Sample Resident Bed Rail Consent Form

What is the Resident Bed Rail Consent form?

The blank on this page is a one-page form headed "SAMPLE – RESIDENT BED RAIL CONSENT FORM". It is hosted on michigan.gov, in the website files of the Michigan Department of Licensing and Regulatory Affairs (LARA). With it a resident, or the person who makes medical treatment decisions for the resident, consents in writing to the installation and use of bed rails on the resident's bed.

At the top the form has lines for the resident's name and the date of request. It prints no form number, no edition date and no name of the office that issued it. Under its title it prints "(Per Michigan PA 437 of 2000, January 9, 2001, amending Michigan Public Health Code, PA 368 of 1968)". The website of the Michigan Legislature lists the Public Health Code as Act 368 of 1978.

Who asks for bed rails, and who signs?

Part One of the form says: "Please initial one of the following blocks indicating the person requesting the use of bed rails." There are three blocks:

• the resident, "while being mentally capable of participation in his/her own health care decisions";
• the resident's "legally appointed and appropriately empowered attorney-in fact", where a team of physicians has determined in a written Medical Determination that the resident is incapable of participating in those decisions;
• the resident's Probate Court appointed guardian.

A line for the surrogate's name follows, with the choices "Attorney-in-Fact" and "Guardian".

The form ends with a signature and date line marked "(Resident, Attorney-in fact, or Guardian)" and a line for a witness signature with its date.

What does the person who signs acknowledge?

In Part Two the person who signs states that they are responsible for the medical treatment decisions of the resident and have been advised that they may request that bed rails be installed on the resident's bed. The form goes on: "The risk and alternatives to using bed rails, as they apply to this resident's particular condition and circumstances, have been clearly explained to me." The form does not list those risks or alternatives.

The person who signs also states an understanding that:

• in addition to the signed consent form, a written order from the resident's attending physician, specifying the medical rationale and the circumstances for use, must be obtained before the bed rails are installed;
• the facility will periodically review and re-evaluate the resident's need for bed rails, and the resident, the responsible party and the attending physician will be consulted;
• the authorization is revocable, "except to the extent of those actions already taken".

The consent itself reads: "I consent to the installation and utilization of bed rails for the care of the above named resident, consistent with the written orders of the attending physician."

Is this the form a nursing home uses?

The form is marked as a sample, and it names no office to which it is sent. LARA's "Nursing Home Bed Rail Use Guidelines", marked "Updated: July 2025", say: "A nursing home shall provide bed rails to a resident only on the receipt of a signed consent form authorizing bed rail use and a written order from the resident's attending physician that contains statements and determinations regarding medical symptoms and that specifies the circumstances under which bed rails are to be used."

The Long Term Care page of LARA lists the Department's bed rail resources, a "Bed Rail Overview" and a "Bed Rail Tool", and says that they "are to assist nursing home staff, residents, and their legal representatives in the appropriate, safe, and proper use of bed rails." The sample form is not among the resources linked on that page.