Background: PA 437 of 2000 (the new bed rail law) states that a "patient advocate", "legal guardian" or "other legal representative" may request and consent to bed rails for a resident if the resident is unable to do so. People have asked what these terms mean, and whether a family member has to get a special legal document before the family member can act on behalf of a resident who is unable to act for himself or herself.

Question: What does a "patient advocate" mean for purposes of requests or consents under PA 437?

Reply: A "patient advocate" under Act 437 is an individual designated under Michigan's Durable Power of Attorney Act (Act No. 386 of 1998) to exercise powers concerning care, custody, and medical treatment decisions for an individual. The designation of a "patient advocate" for these purposes must meet the specific requirements of the Durable Power of Attorney law and the individual designated as the patient advocate must sign an acceptance of the designation.

Question: What does "legal guardian" mean for purposes of requests or consents under PA 437?

Reply: A legal guardian is an individual who has been appointed to act on behalf of an incapacitated individual by virtue of a court authorized document.

Question: May a family member who has not been officially designated as the resident's "patient advocate" or "legal guardian" request or consent to the use of bed rails for a resident when the resident is unable to do so?

Reply: Yes. In addition to a "patient advocate" or "legal guardian", Act 437 permits an individual who is an "other legal representative" of a resident to request bed rails and consent to their use when a resident is unable to do so. A nursing home may have a policy that it accepts the request and consent of a family member who is not legal guardian or patient advocate when the family member generally represents the resident in matters with the facility. The family member in such a case is considered an "attorney in fact" and falls into the category of "other legal representative" for purposes of the Act. In the survey process, the Department makes the assumption that the individual who has made the request and signed the consent is authorized to do so if they have been recognized by the facility for this purpose unless there is specific reason to question the authority of the signer. Therefore it is important that a facility be careful in ascertaining the status of the individual who signs the document.

Question: I have heard there are new M Tags related to the bed rail guidelines. What are they?

Reply: Three M Tags were developed to reflect requirements in the Michigan bed rail law which are not also in the federal requirements. These tags closely follow the language in the statute.

Tag M0370 would be used if there is a failure to comply with the part of Section 21734 (1) of the code which now requires a facility to offer bed rails. That section provides: "Notwithstanding section 20201 (2)(1) a nursing home shall give each resident who uses a hospital-style bed or the resident's legal guardian, patient advocate, or other legal representative the option of having bed rails. A nursing home shall offer the option to new residents upon admission and to other residents upon request. Upon receipt of a request for bed rails, the nursing home shall inform the resident or the resident's legal guardian, patient advocate, or other legal representative of alternatives to and risks involved in using bed rails…."

Tag M0371 would be used if there is a failure to comply with the part of Section 21734 (1) of the code act which now requires consent to bed rails and physician orders. That section provides:
"…A resident or the resident's legal guardian, patient advocate, or other legal representative has the right to request and consent to bed rails for the resident. A nursing home shall provide bed rails to a resident only upon receipt of a signed consent form authorizing bed rail use and a written order from the resident's attending physician that contains statements and determinations regarding medical symptoms and that specifies the circumstances under which bed rails are to be used. For purposes of this subsection, "medical symptoms" includes the following:

(a) A concern for the physical safety of the resident.
(b) Physical or psychological needs expressed by the resident. A resident's fear of falling may be the basis of a medical symptom."

Tag M0372 would be used if there is a failure to comply with Section 21734 (2) of the code act which now requires monitoring and reevaluation of bed rail usage. That section provides:
"A nursing home that provides bed rails under subsection (1) shall do all of the following:

(a) Document that the requirements of subsection (1) have been met.
(b) Monitor the resident's use of the bed rails.
(c)In consultation with the resident, resident's family, resident's attending physician and the individual who consented to the bed rails, periodically reevaluate the resident's need for the bed rails."

 

Question: One of the forms on your site, "Factors for Review of Bed Rail Use", lists FTags and Michigan Rules. If we get a citation, will all of the regulations and rules be included?

Reply: The Interim Guidelines are recommended practice and not regulations. Because of this, the Interim Guidelines will not be cited as violations in the survey process. However, failure to perform and document certain activities addressed by the Interim Guidelines may reflect a violation of existing requirements. The M Tags and F Tags listed in the Factors document alert facilities to the requirements that might be involved. The specific Tags cited, if any, will depend on the investigation findings.

The form, "Factors for Review of Bed Rail Use" dated March 28, 2001 was originally intended for use by surveyors to assess the process utilized by the facility in implementing the Interim Guidelines. The idea was that an assessment of the process used by the facility would be useful in determining if a situation was avoidable or unavoidable related to the practices employed by the facility and, if a citation was issued, in determining severity. While the process used by the facility will still be considered in making these determinations, experience in the field proved that the form was best filled out by the facility, as the staff has access to the documentation, rather than by the survey team.

Reflecting this, the March 28 form has now been replaced with a form entitled "Documentation: Implementation of Interim Guidelines for Bed Rail Use" dated May 29, 2001. If an investigation of the use of bed rails is triggered at a facility, the surveyor will request facility staff (Administrator or DON) to fill out the checklist. The purpose and content, with the substitution of the new MTags, of the form remains the same, but the process may be described more completely if the facility staff utilizes the tool, as they are most familiar with what is in place. The tool may also be used on a continuing basis by the facility to evaluate the process used in implementing the Interim Guidelines.

Question: We are trying to implement the new guidelines. How do they apply to residents who had side rails before April 1?

Reply: This answer refers to the checklist for Implementation of the Interim Guidelines which is found on our web site.:
If the bed rails were installed prior to April 1, 2001:

Section I Documentation of Offer, Informed Consent, and Physician Order

Items 4, 5, 6 will apply, as these are HCFA requirements which existed before the Interim Guidelines.

Section II Documentation of Initial Bed Rail Design and Installation

All items will apply.

Section III Documentation of Monitoring the Use of the Bed Rail

Items 3, 4, 5, 6, 7 will apply.

Section IV. Documentation of Education for Nursing and Other Direct Care Staff

Will apply because training of all current staff was to be scheduled by April 1, 2001 and it was to be completed by April 30, 2001.

Section V. Documentation of Education and Training for Maintenance and Environmental Services Staff

Will apply because training of all current staff was to be scheduled by April 1, 2001 and it was to be completed by April 30, 2001.

 

Question: We are working on compliance with the bed rail guidance, but we have a problem with the 4.5 inch corner triangle. We have been working with a plastics manufacturer in developing a corner for our beds in order to eliminate the greater than 4.5 inch triangle. Are there any restrictions that we should be aware of? The only other product that we have found is not sturdy, costs too much, will not survive 6 months of bed-making, and is made for use of 2 side rails.

Reply: Thanks for contacting us with your question. I don't know if you are from Michigan, but I need to start out by saying that these Interim Guidelines for Bed Rail Use were written for long term care facilities in Michigan only. Secondly, these are only interim guidelines and the dimensions may change pending the report of the FDA Hospital Bed Work Group. That having been said, your question is a common one. Whatever material you choose must meet fire safety requirements, be safe for use with the resident and be easily cleaned. In the meantime, make sure you assess each individual resident for whom rail usage applies-assess the resident's needs with regard to the equipment and how he uses it, as well as safety needs pertinent to the space, use of equipment, and the resident's particular condition and circumstances. Then care plan, in an individualized manner based upon this assessment, interventions to meet the resident's needs and safety requirements. Also be sure to have documentation supporting your efforts to resolve the issue from a facility-wide basis so that you can further demonstrate a proactive response to the issue and indicate that attempts are in progress to monitor the situation and to secure appropriate equipment to maintain safety for your residents.

Question: Do the Interim Guidelines for Bed Rail Use apply to enablers and assist bars?

Reply: The Interim Guidelines for Bed Rail Use apply to devices manufactured and sold for use as bed rails. This would include full, half and three-quarter rails. Devices sold as enablers and assist bars are not included; however, these devices still need to be assessed for safe use. A safety regulation, such as F323, could apply to the use of such equipment.

Question: We use half rails as enablers. Do we still need to follow the guidelines?
Our controls are in the rails. Do we still need to follow the guidelines?

Reply: Whenever you are using equipment manufactured and sold for use as a side rail, the Interim Guidelines for Bed Rail Use apply. Although you are making the decision to use the equipment for another purpose, it is still a bed rail.

Question: What body parts should we be measuring? The guidelines only refer to the head.

Reply: With regard to measurements, the guidelines don't specify what, beyond head width, you are required to measure. The focus of the Interim Guidelines regarding measurements is intended to prevent life-threatening events. The committee which developed the Interim Guidelines focused on head, neck and chest entrapment. Assess your resident with regard to safety needs and how he uses the equipment chosen. The size of the resident can create different gap sizes affected by such factors as mattress compression related to the mattress, resident weight, body size, the configuration of the bed, or a combination of these. Based upon circumstances, your facility may determine other measurements as necessary.

Question: If we're not using side rails, do we still have to be concerned about the space between the headboard and the mattress and the footboard and the mattress?
Does the mattress still need to be monitored?

Reply: The Interim Guidelines apply only to the use of bed rails; however, federal regulations require the provision of safe care in a safe environment. You must always address the safety needs of the resident.

Question: Our facility has special needs hospice beds. I am ordering new beds, but I was told by colleagues that the guidelines don't apply to these beds. Do they?
We have a Home for the Aged and a Skilled Nursing facility. Should all the beds meet the guidelines?

Reply: The Interim Guidelines apply to bed rail use for all long term care surveyed beds. If the beds are located within a facility that is surveyed by the Nursing Home Division, the Interim Guidelines apply.