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Reducing the risk of accidental hangings, entrapment

April 1, 2010
by Betty MacLaughlin Frandsen, RN, NHA, MHA, CDONA/LTC, C-NE
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At a glance…

Accidental deaths by hanging and entrapment should refocus nurse leaders' efforts on the important job of providing a safe environment for residents. Many residents use assistive devices that are not considered restraints, however, all of the precautions required for restraint use should be enacted.

In December 2009, two resident deaths occurred in nursing homes in Colorado from side rails used as assistive devices,

1 even though they were designed to cover a quarter or less of the length of the resident's bed. Many similar deaths have resulted elsewhere in our nation from entrapment.

As nurse leaders, these tragic events should refocus our efforts on the important job of providing a safe environment for our residents. Many residents use assistive devices and because they are not considered a restraint, all of the precautions required for restraint use may not be put into place.

What went wrong?

In these specific examples, the rails were used as mobility assistive devices and were not intended to serve as restraints. In reviewing what went wrong, Colorado Department of Health surveyors determined that there were several common factors in these deaths:

  • Because the rails were considered assistive devices, the facilities had not conducted a restraint or safety assessment for their use.

  • Because the rails were not considered restraints, informed consent was not obtained for their use. There had been no documented discussion of potential threats versus expected benefits.

  • The devices, when attached to the bed, left a 3″ to 4″ gap between the inside edge of the device and the mattress.

  • In each death, the resident's upper head, neck, or torso became entangled between the device and the mattress.1

Frail elders are especially vulnerable to entrapment, which often results when a resident is caught or entangled in spaces such as a bed rail, between the mattress and bed frame, between the mattress and side rail, or in a wheelchair between the seat and an attached restraint. Entrapment can result in serious consequences including significant injury or death.

There were 691 entrapment reports received by the Food and Drug Administration (FDA) over a period of 21 years, from January 1, 1985 to January 1, 2006. These reports told of patients becoming entrapped in beds while in healthcare facilities. Of the 691 patients, 413 died, 120 were injured, and 158 avoided injury thanks to prompt intervention.2 It is evident from the 2009 deaths that this issue has not been resolved.

Three primary body parts are at risk for life-threatening entrapment in seven zones of a bed system. They are the individual's head, neck, and chest. The seven potential zones of entrapment are (1) within a bed rail; (2) under a rail, between the rail supports, or next to a single rail support; (3) between the rail and mattress; (4) under the rail, at the ends of the rail; (5) between split bed rails; (6) between the end of the rail and the side edge of the head- or footboard; and (7) between the head- or footboard and the mattress end.2

Bed safety program

Evaluating dimensional limits of gaps in beds is one component of a bed safety program, which should also include a comprehensive plan for a resident/bed assessment to determine the right size and type of bed for the specific resident using it. The FDA has determined the size of gaps that place residents at risk for entrapment based on the most likely body parts to be impacted. Gap limits for use in monitoring efforts are: head-4¾; neck-2⅜, and an angle >60 degrees; and chest-12½.2

Ben Franklin's quote, “An ounce of prevention is worth a pound of cure,” is so true when applied to our efforts to ensure resident safety. As nurse leaders, we should schedule periodic reassessment of assistive and restraint devices, looking for worn bed components (e.g., wobbly bed rails, damaged rails, too soft mattresses) that could cause increased spaces within the bed system.

If your facility does not have a bed safety program in place, it is critical that it be initiated immediately.

Reassessment should be conducted when mattress overlays or positioning items are added or removed, when bed rails or mattresses are changed, or when a resident is placed into a different bed. Most residents can be in bed safely without rails when appropriate safety actions are taken. These include using beds that can be raised and lowered close to the floor to accommodate both resident and caregiver needs, and that are kept in the lowest position with wheels locked when care is not being given. Mats by the bedside, concave mattresses, or positional padding may help reduce the risk of falls with injury and may help to protect residents from entrapment, strangulation, or other serious injuries. An overhead trapeze may meet the needs of some residents for mobility assistance. If a bed rail is used as a bed mobility aid, it must be monitored for safety just as closely as if it were considered a restraint.


The American Association of Nurse Assessment Coordinators (AANAC) is a nonprofit professional association representing nurse executives working in the long-term care industry. AANAC is operated by nurses for nurses and is dedicated to providing members with the resources, tools, and support they need in their specialized role of leaders and managers in long-term care.