May 15, 2013_CRS "Dear Provider/Administrator" Letters

May 15, 2013

ALTSA: CCRSS 2013-002

Dear Certified Community Residential Services Provider:

We recently heard about a death involving bed rails of an in-home personal care client.  The purpose of this letter is to remind you about the safety risks associated with the use of medical devices. This letter replaces a letter sent out to CRS providers in 2009 (CRS#2009-007).
Not all medical devices are potentially dangerous for clients.  However, some examples of medical devices with known safety risks when used include transfer poles, Posey or lap belts, and side bedrails.  Potential risks of medical devices may include strangling, suffocating, bodily injury, skin bruising, cuts, scrapes, agitation, feeling isolated or unnecessarily restricted.
If you are using or considering the use of a medical device for a client, review the following carefully:

  • The client assessment will include the client's strengths and any needs for which a medical device might be considered.  NOTE:  The assessment identifies the client's needs.  Do not use the assessment to justify the use of the device.
  • Identify and implement interventions that might decrease the need to use a medical device.
  • Document the use of less restrictive and less invasive options, successful or not.  
  • Clients and/or legal representatives must be provided with enough information about the significance and level of the safety risk of use of the device to enable them to make an informed decision about whether or not to use the device.
  • Obtain a physician's order for use of the device including the medical necessity and anticipated duration of use.
  • Provide staff with written instructions regarding safe and proper use of the device.
  • A medical device must not be used as a restraint or for staff convenience.

It is always important to evaluate the safety of each client and recognize the risks of using medical devices.  For more information, the Federal Food and Drug Administration brochure, A Guide to Bed Safety, is available on the Department's CCRSS Professionals page under the heading "Side Rail Safety."  

If you have any questions, please contact Robert McClintock, Quality Assurance Administrator, at (360) 725-2419.


Joyce Pashley Stockwell, Director
Residential Care Services