by Patricia A. Maben, RN, MN Few people consider the design or arrangement of a bathroom or toilet room when selecting a nursing home or assisted living facility. However, the issues of privacy, dignity, and safety in the room used for bathing, showering, grooming, and activities that are so personal they aren't even mentioned in "polite society," should receive great consideration. The bathroom should be of concern to anyone caring for residents and to those designing the spaces where care and assistance will be given. In my role as director of the Long Term Care Program for the Kansas Department of Health and Environment, Kansas's regulatory agency, and as a member of the Society for the Advancement of Gerontological Environments (SAGE), I have had the opportunity to review architectural plans for a number of long-term care facilities. And as a registered nurse with more than 34 years' experience in long-term care, I've seen how a well-designed bathroom can improve residents' quality of life and how a badly designed one can make life more difficult-for residents and caregivers alike.
During the past six years, I have had the opportunity to work with a number of good architects and members of SAGE. These individuals have shared many ideas and concepts that have enriched my knowledge and ability to provide consultation to companies building and remodeling health-care facilities in Kansas.
The Toilet Room
The toilet room is an area of design that generally has not been emphasized in new construction and remodeling of long-term care facilities. Because good toilet-room design can prevent excess disability in elders, and because many elders need assistance with transfer before and after toileting, the placement of the toilet makes a significant difference in safety for both residents and staff.
The design of toilet rooms in nursing and assisted living facilities is usually driven by the examples provided in the Americans with Disabilities Act (ADA) Accessibility Guidelines. The design examples illustrated in these guidelines are intended for persons who do not need physical assistance in transferring on and off the toilet. Individuals with good upper-body strength can use the grab bars for transfer, but most elders, especially older women, do not have good upper-body strength and cannot effectively use the grab bars in the standard position.
Another problem I often see is that the toilet is too close to the wall (typically within 18") for residents who need staff assistance with toileting. This small space does not allow for easy and safe transfer.
In Kansas, staff from the licensing agency met with staff of the attorney general's office responsible for ADA enforcement. The agency was in the proc-ess of amending regulations and asked for a review of proposed changes to ensure ADA compliance. The discussion led to a review of subsection 2.2 of the ADA guidelines, which provides for "equivalent facilitation" of the guidelines. The subsection reads as follows:
- 2.2 Equivalent Facilitation. Departures from particular technical and scoping requirements of this guideline by the use of other designs and technologies are permitted where the alternative designs and technologies used will provide substantially equivalent or greater access to and usability of the facility.
This provision in the law provides the opportunity for architects and owners to explore alternative designs that can better meet elders' needs.
During the past seven years there has been a significant increase in new construction and remodeling of nursing and assisted living facilities in Kansas. Owners and architects are encouraged to meet with staff of the licensing agency early in the process. The Kansas Department of Health and Environment no longer has a licensed architect on staff to review and approve architectural drawings. Instead, the department's Long Term Care Program staff review plans for compliance. The project's architect is required to certify that the architectural drawings are in compliance with the appropriate regulations prior to beginning construction.
Reviewing plans early in the process has been very productive. This allows both providers and architects to dialogue with licensing staff about their "dreams" for the new facility. It is also a time to review the regulations and deal with "myth" regulations that have often limited good design.
Every state has these "myth" regulations. For example, during a tour of a new, innovative facility, an administrator from another facility asked why we (the "state") had not required the new facility to have a door on the soiled utility room. I told him there was no requirement for a door and pointed out that in most facilities, the door to a soiled utility room remains open most of the time. It is important that architects and owners read the construction regulations carefully and, when in doubt, contact someone at the licensing agency.
The design elements reviewed for a toilet room include the following: door and door swing, position of toilet, grab bars, lavatory and mirror placement, storage, shower, and use of color and lighting. If the components of the toilet room are correctly designed, the elder will have greater opportunity to be as independent as practicable, and assistance provided by staff will be safer for both parties.