Our Blog

Bed Rails in Nursing Homes: What you need to know

A 94-year-old woman died last weekend when her head became stuck between her mattress and a bed rail at a Pennsylvania nursing home. The county coroner ruled the cause of death as “accidental asphyxiation due to compression.” Sadly, this tragic event could have been prevented.

Experts have known about bed rail dangers for nearly two decades

Dr. Steve Miles, a bioethicist and medical professor at the University of Minnesota, first made federal regulators aware of bed rail-related deaths in 1995. Since that time, over 500 patients have died due to bed rails, with 155 deaths occurring from 2003-2012.

Despite repeated efforts by consumer groups to increase regulations, such as requiring warning labels, the FDA decided against it due to resistance from manufacturers. In 2006, the FDA issued voluntary guidelines for hospitals and nursing homes that included recommended size limits for openings and identified common entrapment risks.

While regulatory challenges remain, the FDA has a new website on bed rail safety that offers information for consumers, caregivers, health care providers and manufacturers.

Identify Risks

High-risk people include those with pre-existing conditions such as confusion, restlessness, lack of muscle control, or a combination of these factors. Additionally, people who are cognitively impaired from the use of

medication or from a medical condition, such as Alzheimer’s or dementia, are at a higher risk of entrapment and injuries, including:

  • Strangling, suffocating, bodily injury or death when patients or part of their body are caught between rails or between the bed rails and mattress
  • More serious injuries from falls when patients climb over rails
  • Skin bruising, cuts, and scrapes
  • Inducing agitated behavior when bed rails are used as a restraint
  • Feeling isolated or unnecessarily restricted.
  • Preventing patients, who are able to get out of bed, from performing routine activities such as going to the bathroom or retrieving something from a closet

If your loved one is in a nursing home or other long-term health care facility, talk to their health care planning team to find out which options are best for them, remembering to reassess their needs on a regular basis.



Greene nursing home resident dies in bed mishap.” By Tom Fantaine, Pittsburgh Tribune-Review, February 25, 2014.

After Dozens of Deaths, Inquiry Into Bed Rails.” By Ron Nixon, The New York Times, November 25, 2012.