Analysis

Topic: Nursing Home Safety Rails
Sponsor: Representative Kuipers
Committee: Senior Health, Security and Retirement
Date Introduced: November 9, 2000
Date Referred to Committee on Health Policy: December 5, 2000
Date of Analysis: November 20, 2000

Position: The Department of Consumer and Industry Services does not support the bill in its current form.

Background: Side rails are adjustable metal or plastic bars that attach to an institutional bed. They come in a variety of sizes and lengths. According to a June, 2000 article in the Illinois Bar Journal, side rails were rarely available on beds for adults until the 1930's. The article continues that side rail use increased after World War II, particularly in hospital settings. Use of side rails and other physical restraints in nursing homes also increased during this period, mirroring hospital practice.

The passage of federal nursing home reforms in the Omnibus Budget Reconciliation Act of 1987 (OBRA) has changed the policy with respect to side rails dramatically. OBRA gave nursing home residents freedom from restraints which are imposed for the purposes of discipline or convenience and which are not required to treat medical symptoms. A recent letter from the Health Care Financing Administration (HCFA) to the State of New Jersey makes it clear that HCFA considers side rails a restraint. The letter states that restraints may be used "only when necessary to treat a resident's medical symptoms".

Side rail use in nursing homes is therefore limited to those situations where a documented comprehensive assessment of medical necessity has been made by a team of health professionals. The resident or resident's legal representative must consent to the use of restraints. In obtaining consent, the nursing home is required to explain the risks and benefits associated with the use of restraints. Michigan law also requires the approval of the resident's attending physician.

Side rail use in nursing homes has been reduced substantially since the passage of OBRA and the issuance of HCFA regulations regarding side rail usage. From 40 percent in the early 1990's, the nationwide rate has declined to 13.5 percent in 1999. The average for Michigan's 450 nursing homes is close to the national average.

Content of the Bill: The bill provides that if a nursing home prohibits the use of safety rails on hospital-type beds, the nursing home must give each resident or resident legal representative the option of having safety rails on the bed. The nursing home is required to offer the option to new residents at the time of admission and to other residents upon request. The nursing home may require the resident or the legal representative of the resident to sign a statement waiving the resident's right to file a civil action for damages for an accident caused by the use of safety rails which was not the result of negligence by the nursing home or nursing home employee.

Arguments For: Side rails can provide significant benefits to nursing home residents by preventing falls and enhancing mobility of residents. Falls are a much more serious threat of injury or death in a nursing home than use of side rails. It has been estimated that half of the nation's 1.5 million nursing home residents fall each year. At least 1,800 of these falls are fatal.

The question of whether or not to use side rails is a very emotional issue. Many believe that the decision is best left to residents and their families. Empowering residents and their families rather than government to make this decision can offset the loss of independence and reduction in the quality of life often associated with residence in a nursing home.

Michigan would be one of a growing number of states that have looked at this issue. Minnesota's Legislature addressed the issue in 1998. The Minnesota legislation shows that it is possible to balance the interests of residents, families of residents and state and regulators. Minnesota permits residents, family members of residents who are not competent, and resident legal representatives to request and consent to the use of a physical restraint in order to treat the resident's medical symptoms. However, the nursing home continues to have responsibilities for documenting and monitoring their use. The nursing home must also inform the resident, family member, or legal representative of the alternatives to and the risks of side rail use. Wisconsin is another state that has addressed this issue and reportedly permits residents to use side rails upon request as long as there are assessments and a doctor's order.

Arguments Against: The dangers of side rails have been frequently documented in the literature. Potential hazards include asphyxiation caused by a resident becoming entrapped between the side rail and the mattress and accidental release of the side rail resulting in compression of the resident's neck and throat. Between 1985 and 1999 the federal Food and Drug Administration received 371 reports of head and body entrapment incidents involving side rails. A total of 228 of these incidents resulted in death. There have been nearly 60 reported incidents involving inappropriate use of side rails in Michigan nursing homes in 2000 resulting in three deaths. The Department of Consumer and Industry Services recently issued an Alert to all Michigan nursing homes regarding the proper use of side rails.

The National Center for Injury Prevention and Control has suggested that restraints may actually increase the number of fall-related injuries and deaths. This is due to functional decline resulting from limiting freedom of movement and personal autonomy. It is also possible that a resident may fall while trying to climb over the side rails, resulting in a longer fall distance and potentially more serious injury. A 1997 article in the Journal of the American Medical Association found that fall-related injuries have decreased in most nursing homes since new federal regulations took effect.

The federal Health Care Financing Administration has adopted side rail requirements that apply to nursing homes that receive Medicare or Medicaid funding. Under these requirements side rails should only be used when other, less severe alternatives fail to address a resident's medical needs, and the benefits of side rail use outweigh the potential risks. Where side rails are used, the nursing home is responsible for ensuring that they are used safely and properly. By departing from long-standing regulatory practice as defined in HCFA rules, recent training conducted by the nursing home industry, and a recent alert issued by the Department of Consumer and Industry Services the bill sends a mixed message to providers

There are alternatives to side rails that can be effective in preventing falls. These include physical conditioning and rehabilitation to improve strength and endurance, a trapeze to increase bed mobility, lowering the bed and surrounding the bed with a soft surface, equipping the resident with a device that monitors attempts to rise, and frequent staff monitoring. Ultimately, the most effective solution may be an integrated redesign of the relationship between side rails, mattresses, and beds. These products are typically sold separately. The Federal Food and Drug Administration has convened a task force to consider bed design issues.

Supporters/Opponents: No positions are available at this time.

Fiscal Impact: There should be no fiscal impact on state government.

Administrative Rule Impact: No change in administrative rules is anticipated as a result of this bill.