


Shelly Glock, Acting Director
Division of Nursing Homes and ICF/IID Surveillance
Center for Health Care Quality and Surveillance