This regulation requires nursing facilities to regularly inspect all bed frames, mattresses, and bed rails as part of a maintenance program to identify and prevent entrapment hazards. Facilities must ensure compatibility between bed rails, mattresses, and bed frames when purchased separately. Surveyors reference FDA guidance documents on hospital bed system dimensions when investigating compliance. This is a physical environment/maintenance standard applicable to long-term care nursing facilities, not a behavioral health, IDD, ABA, or foster care setting.
View official sourceF909 (Rev. 173, Issued: 11-22-17, Effective: 11-28-17, Implementation: 11-28-17) §483.90(d)(3) Conduct Regular inspection of all bed frames, mattresses, and bed rails, if any, as part of a regular maintenance program to identify areas of possible entrapment. When bed rails and mattresses are used and purchased separately from the bed frame, the facility must ensure that the bed rails, mattress, and bed frame are compatible. GUIDANCE: §483.90(d)(3) For concerns related to the inspection or compatibility of bed frames, mattresses and bed rails, cite those here. For additional guidance on the assessment of individual’s needs, including the potential risks and benefits of the use of bed rails, refer to F700 Bed Rails located in Quality of Care at §483.25(n). PROCEDURES: §483.90(d)(3) When investigating F909, surveyors may reference Food and Drug Administration (FDA) documents entitled “Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment” dated March 10. 2006, “Practice Hospital Bed Safety” dated February 2013, and “Guide to Bed Safety Rails in Hospitals, Nursing Homes and Home Health Care: The Facts” as to the proper dimensions and distances apart of various parts of the bed such as distance between bed frames and mattresses, bed rails and mattress etc. to prevent entrapment by users of the bed. PROBES: §483.90(d)(3) How does the facility assure the inspection of all bed frames, mattresses and bed rails, if any, as part of their regular maintenance program? Is equipment inspected and maintained according to manufacturer’s recommendations and requirements and timeframes? Does the mattress fit the bed frame properly limiting entrapment zones? Is the bed rail securely and properly installed according to manufacturer’s requirements to limit entrapment zones?