Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
F700 in North Carolina. Pick another state for the same tag.
Against expectation — 2025
North Carolina cites F700 more often than its own record predicts
Versus expected share2.35×
2.35 times the share F700 takes of citations nationally.
Share of North Carolina citations0.91%
Of every deficiency written in North Carolina in 2025, this is the portion that was F700.
North Carolina0.91%
National0.39%
Share of all citations that were F700.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What North Carolina surveyors wrote
F700 findings written in North Carolina, one from each severity band recorded here, most serious first.
Severity is as the surveyor wrote it. Some findings had already been corrected before the survey.
J · Immediate jeopardy, isolatedJanuary 17, 2024
Based on observations, record review and interviews with the Emergency Medical Technician, the Medical Doctor, and staff the facility failed to comprehensively assess the risk of entrapment and the use of quarter length bilateral bed rails for a dependent resident with severe cognitive impairment who required extensive 2-person assistance with bed mobility after the placement of an alternating pressure air mattress. The resident experienced a fall from the bed equipped with the alternating pressure air mattress and quarter rails on both sides of the bed in an up position. The resident was found with no signs of life and observed to be partially on the floor and partially on the bed with his head pressed against the bed rail. …
Based on observations, record review, Nurse Practitioner (NP), family, and staff interviews, the facility failed to accurately assess a resident (Resident #1) for bed rail assist bars, failed to assess a resident (Resident #1) prior to implementation of bed rail assist bars, and failed to review the risks associated with the use of bed rail assist bars with Resident #1's Resident Representative. Resident #1 sustained a hematoma to her left arm from the bed rail assist bar and was transferred to the hospital emergency roiagnom on [DATE] and 8/31/24 for treatment. Resident #1 was admitted to the hospital related to her hematoma injury on 8/31/24 and required a blood transfusion during her hospitalization . This deficient practice occurred for 1 of 5 residents reviewed for bed rails. …
D · No harm, potential for more than minimal, isolatedAugust 13, 2026
Based on observations, record review, and resident, staff, and resident representative interviews the facility failed to document bed rail entrapment risk assessments for the use of bilateral bed rails (Resident #103, Resident #125 and Resident #15) and failed to review the risks and benefits and obtain informed consent prior to installing and utilizing bilateral bed rails (Resident #15). The deficient practice was for 3 of 3 residents reviewed for accidents.
The findings included:
1. …
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