Falls from bed are prevented by combining three things: lowering the sleep surface so that any fall is from minimal height, removing the need to climb over barriers to exit, and ensuring the person can safely transfer in and out when they want to. Side rails alone do not prevent falls and can increase injury severity when a person climbs over them. The most effective single intervention for people at high risk is a profiling bed that lowers to floor level, used alongside a structured falls risk assessment.
Who is at risk of falling from bed?
Bed-related falls disproportionately affect older adults, people with dementia or delirium, people recovering from stroke, and anyone with reduced lower-limb strength, postural hypotension, or nocturia. Around one in three adults over 65 will fall each year, and a significant proportion of these falls happen at night, during transfers in and out of bed, or while attempting to reach the toilet.
Risk factors fall into three groups:
Intrinsic factors are characteristics of the person - age, cognitive impairment, polypharmacy (particularly sedatives, antihypertensives, and diuretics), poor vision, reduced muscle strength, balance impairment, continence issues, and a history of previous falls.
Extrinsic factors are environmental - bed height, surface firmness, lighting, floor coverings, clutter, footwear, and access to call bells or mobility aids.
Behavioural factors include unassisted attempts to mobilise, refusal of help, restlessness or wandering, and attempts to climb over bed rails.
A structured assessment should consider all three. The bed itself sits at the intersection of extrinsic and behavioural risk: it determines how far someone falls, whether they need to climb to get out, and whether they can transfer with the dignity and independence that reduces unassisted attempts in the first place.
Why side rails are not a falls prevention solution
Side rails (sometimes called bed rails or cot sides) are widely used but are clinically problematic when used as a primary falls intervention. The MHRA, NICE, and multiple national patient safety bodies have all issued guidance highlighting risks of entrapment, climb-over injuries, and increased agitation in people with cognitive impairment.
Side rails have a legitimate role in supporting bed mobility - for example, helping a person reposition or providing a handhold during transfers - but they should not be relied upon to keep someone in bed against their will. A determined person who wants to get out of bed will climb over a rail, and the fall from that height is significantly more harmful than a fall from a low bed surface.
The clinical principle is harm minimisation: assume falls will happen and reduce the consequences when they do.
How floor-level beds reduce falls injuries
A bed that lowers to floor level reduces the fall distance to a few centimetres. Combined with a crash mat alongside, this turns a potentially fracture-causing event into a controlled descent. Floor-level beds are particularly effective for:
- People with dementia who exit the bed without recognising the risk
- People who experience nocturnal confusion or delirium
- People recovering from hip fracture or other lower-limb surgery where re-injury must be avoided
- People with epilepsy or other conditions causing nocturnal falls
The bed should rise to a working height for care delivery and transfers, then lower fully when the person is sleeping. The lift range matters: a bed that only lowers to 30cm is not a floor-level bed. True floor-level beds reach 7–10cm from the floor.
What does a bed-related falls risk assessment include?
- History of falls - number, circumstances, time of day, injury sustained
- Cognitive status - capacity to understand risk, recognise the call bell, follow instructions
- Continence and toileting needs - particularly nocturnal patterns
- Medication review - sedatives, anticholinergics, antihypertensives, hypoglycaemics
- Postural and transfer ability - sit-to-stand strength, balance on transfer, use of mobility aids
- Environmental review - bed height, lighting, floor surface, distance to toilet, call-bell accessibility
- Footwear and clothing - non-slip footwear, nightwear that does not trip the person
- Carer availability - overnight staffing, response time to call bells, supervision level
The output of this assessment should drive equipment prescription - not the other way around. Specifying a floor-level bed without addressing toileting or medication still leaves the person at risk.
When should a floor-level bed be prescribed?
- The person has had a fall from bed, or has fallen attempting to exit
- They are at high risk of falls and unable to reliably use a call bell
- They have cognitive impairment that prevents reliable use of side rails or supervised transfers
- Restraint (chemical or physical) is being considered as an alternative - a floor-level bed is almost always preferable
- The person is end-of-life and dignity in transfers is a priority
The prescription should specify the lift range, the side-access requirements (full-length safety mats versus partial rails), and any need for paediatric configurations if the person is a child.
How Accora supports falls prevention
Accora's FloorBed range was the first truly floor-level nursing bed on the UK market and continues to be specified across NHS community services, hospices, and acute trusts for falls-risk patients. The FloorBed 1 lowers to 71mm - low enough that a fall from the sleep surface is rarely injurious - and rises to a full working height for care delivery. The FloorBed 1 Plus extends this for larger service users, and the Proxima provides the same floor-level functionality optimised for acute care environments.
Our clinical team offers free joint visits with prescribing OTs to assess whether a floor-level bed is appropriate, and our Academy programme includes free CPD-accredited webinars on falls prevention for healthcare professionals.
Related clinical questions
References and further reading
- NICE CG161: Falls in older people - assessing risk and prevention
- MHRA guidance on bed rails (Medical Device Alert)
- Royal College of Physicians National Audit of Inpatient Falls
- NHS RightCare Falls and Fragility Fractures Pathway