Acting Director Division of Nursing Homes and ICF/IID Surveillance Center for Health Care Quality and Surveillance
June 19, 2015
Subject: DAL NH 15-05 – Entrapment Risk with Bed Systems and Components
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.