Are Your Hospital Bed Rails Compliant with Entrapment Guidelines?


In this post, we discuss the importance of rail compliance audits to prevent patient entrapment in long-term care, plus how to tell if your bed rails are compliant with entrapment guidelines.

Although bed rails (a.k.a. side rails) are commonplace in long-term care, they can pose the risk of entrapment. Entrapment occurs when a resident becomes trapped in the hospital bed, leading to serious injury or even death.

Elderly patients are most vulnerable to the dangers of entrapment. According to Health Canada, the majority of reported cases of entrapments were in long-term care facilities.

Notably, most entrapment cases are preventable. To address this risk, Health Canada released 2008 entrapment guidelines which outline the 7 zones of potential entrapment and how to reduce your risk.

7 Zones of Entrapment - SFI Medical Equipment Solutions

What Do the Regulations Say for Long-Term Care Facilities? 

Most hospital beds are Class I medical devices according to Canada’s Medical Devices Regulations. While they don’t require pre-market review, they must comply with safety and efficacy requirements which includes reducing entrapment risk.

Entrapment prevention is the responsibility of not one but multiple stakeholders: the manufacturer (bed design), long-term care facilities and hospitals (operations and resources), and clinical and care teams (caring for vulnerable patients).

A rail compliance audit by trained auditors is one way to assess entrapment risk of your facility’s beds. Once done, you can take steps to mitigate risk based on the results (e.g., changing to a better fitting mattress, keeping up with preventative maintenance procedures, etc.).

Rail compliance audits are important and essential for any LTC facility.

How do you know your facility needs a compliance audit? Read on.

Common Concerns When Considering Rail Compliance Audits 

Many facilities are unsure whether they need to audit their beds. There are many common reasons for this uncertainty and even hesitancy.

While most facilities understand that rail compliance is part of their licensing obligations, it can be confusing to know who is truly responsible for getting it done. Is it the manufacturer? PSWs? Maintenance manager?

Or, you have been inspecting beds but are unsure if it has been done correctly – many teams find they have been doing it wrong for years once an external audit has been commissioned.

Other times, you may think the beds are being accurately assessed, when in reality important risks are being missed (which trained auditors would have caught). You might also wonder if the disruption and added expense of bringing in external auditors worth it.

The Benefits of Professional Rail Compliance Audits 

The main benefits of proper compliance audits are hard to ignore:

  • Protecting the safety of residents from a known (and preventable) hazard 
  • Complying with Health Canada’s entrapment guidelines 
  • Fulfilling your licensing obligations 
  • Reducing inconvenience from spot-checking and correcting single beds at a timeB4000 Rail Compliance Test Kit - SFI Medical Equipment Solutions

What is Included in a Rail Compliance Audit? 

Rail compliance audits should be done by experienced technical auditors familiar with all makes and models of beds, as well as the correct process for assessing the 7 potential zones of entrapment using the industry standard B4000 test kit.

Our rail compliance audits include:

  • Grading the mattress and checking/altering the bed frame for proper size, fit and mattress retention 
  • Bed rails tightened and worn hardware replaced where required. Corners, caps, and mounting points serviced 
  • Rail latch engagement test in all positions 
  • Comprehensive summary spreadsheet containing complete details of the fleet and audit provided to the facility digitally 
  • Certificate is issued upon reaching full compliance 
  • Includes asset tracking

For most facilities, our team will audit from 30 to 50 beds per day. This depends on access to the home, PPE needed, room size (smaller homes can take longer to navigate around objects and other furniture in room), etc.

As mentioned, you may decide to perform your own compliance audits in-house. In these cases, we provide training for facility teams to ensure the audit is done in accordance with the guidelines. This helps ensure proper use of the B4000 kit and correct assessment of each zone on the beds – and ultimately resident safety.

When Might Hospital Beds Need to Be Reassessed for Entrapment? 

Often it has been a long time since a bed has been audited or even inspected. Over the long lifetime of beds—a single bed could be used for 10 to 15 years if not more—many things could have changed that presents added entrapment risk.

Signs that your beds may need to be reassessed for entrapment include:

  1. Some components are worn (e.g., rails wobble or are damaged, mattresses are softer) and could cause increased spaces in the bed system 
  1. When accessories such as mattress overlays or positioning poles are added or removed 
  1. When components of the bed system are changed or replaced (e.g., new bed rails or mattresses) 

More detailed information can be found on Health Canada’s website, Adult Hospital Beds: Patient Entrapment Hazards, Side Rail Latching Reliability, and Other Hazards.

Ready to Schedule a Compliance Audit? 

To date, the SFI Medical team has audited over 5000 beds across Canada since 2013.

Contact us today to schedule an audit or speak with our customer service team to see how we can help!

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