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A North Carolina nursing home has been fined by the state after a resdient in the facility died when she was suffocated in between her mattress and the raised bed rails of her bed. The state found that the facility was improperly using the bed rails as a means of restraint. Six other residents were found to have bed rails in place which were not ordered by a physician.

There are two major risks associated with the use of raised bed rails. One is a risk that residents will become entrapped in between the mattress and raised bed rails, leading to suffication or other injuries. The other risk is that a resident will try to climb over the top of the raised rails, leading to falls.

Because raised bed rails are such a risk, a physician order is requried before they can be used. The physician and staff must use the least restrictive means to achieve the same results as intended by the use of the rails.

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