A bed is a resident’s safe place, but when mattresses, bed rails or grab bars do not fit properly, problems can arise.

Deaths and injuries from entrapment result when the patient slips between the mattress and side rail or gets trapped within the side rail itself. The risk of entrapment increases when there are large gaps or openings in the bed system that could entrap a patient’s neck, head or chest. Gaps can be caused by mattresses that aren’t the recommended size, loose side rails or design elements such as wide spaces between the openings in the rails.

Patients at highest risk for entrapment are older or frail adults and those who have conditions such as agitation, delirium, confusion, pain, uncontrolled body movement, hypoxia, fecal impaction or acute urinary retention. These conditions make them likely to move about in the bed or try to get out of it.²