Greta Woolsey's 96-year-old mother is in a Galesburg nursing home. Two weeks ago, she fell out of bed. Woolsey, and her sister, Fran Henley, are incensed. "This would never had happened if the home had left the bedrails on the bed." That's when the two-woman campaign to get the rails back on their mother's bed started. Along the way, the pair uncovered a morass of state and federal regulations, conflicting interpretations, and laws with good intentions gone awry.
According to interpretations of state and federal laws as implemented by administrators at area nursing homes, the bed rails must come off the beds even if the elderly residents are in danger of falling onto the floor. Woolsey, who praises the Marigold for the care the residents receive, the food, the activities and every aspects of her mother's waking hours, the removal of the bed rails was not their fault. "They started taking them off about three months ago; they told us that according to the law there could be no more rails. They are now considered restraints and restraints are illegal. They removed them completely and residents have since fallen out of bed."
Woolsey says the nursing homes appear to be confused by state inspectors. "They told me they'll get marked down if they have bedrails even if a doctor requested them. That's why they removed them completely."
She contacted State Representative Don Moffitt who says that "if a doctor orders that the guardrails be placed in the up position when the patient is napping or sleeping, the nursing home must follow the orders."
A spokesman for the Illinois Department of Public Health, which regulates nursing homes, agrees. "There is no problem using side rails as long as a doctor approves them. They are not prohibited. It all comes down to the needs of the resident and what's best for them. Several years ago the federal law changed and they now classify siderails as a restraint. but that doesn't mean they're not appropriate for some residents."
A quick survey of Galesburg nursing homes indicated that side rails are rarely used. Tom Wagner, administrator of Seminary Manor, says they avoid use of bedrails, too. "They are now considered a restraint. With a physicians order, they can be used. Generally, we put the bed on the floor and we have some beds that lower much closer to the floor."
Wagner says that siderails can be useful in some cases to help the patient's mobility but there have been cases where the rails have caused serious injury. "Sometimes people get confused and try to climb over them. Sometimes, they'll get caught."
A memo from the Illinois Department of Public Health affirms their contention that "One misconception is that side rails are in and of themselves prohibited by state and federal requirements. Depending on their purpose, side rails may or may not be restraints. When used for the purpose of keeping a resident from getting out of bed and that resident wants to get out of bed, side rails meet the conditions of physical restraints." When used to facility mobility in or out of bed, side rails do not meet the definition of physical restraints. However, it concludes, "When side rails serve multiple purposes, they must be evaluated as physical restraints."
The memo also says that the use of side rails is to be determined by an assessment of an individual resident's needs weighing the risks and the benefits. It suggests putting a soft mat aside the bed or lowering the bed as alternatives. "Federal law prohibits side rails as restraints only when there is no medical symptom warranting their use."
A March 17 , 1997 letter from the U.S. Department of Health and Human Services clarifying federal law on the issue states that the rails are not a "benign safety device. Depending on the resident's status, all types of side rails may pose an increased risk to safety."
Many guardians of nursing home residents, including Woolsey and her sister, think they should have a say as to whether rails are used or not. Both federal and state regulatory agencies give that responsibility to the physician many of whom are reluctant to order the rails be used. If a doctor orders side rails, he or she must also document the need in the patient's record and formulate a plan to evaluate their use and eventual discontinuation. The doctor must also certify that the use of the restraint or confinement is "necessary to prevent a resident from injuring himself or others."
The use of side rails in nursing homes is an issue that's not easy to resolve. Everyone is blaming someone else for a maze of regulations that make it difficult to know what's best, legal or appropriate for each resident.
In the meantime, Woolsey's mother's doctor eventually called the nursing home and the rails are back on her bed; that's one fewer resident in danger of falling.