Clarification from CMS about Requirements of Participation related to use of bed rails

We appreciate the opportunity to clarify our guidance related to bed or side rails.  You have sent several questions, which we will address separately.


Question:  “…are there acceptable alternatives to removing the rails; for example disabling them in some way to ensure they are not used by the resident currently utilizing the bed?”

Response:  The CMS guidance at F700 does not specify what acceptable alternatives are, however, we would encourage facilities to refer to published information from recognized authorities such as the FDA, which has identified the following alternatives:  “Alternatives include: roll guards, foam bumpers, lowering the bed and using concave mattresses that can help reduce rolling off the bed.”  This and more information may be found at – This webpage was last updated in December, 2017.

Question:  You go on to ask if disabling them in some way to ensure they are not used by the resident currently utilizing the bed would be an acceptable alternative to removing the rails how does this impact the entire process?

Response:  CMS recognizes that there are many different types of beds, some with bed rails installed, or bed rails with the call button and lights incorporated into the rail, and others without bed rails, for which a separate rail could be installed.  CMS regulations do not specify that bed rails must be removed when not in use.  We believe the regulations at F700 were intended to address both installation and use of bed rails.  This means that prior to installation (or use), facilities will attempt appropriate alternatives, ensure correct installation, use, and maintenance, which includes:

  • assessment for entrapment risk;
  • reviewing risks and benefits with the resident or representative, and obtain informed consent prior to installation (or use);
  • ensuring bed dimensions are appropriate for resident size/weight; and
  • following manufacturers’ recommendations and specifications for installing, (using) and maintaining bed rails.

Question:  You ask how this impacts the entire process?

Response:  By this, we assume you mean the facility’s process for ensuring beds (and rails if used) can safely meet the needs of its residents and adhere to the requirements.  Facilities should have a process for determining whether beds (and their rails) are appropriate for its residents.  For beds with rails incorporated or pre-installed, consideration should be given to how the rail would be disabled from use if determined a risk for the resident.  Could the rail simply be moved to the down position and tucked under the bed frame?  When in the down position, does it pose a tripping or entrapment hazard?  Would it have to be physically removed to eliminate a tripping or entrapment hazard?  CMS defers to manufacturers’ recommendations/instructions regarding disabling or tying rails down.

Concern:  There appears to be some concern as to bed rail use as an enabler.

Response:  There is no restriction to using a bed rail as an enabler if all of the requirements have been addressed.  Additionally, the alternative that is attempted should be appropriate for the intended use of the enabler.  For example, a low bed, or concave mattress would not be an appropriate alternative to an enabler for a resident receiving therapy for hip-replacement.  If there is no appropriate alternative that would be suitable as an enabler (to assist the resident to move in bed, or to a sitting position), the medical record would have to include the following documentation:

  • notation that no suitable alternative exists for an enabler;
  • assessment of the resident, the bed and rail for entrapment risk (which should include ensuring bed dimensions are appropriate for resident size/weight), and
  • risks versus benefits were reviewed with the resident and/or representative, and informed consent given.

CMS believes that documentation of manufacturers’ recommendations/specifications for installation, use, and maintenance are not required to be kept in the medical record, but would have to be available if necessary as part of an investigation.

Concern:  One writer expresses concern that prior to using a bed rail as an enabler, the facility must attempt alternatives for 2-3 days, impacting a resident’s therapy regime.

Response:  The regulation does not specify a timeframe for attempting alternatives.

Debbie Lyons, RN
Health Insurance Specialist
Centers for Medicare & Medicaid Services
Center for Clinical Standards and Quality,
Quality, Safety & Oversight Group (QSOG)
(formerly Survey & Certification Group)
Division of Nursing Homes
Mailstop: C2-21-16
7500 Security Blvd
Baltimore, MD 21244-1850