MDH Releases New Side Rail FAQ for Assisted Living

Posted on May 10, 2022 by Kari Everson

The Minnesota Department of Health (MDH) has recently released new guidance on using side rails in assisted living communities.

Level 3 deficiencies in assisted living organizations related to side rails have climbed exponentially over the last several months. LeadingAge Minnesota had several lengthy conversations with the Minnesota Department of health focused on this side rail issue.

Earlier this week, the MDH released an updated side rail FAQ. The FAQ distinguishes between how to physically assess assistive devices on consumer beds versus assistive devices on hospital beds. For consumer beds with portable assistive devices, which would include bed canes, transfer poles (even though they're not "attached" to the bed), ½ side rails, u-bars, etc., these should be installed per manufacturer's guidelines. Please note that there are no longer measurements required for these types of assistive devices unless otherwise indicated in the manufacturer’s guidance.

In some instances, it may be challenging to determine the manufacturer of the side rail. If you cannot determine the manufacturer, you can’t assess for safety, and you should note the risk in your discussion with the resident and/or responsible party.

Sometimes, we also see homemade assistive devices in our settings. These are not appropriate for use in assisted living, and you should use all interventions to have the rail removed.

For hospital beds, for example, hospice-provided beds, you must take measurements, and the FDA 2006 guidance on entrapment measurements needs to be used. 

Device Assessment

Because MDH has issued so many deficiencies, review what should be included in an assistive device assessment:

• Complete and document an assessment.
• Ensure bed rails do not act as a restraint.
• Ensure portable bed rails were installed and maintained according to the manufacturer's guidelines.
• Make the manufacturer's guidelines accessible upon request.
• Know whether they meet FDA guidelines.
• Document the measurements.
• Conduct and document a conversation about the risks and benefits with the resident/responsible party.

LeadingAge MN is working on a toolkit for side rails in assisted living and will be issued in the next week or so. For further questions on side rails, please contact Kari Everson.