We are investigating the death of a 91 year old who choked to death in the side rails of her bed in an adult foster care facility. Nursing homes rarely, if ever utilize side rails following the rash of choking deaths that occurred in the 1980’s and 1990’s. The deaths were caused by mattresses that pulled away from the side of the bed creating a gap. Frail individuals would slip into the gap. They would literally be found “hanging” from the side of their beds. A side rail is a restraint that requires a physician’s order in a long term care setting. Under no circumstances should consumers ever permit use of a side rail for a loved one in any facility without a specific order from a physician.