Michelle Teasdale, DNP, APRN, FNP-C, CCHP

If you are a provider in a correctional facility, chances are you have seen several inmates in your clinic requesting a bottom bunk – usually for an old injury. I receive these requests so often that I wanted to find out why. I decided to Google, “Why do inmates want the bottom bunk?” There are several blog postings and you tube videos from people who have been incarcerated that explain some of the reasons. I have listed a few of them below.

• They are considered prime real estate and indicate the inmate has high status. 
• Heat and offensive smells rise, making the top bunk an unpleasant place. 
• The top bunk is exposed to light, which makes sleeping more difficult.
• They have more privacy. In some facilities, inmates hang up a towel providing additional privacy.
• They do not have to climb up and down, which is also beneficial for going to the bathroom in the middle of the night.
• The bottom bunk can be used for bargaining. For instance, if an inmate has a bottom bunk clearance, they can trade it for commissary.

Now that we know some incentives for the requests, what constitutes the need for a bottom bunk? Dr. Keller posted a sample guideline that is beneficial when determining who should or should not be given access to “prime real estate.”

Sample Guideline: Bottom Bunk Requests

Posted on December 6, 2018 by Jeffrey Keller MD

This clinical guideline is intended to be used as a template to help clinicians and administrators create their own policies. This sample guideline must be modified to make it applicable to each unique correctional facility. This guideline is not intended to apply to all patients. Practitioners should use their clinical judgement for individual patients.

Introduction. Occasionally, inmates who have been assigned the top bunk of a bunk bed state that they have a medical condition that requires them to be given the bottom bunk instead. Since medical providers must be fair and consistent, it is important to differentiate medical need for a low bunk from requests made for non-medical reasons such as a desire for convenience or as a sign of increased status.

Medical need. Medical need for a low bunk generally falls into one of two categories: Patients who are unable to safely climb onto the top bunk because of physical limitations and patients who have a medical condition that might lead them to fall off of the top bunk and injure themselves.

Patients who are unable to safely climb onto the top bunk because of physical limitations include:

• Obesity (BMI >30)
• Advanced age and/or infirmity
• Late term pregnancy.
• Permanent physical disabilities, such as amputations, paralysis, or previous strokes.
• Temporary physical disabilities such as a broken bone or recent surgery.

Patients who have a medical condition that might lead them to fall off of the top bunk include:

• Seizure disorders which are current and ongoing.
• Conditions causing vertigo or dizziness, such as Meniere’s disease.
• Conditions which impair coordination such as cerebral palsy.

Chronic pain syndromes independent of other conditions such as those listed above generally do not constitute a medical need for a bottom bunk assignment.

Patients who have been successfully using a top bunk generally do not have a medical need for a bottom bunk reassignment unless their medical condition has acutely changed, such as with a traumatic injury. Example. A patient has been using a top bunk for three weeks. Now he comes to medical stating that there are several bottom bunks available in his pod. He would like medical to approve a bunk reassignment for him because of an old leg injury. The fact that he has been using a top bunk for three weeks indicates that this patient does not have a legitimate medical need for a bottom bunk.

Nursing Personnel may address routine patient requests for low bed assignments based on this guideline. If nursing personnel are unsure or have questions, they may refer the patient to a medical practitioner.

Documentation. Security personnel assign bunks, not medical personnel. Medical personnel are being asked if a patient has a medical need for a low bunk assignment. Therefore, medical personnel should document the answer to this question only.

Incorrect: “Bottom bunk request is not approved.” Correct: “This patient does not have a medical need for a bottom bunk assignment.”

Incorrect: “Bottom bunk is approved for medical reasons.” (Security staff may elect to place the patient on a single bed, a cot, or a floor “boat” instead of a bottom bunk.) Correct: “This patient should not be assigned a top bunk for medical reasons.”

If a patient does have a legitimate medical need for a low bunk assignment, consideration should also be paid to the patient’s other housing needs. For example, a low bunk may not actually meet the patient’s needs; the patient may need a hospital bed. Patients who have a medical need for a low bunk assignment may need to be restricted to a bottom tier so that they will not have to climb stairs. Patients who are inmate workers may need work restrictions. If the medical need for a low bunk assignment is temporary (such as a broken arm), the bottom bunk memo should have a time limit.