PROVIDER ALERT – Bed Siderail/Enabler Entrapment Issue

Karen Morris and Nancy Leveille in Clinical & Quality

NYSDOH Survey and Surveillance staff have alerted the associations to a bed siderail/enabler entrapment issue resulting in an immediate jeopardy citation. Recently, facilities have purchased new beds and upon assembly and use, they have not met the proper requirements to prevent entrapment, even with proper assembly. The facilities were cited for failure to assess the entrapment risks. The specific issue in this case was with the horizontal space between the bottom of an enabler bar and the top of the mattress. This space cannot be more than 2 and 3/8”. This is just one area (or zone) of risk that can occur in new or old beds with side rails or enablers, or when different size mattresses are applied to beds, or when the depth of a mattress changes due to use or the weight of the person in the bed. 

All providers should be using the 2006 FDA guidance located at as part of their ongoing bed safety program to help identify entrapment risks that may exist in any of the 7 zones addressed by the guidance. 

The NYSDOH will be issuing a DAL in the coming weeks related to this issue, as well. If you have any questions, please contact us.


Karen Morris, RN, MS
Director, Clinical & Quality Services
518-462-4800 x15

Nancy Leveille, RN, MS
Sr. Director, Member Operational Support
518-462-4800 x20