The first two questions with rails, grab bars, assist bars, etc. are restraint and safety. Looking at safety is much more broad than the aspect of acting as a restraint.
Here are the questions from a side rail assessment that we developed after a survey tag r/t safety.
Physical restraint: Any manual method or physical or mechanical device, material or equipment attached to or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to ones' body.
Does side rail use meet the definition of a restraint for this resident?
STOP HERE-SIDE RAIL USE NOT INDICATED FOR THIS RESIDENT
Mark rails with Red tape or remove from bed.
Is resident immobile (comatose, paralyzed, no spontaneous movement)? *Yes/ No
If primarily immobile, does the resident have enough mobility to turn or slide to one side? *Yes/ No
Has resident ever sustained bruises, skin tears, lacerations or fractures from a side rail? *Yes/ No
Has resident ever become entangled in the side rail or entrapped between the mattress and the side rail? *Yes/ No
Is the resident able to turn from side to side independently with use of rail? Yes/ *No
Does side rail use increase resident's physical mobility? Yes/ *No
If any starred answers chosen, side rail use indicated only with presence of staff.
Mark rails with Yellow tape.
If mobile, does resident make any attempt to get out of bed? Yes/ No
If mobile, can resident get in/out of bed safely without any human assistance or assistive device? Yes/ *No
If mobile, is the resident at risk for orthostatic hypotension or does resident have difficulty with balance/trunk control? *Yes/ No
If mobile, does resident have decreased safety awareness due to confusion or judgment problems? *Yes/ No
If starred answers chosen, rails increase risk for falls. Document increased risk and informed consent from resident/ family member (include name of family member giving consent).
Does side rail use increase resident's risk for falls? Yes/ No
Is this resident safe to use rails when they wish? Yes/ No
If yes, mark rails with Green tape.
Is OT/PT evaluation needed for transferring and/or ambulation skills? Yes/ No
After completing assessment, please mark side rails with appropriate color tape:
Green= Go-may be up at any time the resident wishes.
Yellow= Use with caution- staff presence required for rail use.
Red= STOP-Do not use Side rail(s) for this resident.
Analysis of risk factors:
RN Assessor: Date: