There have been recent queries regarding support for individuals who roll from a low-rise bed onto a crash mat, and whether this should be classified as a fall, and therefore managed via the falls pathway.
To clarify, rolling from a low-rise bed onto a crash mat is not considered a fall. It should be recorded as a prevented fall, as both the low-rise bed and crash mat are risk mitigation measures designed to reduce harm from falling out of bed.
If rolling from a low-rise bed onto a crash mat occurs occasionally, (i.e., in a ‘one-off’ scenario), staff should follow the falls protocol, complete the appropriate checks, and assist the person back up from the floor, either by giving the person verbal instructions (so the person gets themselves up), or using suitable equipment, such as an ELK or MANGAR cushion where available, or by calling the Avoidance of Admission Services if staff are unable to get them off the floor safely using any of these methods.
However, if someone is regularly (i.e., not occasionally) rolling onto the crash mat and there is no access to equipment such as a MANGAR cushion—resulting in the need for more complex transfer methods (e.g. hoisting), which may present logistical challenges, such as staff needing to regularly, or repeatedly work down on the floor to put the sling in place, or having to negotiate how to manoeuvre the hoist around the crash mat, or if staff are finding it awkward or strenuous—it would then be advisable to review the Bed Rail Risk Assessment.
Consideration of the situation will need to establish alternative strategies, and it may even be appropriate to reconsider whether, in certain circumstances, the benefits of using bed rails outweigh the risks. In this case, your documentation MUST clearly demonstrate this reasoning. In the community, an OT review may be required. In care homes, senior staff should complete the review and can check our Bed Rail Risk Management Tool Bed-Rail-Risk-Assessment-Management-Tool-JUNE-2025.pdf and they should request OT input to support the decision-making process if needed (please see FAQ’s for more info) . These assessments and reviews can be requested through the GP, therapy hub or through Adult Social Care. A Deprivation of Liberty Safeguard may be required in certain circumstances. Accurate documentation should be in place to reflect the reasoning and decision making at all stages.
In the event that a person is injured for any reason when rolling from the low-rise bed to the crash mat, the injury can be managed using a system which recognises the need to call 999 for any RED FLAGS, or the Avoidance of Admission Services for your local area for any AMBER FLAGS. See The Hertfordshire Management of a Person who has Fallen Pathway and accompanying paperwork here – Falls Pathways.
Whilst rolling from a low-rise bed onto a crash mat is not considered to be a fall, and should be recorded as a prevented fall, it may be useful to always use the ‘The Hertfordshire Management of a Person who has Fallen Pathway’ to check for and appropriately escalate when there are any red or amber flags.
Frequently Asked Questions – Falls and Equipment
Use of Crash Mats
Crash mats should be used with caution, as they can create complexities and further risk to the person and staff if not used correctly, or if the risks are not fully considered. If further risks are identified, further support may be required from a specialist (e.g. Occupational Therapist).
Key considerations:
- Can create a trip hazard for patients and staff.
- Must be removed and stored safely when not in use.
- Is the person likely to try to stand from the mat?
- Have they attempted this before? Was there an injury?
- Could they stand safely if they did get up from the crash mat?
- Would another option (e.g. bed rails or sensor technology) reduce the risk more effectively?
- Would a sensor (e.g. laser or pressure) help alert staff if the person attempts to get up?
Always weigh up the benefits vs risks for each individual.
Use of Fall Sensors
Fall sensors do not prevent falls, but alert staff to respond quickly to reduce the risk of a fall occurring.
Key considerations:
- Record whether the alarm activated and if it was effective.
- Review risk assessment if a fall occurs despite the sensor.
- Choose the appropriate type (pressure, discreet alert, laser detection).
- Be mindful that alarm noise may increase agitation for some people receiving care.
- Be mindful that the sensor just being there may cause distress for some people receiving care, and they may have an increased risk of falling because they try to step over it, or bend down to move it out of the way.
Always weigh up the benefits vs risks for each individual.
More information on the types of sensor mats available can be found on the Falls section of the HCPA website.
Use of Low-Rise Beds
Low-rise beds can reduce injury risk but are not required in all cases and careful consideration should be made as to whether it is an appropriate choice. If you believe that the low-rise bed is causing more risk than is beneficial, a review should be requested. If you are the decision maker the following points should be considered.
Key considerations:
- Should not be used as a stand-alone falls solution.
- Inappropriately using a low-rise bed for a mobile person may be considered restraint.
- There are low-rise beds (that lower to 20cm) and ultra low-rise beds (that lower to 7.5cm), so if using a crash mat/mattress the height of this should also be considered to minimise the height difference as much as possible.
- Consider likelihood and severity of harm if the low-rise bed is not provided.
- Use only where clearly justified through the risk assessment.
As this can be quite a complex decision further guidance is available in the Bed Rails checklist section of our website.
Gaps Between Bed and Wall
If bed rails present an entrapment risk, lowering them alone is not sufficient — they must be removed if unsafe. If an OT has assessed they will usually arrange for them to be collected and care home will have the responsibility of removing them.
Where profiling beds cannot sit flush to the wall:
- A lowered rail with a bumper may reduce entrapment risk.
- This should only be used following an appropriate risk assessment.
- Use of a lowered rail with a bumper should be recorded clearly as a risk management technique in the care plan
Who do we refer to if we are in a residential or nursing home?
For advice and support, both HCT and Adult Social Care can be contacted for their Occupational Therapy Service.
With referrals to either of the above, please ensure that you have used your in-house teams for advice and support first. If this has not been successful, or you feel the issue is more complex, or is outside of your scope of practice, then Adult Social Care can be referred to through informandadvise@hertfordshire.gov,uk
Always bear in mind when making referrals for support regarding falls, please only refer to the Community Physiotherapy teams at HCT if you think there is a possibility for rehab potential. Please consider also, whether a person has the ability to retain information so that they can improve.
Please note that if you wish to refer for Physiotherapy support regarding falls from the Hertfordshire Community Therapy Team, this can be done through GP.